Post on 21-Jan-2016
transcript
How would my patient be after this surgery???
What can I do to make my patient
safe & get well soon?!?
VS
Traditional Peri-operative Care
• Poor counseling • Starved • Drowned• Stressed • Poor analgesia • Enforced bed rest• Long hospital stay
Multi-model Strategies• Anxiety/Fear• Organ dysfunction• Hypothermia• Nausea, vomiting,
ileus, semi- starvation • Hypoxemia• Sleep disturbance• Drains, NG tubes,
catheters
• Patient info• Optimise nutrition• Modify alcohol/smoking• Neuraxial blockade• Laparoscopic surgery• Normothermia• Nausea and ileus
prevention• Early enteral feeding• Undisturbed sleep• Opiate sparing analgesia
Del
ayed
Acce
lera
ted
Adapted Luff, 2003
Func
tiona
l cap
acity
Surgery
Multi-modal intervention
Traditional care
Preop WeeksTime
Days
Adapted Luff, 2003
Optimal pain relief
Perioperative fluid restriction
Early enteral nutrition
Early postoperative mobilization
Minimal use of tubes, drains, and catheters
Reduce:• stress
response• organ
dysfunction
Accelerated convalescence
Reduction of overall complications
Shorter hospital stay
Increased patient comfort
Modified W. Schwenk und J.M. Müller, 2005
Enhance
E R A S
RecoveryAfter
Surgery
Preadmission counseling
Selective bowel-prep
Short fasting/CHO- loading
No premed
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralanalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxisResume Normal Activity Sooner!!
Counseling
Preadmission counseling
Selective bowel-prep
Short fasting/CHO- loading
No premed
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxis
Preoperative Bowel Preparation
Selective bowel-prep
Short fasting/CHO- loading
No premed
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxis
Preoperative Fasting
There was no evidence to suggest a shortened fluid fast results in an increased risk of aspiration,
regurgitation or related morbidity compared with the standard ’nil by mouth from midnight’ fasting
policy.
Response to Surgery and FastingSurgery Fasting
Endocrine response• Glucagon • Insulin
Metabolic response• Glycogen breakdown • Protein breakdown • Lipolysis
Insulin resistance
Fasting further increases metabolic response to surgery
Insulin resistance is a useful metabolic marker
Preoperative Carbohydrate Loading
Preoperative Carbohydrate Loading
- Attenuate stress response - Improve insulin resistance- Reduce recovery time
Short fasting/CHO- loading
No premed
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxis
Premedication
• Avoid long-acting agent • Benzodiazepine(Short-acting: Midazolam)• Beta-Blocker• Alpha2-agonist
Premedication
• Beta-Blockers
– ↓circulating catecholamine
– ↓perioperative cardiovascular events
– ↑hemodynamic stability
– ↑faster emergence & ↓postoperative side effects
– ↑facilitate the resumption of normal activities
Premedication
• Alpha2-agonist
– ↓the use of opioid analgesics, PONV and
intraoperative blood loss
– ↓ the duration of paralytic ileus (IV clonidine +
Epidural clonidine)
– ↑facilitate glycemic control
– ↓reduce myocardial ischemia
No premed
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxis
Thromboembolic Prophylaxis
• LMWH• UFH
• Thromboembolism-deterrent stockings
Antimicrobial Prophylaxis
• 1 hour prior to skin incision• Prolonged cases (>3 hours)• Second-generation cephalosporin and
metronidazole
Surgical Technique
VS
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxis
Standard Anesthetic Protocol
GA VS RA
Standard Anesthetic Protocol
• General anesthesia
• Short acting- agents
• Less-soluble volatile anesthetics
• The beta -blocking drugs
• Short or intermediate NMBDs
• Sugammadex
Standard Anesthetic Protocol
Preventing Hypothermia
Fluids
WET IS BEST
Fluids
TRADITIONAL
BALANCED
4-6L2-3L
2-3L 1-2L
OPERATION POST-OPERATION
2-4d
1-2d3-6kg
Positive salt and water balance sufficient to cause a 3 kg weight gain after surgery delays return of gastrointestinal function and prolongs hospital stay in patients undergoing
elective colonic resection.
Fluids
BALANCED IS BETTERWET IS BEST
Fluids
Relative Intravascular Hypovolemia
Fluid loading
Epidural Anesthesia
Vasopressor
• Transesophageal Doppler
Fluids
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Nasogastric Intubation
• For evacuation air
• Increased GER
• Remove before reversal of anesthesia
• Delayed bowel function
Drainage
No NG tubes
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Preventing and Treating PONV
• Multimodal strategies– Multi antiemetic drugs– Propofol and local anesthetic-based analgesic
techniques– Minimizing opioid use– Adequate hydration– Beta-blocker or alpha2-agonist – Nonpharmacological techniques
Preventing and Treating PONV
• Risk Factors
– Female
– Non-smoker status
– Hx of PONV / Motion sickness
–Postoperative opioid use/intraoperative use
of volatile or high dose opioid technique
Preventing and Treating PONV
• Moderate risk (= 2factors) -
– Dexamethasone(induction) – or serotonin receptor antagonist
• High risk (= 3factors)– General anesthesia with propofol and remifentanil– Dexamethasone +– Serotonin receptor antagonists / droperidol
/metoclopramide
Postoperative Analgesia
• Epidural Analgesia• Acetaminophen• NSAIDS• Opioids ??
Standard mobilization
Non-opial oralAnalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Prevention Of Postoperative Ileus
Promote postoperative bowel function
Intravenous Opioid Analgesia
Laparoscopy
Oral Alviopan
Oral magnesium oxide
Midthoracic Epidural Analgesia
Fluid overloading
Postoperative Nutritional Care
Postoperative Early Enteral Nutrition
Early Mobilization
Traditional Care Day 1
ERAS Day 1
Preadmission counseling
Selective bowel-prep
Short fasting/CHO- loading
No premed
No NG tubes
Thoracic epidural anesthesia
Short-acting anesthetic agents
Avoidance ofSodium/fluid
overload
Short incisions/surgical technique
Warm air bodyheating in
theatre
Standard mobilization
Non-opial oralanalgesics/NSA IDs
Prevention of nausea and vomiting
Stimulation of gut mobility
Early removal ofcatheters/drains
Perioperativeoral nutrition
Audit of compliance/outcomes
ERAS
Core Protocol
Thromboembolic prophylaxis
Antimicrobial prophylaxis
GOOD JOB..GOOD OUTCOME…AND GOOD BYE…