ERAS! THE ROLE OF ANAESTHESIOLOGIST

DR.P.C.VIJAYAKUMARPRESIDENT-IAPEN- TAMILNADU CHAPTER

SOORIYA HOSPITALCHENNAI,TAMILNADU,INDIA.

TRADITIONAL PERIOPERATIVE CARE

•1.STARVE!!IATROGENIC STARVATION

2.STRESS!! INCISION,PAIN,IMMOBILIZATION

3.DROWN! DROWNING IN THE I.V.FLUIDS!

CHANGE THE TRADITION !

Enhanced recovery after surgery

Surgery Multi-modal intervention

Traditional care

Days Weeks

EVIDENCE TO SAY NO TO STARVATION!

Mendelson's syndrome

2006 saw the 60th anniversary of the publication of New York obstetrician Curtis Lester Mendelson's classic paper, ‘The aspiration of stomach contents into the lungs during obstetric anesthesia’.

Mendelson went on to show that acid was responsible for this asthma-like syndrome. He instilled into the respiratory tracts of rabbits a variety of substances including 0.1N hydrochloric acid and vomitus (both untreated and neutralized) from pregnant women.

He concluded that gastric retention of solid and liquid material is prolonged during labour, and that aspiration of vomitus into the lungs can occur while laryngeal reflexes are abolished.

‘Respiratory failure secondary to aspiration pneumonitis during anaesthesia’ became synonymous with Mendelson's syndrome, and its prevention a cornerstone of anaesthetic practice.

Key pointsResidual gastric volume (RGV) and pH (two surrogate end-points of aspiration risk) are determined by oral intake, gastric secretion and gastric emptying. A 2 h fasting interval (vs. midnight) for fluids neither increases RGV nor decreases pH.

Gastric emptying of liquids is an exponential process. The half-time for water is about 10 min. It is wrong to regard the stomach as either ‘empty’ or ‘full’, and induction of anaesthesia ‘safe’ or ‘unsafe’.

Current accepted fasting intervals for elective cases are 2 h for water and clear fluids, 4 h for breast milk, and 6 h for food (including milky drinks). ‘Nil by mouth from midnight’ has no place in modern perioperative practice.

Gastric emptying is impaired by trauma, labour and opioid analgesia. Fasting intervals assume limited importance compared with other aspects of the anaesthesia regimen (e.g. choice of airway management) in the prevention of aspiration.

The ‘top 3’ risk factors for aspiration are emergency surgery, light anaesthesia/unexpected response to stimulation and upper/lower gastrointestinal pathology.

CHO LOADING

What is it?• 100G ;12.5% ;CHO

PREVIOUS DAY NIGHT• 50G ;12.5% ;CHO 2 HOURS

BEFORE SURGERY• CHO MUST BE COMPLEX

MALTODEXTRINS AND NOT THE PLAIN GLUCOSE!!!

• NEED A COMMERSIAL FEED FOR THIS PURPOSE!

Advantages• Gives satisfaction • Decreases stress• Decrease insulin resistance• No increase in GRV• No increase in aspiration

• CAN HAVE NORMAL ORAL DIET 2 HOURS AFTER REGIONAL AND 4 HOURS AFTER GENERAL ANAESTHESIA

• DON’T EVER RESIST THE NATURAL APPETITE!

SAY NO TO PREMEDICATION

• ADMISSION ON THE DAY OF SURGERY

• NO NEED TO PREMEDICATE• SEDATIVES DELAYS RECOVERY• NO ROLE FOR PROPHYLACTIC

ANTIEMETICS• GASTRIC ACID SUPPRESSION

DELAYS APPETITE• GLYCO TAKES OUT THE

TASTE /DYSPHAGIA

PREMED• SEDATIVE

DIAZEPAM

• H2 BLOCKER/PROTON INHIBITORS RANITIDINE/OMEPERAZOLE

• ANTISIALOGOUGE ATROPINE/GLYCOPYRROLATE

PONV-PREVENTION

• PREOP RISK FACTORS MILD/MODERATE/SEVERE YOUNGER/FEMALE/OBESE/ANXIETY/MOTION SICKNESS/PREVIOUS PONV

• TIVA INSTEAD OF GA IN HIGH RISK• AVOID NARCOTICS/VOLATILES/N2O/REVERSAL• LIBERAL ANTIEMETICS

MULTIMODAL STEROIDS/5HT ANTAGONIST/METACLOPROMIDE/DOMPERIDONE

PAIN RELIEF!• REGIONAL ANALGESIA MIDTHORASIC-

T8/T9; EPIDURAL LUMBAR EPIDURAL TAB-TRANSVERSUS ABDOMINIS BLOCK

• ONLY LA ; HIGH VOLUME/LOW CONCENTRATION

• NO NARCOTICS ;PREFERABLY SHORT ACTING FENTANYL; NAUSEA/ILEUS/IMMOBILITY

• BUT CLONIDINE/DEXMED IN RA

• GENEROUS USE OF NSAIDS PARENTERAL PARACETAMOL NSAID SUPPOSITORIES

Why epidural analgesia ?

EPIDURAL MANAGEMENT• IT ATTENEUATES THE STRESS RESPONSE (TETRAD OF

ANAESTHESIA) OF SURGERY/DECREASES CATACHOLAMINES

• EPIDURAL ANALGESIA IN LAPAROSCOPIC SURGERIES????

• MANAGE HYPOTENTION WITH VASOPRESSORS

• DON’T INFUSE MORE VASOPRESSORS

• USE LESS FLUID CHALLENGES

• AVOID LIMB PARESIS

• BALANCE ANALGESIA AND HYPOTENTION

INTRA-OP HYPOTHERMIA

HYPOTHERMIA PREVENTION• TEMPERATURE

MONITORING• HYPOTHERMIA MORE

COMMON WITH REGIONAL ANAESTHESIA

• O.T ROOM TEMPERATURE• EXTERNAL WARMER• FLUID WARMER

ILL EFFECTS OF HYPOTHERMIA • INFECTION• POST OP SHIVERING/STRESS• BLEEDING• MI• ARRYTHMIA

EARLY MOBILIZATION

• WALKING EPIDURAL• SEGMENTAL EPIDURAL WITH PRESERVED

BLADDER SENSATION• NO SEDATIVES• NO NARCOTICS

HIGH INSPIRED OXYGEN 80%-BAG&MASK

• OXYGEN IS REQUIRED BY IMMUNE CELLS TO PRODUCE FREE RADICALS-A DEFENCE AGAIST PATHOGENS

• NEED FOR COLLAGEN SYNTHESIS / ANGIOGENESIS

• IMPROVES ANASTAMOTIC HEALING• DECREASE SURGICAL SITE INFECTIONS• REDUCE PONV

NO DROWNING IN SURGERY!!

GOAL DIRECTED INTRAOP FLUID THERAPY

• EXCESS FLUIDS DELAYS GUT FUNCTION/CARDIAC MORBIDITY

• LiDCO/PICCO DEVICES/OESOPHAGEAL ECHO

• CO/SV/TLW ARE THE GOAL PARAMETERS

• MINIMAL GOALS-UO/MAP/CVP

• POST OP FLUIDS NOT MORE THAN 2.5 L/DAY

RESUSCITATION ELECTIVE SURGERY

WET IS BEST BALANCED IS BETTER

MAINTAIN I/O CHART AVOID POSITIVE BALANCE

=

POISON

9g Sodium Chloride = 36 Bags of Chips,or 1L Bag of Saline

The ability of the patient to get rid of the accumulated sodium is greatly curtailed in the postop period!

THE VERDICT ON SALINECompared with balanced crystalloids, saline use is associated with:• Increased mortality1

• Hyperchloremic acidosis1,2,3,4

• Adverse effects on the kidney1,2

• Increased morbidity1

• Increased resource consumption1

• DELAYED GUT FUNCTION-PARALYTIC ILEUS

1. Shaw AD, et al., Ann Surg. 2012 May; 255(5):821-9 2. Chowdhury AH et al. Ann Surgery 2012 ;256(1):18-24 3: McFarlane C. & Lee A . Anaesthesia 1994;49:779-81.4: Hadimioglu N. et al. Anesth Analg. 2008;107:264-9

The future of IV Fluid Management: Balanced Crystalloids

HOW DO I LIMIT IV FLUIDS/SODIUM?

TAKE THE DRIP DOWN ON THE

FIRST POST-OP DAY

LET US SEE WHEATHER THIS FIRE WORKS!

THANK YOU!!

T