eras-190712195906.pptx enhanced recovery after surgery

advanced recovery protocol

1. E nhanced R ecovery A fter S urgery The ERAS protocol Ankit Raj Postgradutate Student(2 nd Year) Unit-III Dept. of General Surgery LHMC & associated Dr RML Hospital New Delhi-110001

2. THE DOGMA What Is a Dogma? /ˈ dɒɡmə / noun ‘a principle or set of principles laid down by an authority as incontrovertibly true’ ;applies to some strong belief whose adherents are not willing to rationally discuss it Dogmas in General Surgery- Preoperative prolonged fasting MBP NGT’s Drains Prolonged bed rest

3. SURGEONS!! TRADITION EVIDENCE BASED MEDICINE

4. What is ERAS? Proposed by Dr. Henrik Kehlet , a Danish Surgical Gastroenterologist in 1990’s “Why is the patient in hospital today?” “Patient-centered,evidence based,outcome driven,multidisciplinary team developed pathways for a surgical specialty and facility culture to maintain pre-operative organ function and reduce the profound stress response following surgery,optimize their physiologic function,and facilitate recovery” Fast Track Surgery These form an integrated continuum, as the patient moves from home through the pre-hospital / preadmission, preoperative, intraoperative, and postoperative phases of surgery and home again

5. Objectives of ERAS • Reducing complications and LOS • Reducing variability • Reducing cost • Improving quality of care • Increasing value = quality/cost

6. Traditional Care VS Provider focused High variability Physician driven ERAS®  Care Patient focused Outcome ddriven Standardised Evidence based Interdisciplinary

7. Recommendations of ERAS ® Society Based on quality of evidence – High – Moderate – Low – Very low Strong recommendation- Means panel is confident that desirable effects outweigh the undesirable effects Weak recommendation’s-Panel is less confident that desirable effects outweigh undesirable effects.

8. Enhanced Recovery in Practice Referral from Primary Care Pre-Operative Admission Operative Post-Operative Follow-up Fluid management Postoperativ glycaemic control Postoperative nutrition Early mobilisation Rapid hydration / nourishment Appropriate iv therapy Catheters removed early Regular oral analgesia Avoid opiates Antimicrobial prophylaxis Multimodal analgesia PONV Optimal fluid therapy Hypotermia prophylaxis Optimised medical c onditions Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

9. Outline Anesthetist approach Surgeon approach Protocolization

10. Preoperative ERAS C omponents Patient information Health/medical optimisation Nutrition Fasting time Carboh y drate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

11. Intraoperative ERAS C omponents Antimicrobial prophylaxis Anesthesia protocol PONV Fluid management Hypotermia prophylaxis

12. Postoperative ERAS C omponents Postoperative analgesia Fluid management Postoperative glycaemic control Postoperative nutrition Early mobilisation

13. ERAS Epidural Anaesthesia Prevention of ileus/ prokinetics CHO-loading/ no fasting Early mobilisation Peri -op fluid management DVT prophylaxis Pre-op councelling Remifentanyl No premed No bowel prep Perioperative nutrition Bairhugger Oral analgesics/ NSAID’s Incisions No NG tubes Early removal of catheters/drains

14. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

15. Patient information Preadmission education and counselling Decrease fear and anxiety Improve wound healing perioperative feeding postoperative mobilisation pain control Reduce the prevalence of complications Enhance Postoperative Recovery and Discharge Evidence Low Recommendation High

16. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

17. Preoperative A lcohol C onsumption ? Preoperative Smoking Cessation? Does it make any difference? If yes for how long? Alcohol consumption should be stopped 4 weeks before surgery Smoking should be stopped 4 weeks Before surgery Smoking should be stopped 4 weeks before surgery Smoking should be stopped 4 weeks before surgery

18. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

19. Questions regarding perioperative nutrition TNP vs EN ? Pre vs post-operative ? Standard vs immunonutrition ?

20. Who should receive preoperative nutrition support? moderately/severely malnutrished nutrition support has been shown to improve outcome – thoraco -abdominal surgery elective surgery and safe to delay for 7-10 days enteral route is always prefered (when possible) combination with postoperative nutrition immune-enhancing formulas

21. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

22. Preoperative fasting Standard practice – fasting from midnight reduce the volume and acidity of stomach contents decreas e the risk of pulmonary aspiration But … Cochrane review of 22 RCTs - fasting from midnight no reduction in gastric content no rise in pH of gastric fluid C lear fluids until 2h before anesthesia Thirst , headaches , hunger

23. Why challange fasting by midnight? Normal physiology Is no guarantee of an empty stomach The same gastric volume with/without clear fluids Improved well being

24. Preop Fasting and Periop Fluids If fasted – risk of dehydration Dehydration and anesthesia --> hypotension Hypotension --> more fluids infused Overload of fluids Preop clear fluids --> less iv fluids --> improved outcomes Gustafsson et al Arch Surg, 2011

25. Metabolic effects of overnight fasting Day Night Hormones Insulin + Insulin – Glucagon Cortizol Substrates Storage Breakdown Utilization CHO > Fat Fat > CHO

26. Surgical stress Insulin resistance

27. Insulin resistance cause complications Complications increase with insulin resistance: 50% reduction in insulin sensitivity: 5-6 fold increase risk of complications 10 fold risk for infections Sato et al, JCEM 2010, 95; 4338-44

28. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carboh y drate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

29. Carbohydrate treatment 20% glucose iv 12.5% carbohydrate drink – 400 ml 2h before anesthesia + 800 ml evening before Induce insulin release

30. Effects of Preoperative Carbohydrates Reduces the metabolic stress of surgery Effectively reduce s insulin resistance Improves pre/postoperative well being Improves postoperative muscle function Reduce lean body mass losses May result in faster recovery

31. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

32. Pre - anesthetic medication Education Short-acting iv drugs Prior epidural/spinal analgesia No sedative medication before surgery Avoid starvation CHO loading U.O. Gustafsson et al. Clin Nutr 2012 ; 3 1 : 783-800

33. Preoperative ERAS components Patient information Health/medical optimisation Nutrition Fasting time Carbohidrate drinking Pre-anesthestic medication Anti-thrombotic prophylaxis

34. Anti–thrombotic prophylaxis Mechanical Pharmacological Compression stockings in all patients Intermitent pneumatic compression LMWH 2hr before Surgery Risk in major surg ery patients DVT – 30% PE – 1% U.O. Gustafsson et al. Clin Nutr 2012 ; 3 1 : 783-800

35. Intraoperative ERAS components Antimicrobial prophylaxis Anesthesia protocol Multimodal analgesia PONV Fluid management Hypotermia prophylaxis

36. Antimicrobial prophylaxis Imperative to reduce the risk of surgical infections Time 30-60 min before the incision repeated doses during prolonged procedure (≥3h) / Massive blood loss/fluid loading Route intravenous Spectrum Suspected germs ( aerobic ± anaerobic bacteria )

37. Intraoperative ERAS components Antimicrobial prophylaxis Anesthesia protocol PONV Fluid management Hypotermia prophylaxis

38. Anesthesia P rotocol • Tri-modal approach - A regional anesthesia block used in addition to GA • Reduced post-op use of opiates • Rapid awakening from anesthesia • Early enteral intake and mobilization • Use of epidural analgesia is superior to opioids

39. Intraoperative Monitoring ERAS BIS Algiscan Oesophageal doppler Glucometer TOF

40. Intraoperative ERAS components Antimicrobial prophylaxis Anesthesia protocol Multimodal analgesia PONV Fluid management Hypotermia prophylaxis

41. Multimodal analgesia Epidural analgesia i / v analgesia Wound catheters/infiltration Peripheral blocks

42. Benefits of Epidural Analgesia Dynamic pain control Obtunds stress response Reduction of ileus Reduced post-operative pulmonary complications Reduced myocardial ischaemia Reduced incidence of DVT/PE

43. Causes of Ileus Degree of surgical manipulation Magnitude of inflammatory and stress response Sympathetic reflexes Opioids Fluid overload/ bowel oedema

44. Intraoperative ERAS components Antimicrobial prophylaxis Anesthesia protocol Multimodal analgesia PONV Fluid management Hypotermia prophylaxis

45. PONV Risk factors Patient : female, non smokers, motion sickness Anestetic : volatile agents, iv opioids, nitrous oxide Surgica l: major abdominal surgery PONV scoring systems Multimodal approach Pharmachological Non- pharmachological techniques: TIVA, minimal fasting, CHO loading, adequate hydration, epidural, NSAIDS

46. Intraoperative ERAS components Antimicrobial prophylaxis Anesthesia protocol Multimodal analgesia PONV Fluid management Hypotermia prophylaxis

47. Perioperative fluid management What type of fluid ? Is there an indication for v asopressors ? When iv fluids should be discontinued ? Apparently, fluid management is an art of medicine and based on personal judgments. Is f luid therapy vital for outcome ? Are the f luid requirements the same ? What about flui d shifts ? What amount ?

48. Perioperative fluid management T ype of fluid Vasopressors are indicated in hypotensive normovolemic patients Iv fluids should be discontinued as soon as practicable Goal directed Therapy Fluid therapy is vital for outcome Fluid requirements are different Fluid shifts should be minimised Fluid administration must be goal directed

49. Intraoperative ERAS components Antimicrobial prophylaxis Anesthesia protocol Multimodal analgesia PONV Fluid management Hypotermia prophylaxis

50. Hypothermia – central temperature < 36 C Risk factor for wound infections , prolonged cicatrisation c ardiac events shivering – increase O2 consumption bleeding coagulation disorders trombocites dysfunction postoperative ileus increase pain prolonge emergence time Methods - warming devices (forced air warming blankets) warmed iv fluids warm gases in laparoscopic surgery Hypothermia Prophylaxis

51. Postoperative ERAS components Postoperative analgesia Fluid management Postoperative glycaemic control Postoperative nutrition Early mobilisation

52. Postoperative analgesia Optimale analgesic regimen Good pain relief Reduction of cardiovascular, cognitive, endocrino – metabolic complications in at risk patients Decrease the risk of chronic pain Allow early mobilisation Allow early return of gut function and feeding

53. Postoperative analgesia Principles of Multimodal Analgesia Avoidance of iv opioids Regional anesthesia techniques Thoracic epidural analgesia (TEA) Spinal analgesia Local anesthetic techniques Transversus abdominis plane (TAP) block The analgesic regimen is specific to the type of surgery/incision

54. Postoperative ERAS components Postoperative analgesia Fluid management Postoperative glycaemic control Postoperative nutrition Early mobilisation

55. Postoperative ERAS components Postoperative analgesia Fluid management Postoperative glycaemic control Postoperative nutrition Early mobilisation

56. Hyperglycemia in S urgical S tress Insulin resistance is the key Traditional belief Hyperglycemia in the acutely stressed patient is ”not dangerous” Glucose levels treated > 200 mg/dl

57. E lective major surgery-opportunity to prevent / attenuate metabolic responses to surgeryrather than having to treat them with insulin. Several stress-reducing interventions in ERAS attenuate insulin resistance as single interventions : preoperative oral carbohydrate treatment e pidural blockade minimally invasive surgery If interventions are combined in ERAS protocol, hyperglycaemia can be avoided even during full enteral feeding starting immediately after major colorectal surgery.

58. Postoperative ERAS components Postoperative analgesia Fluid management Postoperative glycaemic control Postoperative nutrition Early mobilisation

59. Postoperative early enteral nutrition Lewis et al BMJ 2001;323(7316):773-6

60. Postoperative ERAS components Postoperative analgesia Fluid management Postoperative glycaemic control Postoperative nutrition Early mobilisation

61. Outline Anesthetist approach Surgeon approach Protocolization

62. Surgeon No bowel prep Food after surgery No drains or KAD No iv fluids, no lines Early discharge All evidence based! Anesthetist Carbohydrates N o fasting No premedication Epidural Anesthesia Balanced fluids Vasopressors No or short acting opioids

63. BOWEL PREPARATION PRO Avoids massive contamination !?! Minor inconvenience to the patient !?! Looks better inside !?! CON Preoperative dehydration !!! Modification of enteral flora !!! Delayed gut motility !!!

64. R ectal cancer – TME (total mesorectum excision) Standardised Enhanced Recovery Programme for the EnROL Trial Day before surgery a voidance of oral bowel preparation except in patients undergoing total mesorectal excision (TME) and reconstruction. Kennedy et al. BMC Cancer 2012, 12:181

65. Reduce surgical injury Minimally invasive surgery FAST TRACK Surgery Early postoperative recovery Decreased stress response Decreased inflammatory response Decreased pain Early bowel movement

66. NO routine NGT 28 multicenter trials >4000 pt s Decreased duration of postoperative ileus Decreased risk of postoperative pulmonary complications Increased patient QOL No increase in anastomotic leak Nelson, R. at all Systematic review of prophylactic nasogastric decompression after abdominal operations. Br. J. Surg., 2005, 92, 673–680.

67. No drains Rationale of drains : A surgical tradition Difficult to be abandoned For how long? 24h / 48h / 7 days ??? In majority of cases – serous drained fluid (physiological reabsorption) “When in doubt, drain” Lawson Tait , english surgeon “ The drain= the surgeon eye in the patients abdomen”

68. No drains RCTs: Unreliable indication of anastomotic leak Underestimates the significance of anastomotic leak Underestimates the postoperative bleeding Does not influence the rate of anastomotic leak Increases the contamination risk Prolongs the duration of postoperative ileus Prolongs the hospital lenght of stay Petrowsky , H. at all: Evidence-based value of prophylactic drainage in gastrointestinal surgery: A systematic review and meta-analyses. Ann. Surg., 2004, 240, 1074–1085.

69. Outline Anesthetist approach Surgeon approach Protocolization

70. Preventing hypotermia Postoperative nutrition Preoperative Fasting Carbohydrates Treatment Properative prophylaxys Early mobilisation PONV Analgesia Preoperative optimisation Analgesia Fluid management Preoperative nutrition Fluid management Protocolization

71. Examples https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202008/table/t1-cuaj-5-342/?report=objectonly https://www.clinicalnutritionjournal.com/article/S0261-5614(12)00178-1/fulltext#sec3.25 https://link.springer.com/article/10.1007/s00268-016-3492-3