ERAS PROTOCOL IN GI SURGERY.pptx by Dr.Manish chaudhary

ERAS PROTOCOL IN GI SURGERY

1. ERAS PROTOCOL IN GI SURGERY Dr.Manish Chaudhary 2 nd year surgery resident CMS-TH

2. DEfinition Enhanced recovery after surgery (ERAS) is a systematic multimodal perioperative care aimed at reducing at the immense surgical stress of the patient and thereby facilitating early recovery.

3. Aims of eras protocol Reduce surgical stress Maintain normal physiological function Enhance early mobilization after surgery

4. BENEFITS OF ERAS Reduce length of stay Decrease surgical complications and readmissions Decrease cost Increased patient satisfaction and quality of life

5. HISTORY Also known as Enhanced Recovery programmes (ERPs) or fast track surgery. First described in 1990 by a Danish Surgical Gastroenterologist Dr Henrik Kehlet . ERAS society was created in 2001. First consensus protocol published in 2005. ERAS guidelines for colonic resection,rectal resection and pancreaticoduodenectomy was published in year 2012. ERAS guidelines for Gastric resection was published in 2014. ERAS guidelines for Bariatric surgery and Liver resection was published in 2016. ERAS guidelines for esophageal resection is under development.

6. ERAS COMPONENTS PREADMISSION COUNSELLING MEDICAL OPTIMIZATION NUTRITIONAL SCREENING AND SUPPORT PREHABILITATION ANEMIA CORRECTION

7. PREOPERATIVE FASTING GUIDELINES CARBOHYDRATE LOADING SELECTIVE MECHANICAL BOWEL PREPRATION ANTIBIOTIC AND SKIN PREPRATION THROMBOPROPHYLAXIS SELECTIVE PREMEDICATION

8. FASTING GUIDELINE Newer evidence from the anesthesiology community has shown that it is safe for patients to have solids upto 6 hours surgery and clear liquids upto 2 hours before surgery. This allows the opportunity for patients to enter surgery in metabolically fed state.

9. CARBOHYDRATE LOADING Current guidelines - complex carbohydrate drinks upto 2 hours before surgery. The administration of preoperative carbohydrate drinks, which reduces insulin resistance induced by surgical stress while reducing anxiety, It is given the evening before the surgery (for example two sachet of Preload® 50 g) and up to 2 h (one sachet) before the procedure. 50% less insulin resistance and decreased loss of muscle mass, suggesting that effects were not only limited to glucose metabolism but protein and fat metabolism as well.

10. SELECTIVE BOWEL PREPARATION Mechanical bowel preparation cleanse the colon to reduce fecal spillage and decrease the infectious complication such as wound infection and anastomotic leakage. The literature regarding bowel preparation is mixed and controversial with some studies showing no benefits and others showing benefits with bowel preparation with combined oral antibiotics. Mechanical bowel preparation leads to large preoperative fluid losses and patients potentially enter surgery in a hypovolemic state. Lead to reflexive administration of additional intravenous fluids to compensate for preoperative losses.

11. SELECTIVE BOWEL PREPRATION Several strategies advocated to minimize the routine use of mechanical bowel preparation for all patients undergoing colon and rectal resections, including use of enemas for rectal resections and omitting preparation for right sided resections entirely .

12. ANTIBIOTICS PROPHYLAXIS Antibiotic prophylaxis is considered crucial in an emergency setting because of high risk of infection, especially in case of bowel perforation and gangrene.

13. thromboprophylaxis Patients can be stratified for risk of VTE according to their age, presence or absence of other risk factors for VTE and the type of surgery that they are to undergo. Those at low risk do not need specific therapy apart from early mobilization, whereas those at moderate or higher risk should receive thromboprophylaxis .

14. THROMBOPROPHYLAXIS When thromboprophylaxis is necessary ,lower –molecular –weight heparin(LWMH) is preferred to unfractionated heparin(UFH) b because it has less tendency to induce thrombocytopenia and is more conducive to once daily dosing.

15. INTRAOPERATIVE Minimal invasive surgery Fluid balance and normovolemia Active warming Locoregional anaesthesia Postoperative nausea and vomiting prophylaxis Selective drain

16. MINIMAL ACCESS SURGERY MAS is an important determinant of an ERAS protocol.,in that it to enhanced recovery and an optimal postoperative outcome. Any surgical procedure causes two types of injury Direct –Direct injury is due to incision and tissue damage from mobilization of tissues and organs Indirect injury-Indirect injury sets in with hemorrhage,anaesthetic techniques,patient positioning and creation of pneumoperitoneum with CO2.

17. Minimal access surgery In open surgical procedures,reducing the surgical wound by performing a smaller incision involving few dermatomes and myotomes decreases the surgical trauma. Intraoperative bleeding may controlled by using ultrasonic technology or electrocoagulation. A much better approach is to perform a laparoscopic procedure whenever feasible. Nevertheless,whenever possible use of MAS approach preferable in ERAS protocol. Drain usage should be limited because it impedes early mobilization and thereby proglonging recovery.

18. FLUID MANAGEMENT Hypovolemia leads to low cardiac output and decreased tissue perfusion. Hypervolemia associated with increases in morbidity,length of intensive care unit stay and post operative mortality. Acute kidney injury Major concern is that oliguria is sign of developing renal failure. As a result,surgeons and anaesthologists strive to maintain urinary output most commonly with intravenous boluses.

19. FLUID MANAGEMENT ERAS calls for a zero sum fluid balance which is obtained by Minimizing crystalloid administration. Increasing use of colloids. Use of ringer lactate , in place of normal saline to lower sodium content and decrease risk of electrolyte abnormalities. Use of vasopressors in place for crystalloid for hypotension.

20. GOAL DIRECTED FLUID THERAPY Use of minimally invasive devices such as esophageal dopplers to measure cardiac output during surgery. Patient is progressively challenged with small boluses of colloid while measuring stroke volume. An increase in >10% in stroke volume means that the patient is on point in starling curve where they are fluid responsive and thus increased fluid delivery will improve cardiac output. Progressive colloid challenges are infused until the cardiac output is less than 10%; at this point patient is considered fluid balance.

21. NORMOTHERMIA Preventing Hypothermia:Hypothermic patients have higher rate of wound infections,more cardiac morbidity and increased rates of coagulopathy. Compensatory shivering: Increases oxygen consumption and patient entering catabolic state. Use of warm infusion saline,forcedair infusion blankets,heating mattress pads and circulating garment system.

22. POST OPERATIVE No nasogastric tube and early oral feeding Early mobilization Multimodal and opioid sparing analgesia Fluid overload avoidance Early drains and catheter removal

23. Post operative Aim of post-operative care is to make patient fit for early discharge. The strategies that enable to achieve this aim are to follow ERAS protocol which recommends to

24. Avoid pain It aims on to decrease stress response/SIRS on postoperative period. Pre-op Epidural anesthesia if indicated First line analgesics- Inj Paracetamol and Inj ketorolac Second line analgesics-add Inj.Tramadol or Inj.Fentanyl Third line analgesics Inj.Fentanyl infusion or Inj.Pethidine /Morphine

25. CONTROL NAUSEA AND VOMITING Postoperative nausea and vomiting must be well controlled. This start preoperatively with risk stratification using scoring system such as the Apfel score and appropriate preoperative prophylaxis.

26. POST OPEATIVE NAUSEA AND VOMITING All patient should receive dexamethasone before induction,ondansetron at the completion of surgery and further intervention such as scopolamine poatches based on their risk stratifications. About 30-40% of post GI surgery patients encounters PONV. We should find out the underlying cause of PONV. Remove drugs that cause nausea and vomiting Use of 5-HT3 antagonists for non-obstructive pathologies NG insertion and decompression if indicated.

27. Early feeding and removal of nasogastric tube In several studies even beyond the ERAS populations,early enteral feeds have shown to beneficial and decrease overall postoperative complications. It also decreases the patient discomfort and anxiety associated with remaining without food and water ,this serves to decrease stress and decrease catabolism. Routine use of nasogastric tube should be discouraged. Not only do nasogastric tube cause patient discomfort.but they have shown to delay return of bowel function and associated with increased pulmonary complications such as atelectasis and pneumonia.

28. CHEWING GUM? Chewing gum had previously been used in an attempt to improve the postoperative recovery of bowel function. Chewing gum in the postoperative period has been described as a form of sham-feeding , whereby a food substance is chewed but does not enter the stomach. Gum is postulated to increase cephalo-vagal stimulation , leading to increased gastric motility and reduced inhibitory from sympathetic nervous system. GI hormones such as gastrin, neurotensin, cholecystokinin and pancreatic polypeptide are also increased and result in vagal stimulation of smooth muscle fibers

29. CHEWING GUM A meta-analysis of several RCTs evaluating the effect of chewing gum on postoperative ileus has subsequently been published. Although there are relatively low patients number a significant of heterogeneity of studies , chewing gum offers significant benefits by reducing the time to pass flatus and the time until first bowel movement.

30. Early mobilization and removal of drains E arly mobilization should be encouraged to prevent pulmonary complication, decreased insulin resistance, prevention of loss of muscle mass and shortened interval to return to bowel function. Immobilization is associated with risk of thromboembolism. Remove all drain as soon as it is requires(to minimize source of infections). E.g -Foley’s catheters , centeral venous catheter.

31. Outcomes/AUDIT The success of any individual ERAS program relies not just on the initial implementation of the program ,but also constant assessment of patient outcomes and program adherence. When more than 70% of the ERAS elements are followed , symptoms delaying discharge,30 day morbidity and readmissions are significantly decreased. It is important to have an ongoing audit process to ensure that goals for the program are being met .

32. THANK YOU