how would my patient be after this surgery??? what can i do to make my patient safe & get well...
TRANSCRIPT
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How would my patient be after this surgery???
What can I do to make my patient
safe & get well soon?!?
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VS
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Traditional Peri-operative Care
• Poor counseling • Starved • Drowned• Stressed • Poor analgesia • Enforced bed rest• Long hospital stay
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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
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Func
tiona
l cap
acity
Surgery
Multi-modal intervention
Traditional care
Preop WeeksTime
Days
Adapted Luff, 2003
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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
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Enhance
E R A S
RecoveryAfter
Surgery
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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!!
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Counseling
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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
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Preoperative Bowel Preparation
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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
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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.
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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
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Preoperative Carbohydrate Loading
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Preoperative Carbohydrate Loading
- Attenuate stress response - Improve insulin resistance- Reduce recovery time
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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
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Premedication
• Avoid long-acting agent • Benzodiazepine(Short-acting: Midazolam)• Beta-Blocker• Alpha2-agonist
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Premedication
• Beta-Blockers
– ↓circulating catecholamine
– ↓perioperative cardiovascular events
– ↑hemodynamic stability
– ↑faster emergence & ↓postoperative side effects
– ↑facilitate the resumption of normal activities
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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
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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
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Thromboembolic Prophylaxis
• LMWH• UFH
• Thromboembolism-deterrent stockings
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Antimicrobial Prophylaxis
• 1 hour prior to skin incision• Prolonged cases (>3 hours)• Second-generation cephalosporin and
metronidazole
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Surgical Technique
VS
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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
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Standard Anesthetic Protocol
GA VS RA
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Standard Anesthetic Protocol
• General anesthesia
• Short acting- agents
• Less-soluble volatile anesthetics
• The beta -blocking drugs
• Short or intermediate NMBDs
• Sugammadex
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Standard Anesthetic Protocol
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Preventing Hypothermia
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Fluids
WET IS BEST
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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.
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Fluids
BALANCED IS BETTERWET IS BEST
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Fluids
Relative Intravascular Hypovolemia
Fluid loading
Epidural Anesthesia
Vasopressor
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• Transesophageal Doppler
Fluids
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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
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Nasogastric Intubation
• For evacuation air
• Increased GER
• Remove before reversal of anesthesia
• Delayed bowel function
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Drainage
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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
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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
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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
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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
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Postoperative Analgesia
• Epidural Analgesia• Acetaminophen• NSAIDS• Opioids ??
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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
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Prevention Of Postoperative Ileus
Promote postoperative bowel function
Intravenous Opioid Analgesia
Laparoscopy
Oral Alviopan
Oral magnesium oxide
Midthoracic Epidural Analgesia
Fluid overloading
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Postoperative Nutritional Care
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Postoperative Early Enteral Nutrition
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Early Mobilization
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Traditional Care Day 1
ERAS Day 1
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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
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GOOD JOB..GOOD OUTCOME…AND GOOD BYE…