ERAS( Enhanced Recovery After Surgery)

I presented this case an intern doctor in my surgery rotation as a part of the department's monthly presentation.
It is a good guide for undergraduate students and intern doctors to understand basics on Enhanced Recovery After Surgery.

1. Welcome.

2. SCIENTIFIC SEMINAR ON ERAS

3. Chaired by Dr. Ehsanur Reza Shovan Associate professor Dept of Surgery MMC Presented by Dr. Ashmita Yadav Intern doctor Surgery Unit 2, MMCH

4. ERAS? ERAS stands for Enhanced Recovery After Surgery. HISTORY THE ERAS SOCIETY 2001- Ken fearon and olle ljungvist met in London at a nutrition symposium and decided to start a collaborative group on peri operative care. Further ideas were put forward in 2003 by professor Kehlet Henrick concerning the concept of multimodal care.

5. Professor Kehlet Henrick Henrik Kehlet was Professor of Surgery at Copenhagen University and is now Professor of Perioperative Therapy at Rigshospitalet , Copenhagen University, Denmark.

6. WHAT DOES IT ENCOMPASS ? It includes the intervals prior to surgery to the day of discharge. It can be best described as a quality improvement tool to To develop perioperative care To improve recovery through research, education, audit and implementation of evidence based practices.

7. GOALS OF ERAS Reduction of stress response to surgery Acceleration of recovery Decreased length of hospital stay Decreased post operative mortality and morbidity Reduction of the rate of re admissions following surgery.

8. Members of ERAS team Surgeons Nurses Anaesthesiologist Occupational therapist Pain management specialist Physiotherapist Dietician Hospital management Audit team

9. ERAS PERIOPERATIVE PATHWAY PRE OPERATIVE Pre admission counseling Fluid and carbohydrate loading No prolonged fasting No or selective bowel preparation Antibiotic prophylaxis Thromboprophylaxis Premedication

10. Minimal access surgery Short acting anaesthetic agents Mid thoracic epidural Avoidance of salt and water overload Maintenance of normothermia INTRA OPERATIVE

11. POST OPERATIVE Mid thoracic epidural No NG tube Prevention of PONV Avoidance of salt and water overload Early removal of foley’s catheter Early oral nutrition Use of non opioid pain medication Early mobilization Respiratory exercise Stimulation of gut motility.

12. PRE EXISTING HEALTH CONDITIONS Optimatisation of pre existing health conditions such as -Hypertension -Diabetes -Smoking -Alcohol - Anaemia and anxiety

13. Hypertension should be controlled and blood pressure should be brought to a baseline level. Diabetes should be monitored carefully depending on whether the it is controlled by diet, oral hypoglycaemic agents or insulin. Patients on insulin should be monitored with GLUCOSE POTTASIUM INSULIN sliding scale regimen. Smoking cessation 4 weeks prior , nicotine replacement therapy and counseling should be done.

14. A minimum of 4 weeks abstinence of alcohol should be done. Blood transfusions should be done at least 1 week before to bring haemoglobin to a baseline level. Iron ,vitaminB12 and folate supplementation should take place at least 4 weeks prior for the effect to take place. Education and counseling with preoperative analgesics and anxiolytics. Any co-morbid cardiac or pulmonary condition should be carefully assessed.

15. ORAL INTAKE Oral intake prior to any surgery and post operatively depends on the type of surgery. There is not enough evidence to support that by ensuring an empty stomach the risk of aspiration is less. Studies have shown that fasting after midnight increases insulin resistance, patient discomfort and decreases intravascular volume.

16. With ERAS protocol in place , the patient is given sips of water or clear liquid on the day of surgery. The diet is then progressed to a regular diet.

17. Early oral feeding has not been shown to increase post operative complications, readmission rates and the incidence of anastamotic leak. On the other hand patient who start early feeding protocol have fewer surgical complications and are less likely to be admitted.

18. POST OPERATIVE NAUSEA AND VOMITING Incidence -20 to 30 % Reduction of post operative fasting, carbohydrate loading and hydration decreases PONV. Serotonin antagonists or application of scopolamine patch or dopamine antagonists.

19. ANALGESIA Thoracic epidural is the gold standard. Avoidance of opioid analgesics. Patient controlled analgesia is the new approach NSAIDS and COX -2 inhibitors such as celecoxib have shown to improve post operative analgesia by reducing opioid consumption.

20. DELIRIUM Post operative delirium is common in critical care and post operative patients. Non pharmacological interventions and use of haloperidol may be necessary to treat post operative delirium.

21. MOBILIZATION Early mobilization is one of the leading factors of ERAS. Instructions detailing the daily mobilization goals should be given to the patient and families prior and it should be ensured even after the surgery. Early mobilization helps in prevention of DVT .

22. RESPIRATORY EXERCISE Respiratory exercises are encouraged to prevent pulmonary atelectasis.

23. REFERENCES Bailey and love’s short practice of surgery 28 th edition Enhanced recovery after surgery ( LISA PARKS, MS,RN, MEGHAN ROUTT,MSN,ACNS BC,ALLISON DE VILLERS) The ERAS PROTOCOLS BY PROF.LOANA GRIGORA S Multimodal approach to control post operative pathophysiology and rehabilitation- Henrik kehlet , Brit J A.