ENHANCE RECOVERY AFTER SURGERY

1. ERAS PROTOCOL
Enhance Recovery After Surgery
Dr Asik Hossain Mallick,
JR, 1ST Year

2. Back To The Past
PREOPERATIVE PROLONG FASTING
MECHANICAL BOWEL PREPARATION
NASOGASTRIC TUBE
DRAIN TUBE, [ in any GIT surgery ]
PROLONG BED REST

3. Evolution of Surgical Principles replaces the dogma
and brought the concept of
THIS CONCEPT WAS FIRST
DESCRIBED BY Dr Henrik Kehlet [1990]
E R A S

4. ERP
• Integrated, Evidence Based,
Multimodal,Consensus on perioperative care

5. ERAS GOAL
1 Reduction of stress response to surgery
2 Accleration of Recovery

6. Team Member of successfull ERP
• NURSES
• DIETITIANS
• PHYSIOTHERAPIST
• PAIN MANAGEMENT TEAM
• ANESTHETIST
• SURGEON
• HOSPITAL MANAGEMENT
• AUDIT TEAM

7. ERP COMPONENT
PRE
ADMISSION
•OPTIMISATION
•COUNSELLING
•ORAL SUPPLIMENT
•Peri operative nutrition
PRE
OPERATIVE
• Admission on day of surgery
• Pre op nutrition
• Reduce preoperative fasting
and carbohydrate loading
• Selective bowel preparation
• Prophylaxis of DVT and
Antibiotic
• Perioperative opoid sparing
analgesic
Anesth
esia
• Normothermia
•Thoracic epidural anesthesia
and short acting anesthetic gas
• Avoid fluid overload
• Non opiate analgesia
SURGICAL
• Approach-
Laproscopic/Transverse
incision/Short incision
• Avoid surgical Drain And
Nasogastric tube
POST
OPERATIVE
• Hydration
•Active Multimodal PAIN
Control
• Aggressive Management
of Nausea vomiting
• Early oral feeding and
Mobilisation
• Nutritional support
• Catheter Drain Omit

8. ERP –KEY ELEMENT
• 1. Pre Admission Counselling
Clear explanation regarding
hospitalisation
Role of patient about food intake,
nutrition supplement,

9. ERP –KEY ELEMENT
2. Pre operative nutrition
In adequate nutrition independly increase risk and hospital stay
ESPN criteria[european society of parenteral and enteral nutrition] of severe
nutritional risk
weight loss> 10-15%.
BMI <18.5
Serum Albumin<30 gm/lit
MANAGEMENT:
Appropriate input
Standerd whole protein liquid nutritional
supplement

10. ERP –KEY ELEMENT
• 3 Admission on day of surgery
• 4 Reduction of Prolong Fasting
as NPO:
increases thirst
no gurentee of empty stomach
very less impact upon gastric volume
PROLONG Fasting stress glucose & insulin resistence

11. ERP –KEY ELEMENT
• 5 CARBOHYDRATE LOADING
Tissue injury
Hypovolemia HPA AXIS CORTISOL Gluconeogeneasis
INFECTION
Hypoxia
weight loss
BETA CELL BLOCK
INSULIN PRODUCTION
Management:
Clear carbohydrate drink the day prior to surgery up to 2 hr before surgery
acclerate recovery and reduce hospital stay

12. ERP –KEY ELEMENT
6 .Selective bowel preparation
Avoid MBP
6 Hr Fast for solid and Particulate food
Clear fluid until 2 hr before induction

13. ERP –KEY ELEMENT
• 7.PREVENTION OF POST OP ILEUS
Normal GI peristalsis is maintained by
1. Enteric Bowel handling & surgical stress
2. CNS opioid
3Hormonal influence intra op fluid overload

14. POST OP ILEUS MANAGEMENT
1 Epidural anaesthesia
2 Non opiate analgesia
3 Avoid short term NSAID
4 Minimal invassive surgery
5 Gentle tissue handling
5 Avoidance of fluid overload
avoid Na and Fluid overload
Oesophageal Doppler monitoring
6 Early feeding
7 Use of chewing gum
presence of sorbitol and hexitol
saliva &pancreatic secretion
cephalovagal stimulation
8 Early Mobilisation
Bed rest insulin resistance

15. ERP –KEY ELEMENT
AVOIDANCE OFNASOGASTRIC TUBE
Increases risk of ATELECTASIS
FEVER
PNEUMONIA
THORACIC EPIDURAL ANAESTHESIA
Decreases GA risk
Block Stress hormone release

16. ERP –KEY ELEMENT
• SHORT ACTING ANESTHETIC AGENT
PROPOFOL, Remifentanyl
Short acting inhalational agent
NORMOTHERMIA
Hyperthermia causes dehydration
Hypothermia increase risk of
bleeding
wound infection
tranfusion requirment

17. ERP –KEY ELEMENT
• AVOID Drain tube
increases hospital stay
increase risk of infection
PREVENTION OF PONV[POST OP NAUSEA & VOMITING]
ONDENSATRON

18. ERP –KEY ELEMENT
• DISCHARGING CRITERIA
Good pain control
Solid food intake
Independendly mobile or same level as prior to
admission willing to go home

19. Thank you