The document outlines an Enhanced Recovery After Surgery (ERAS) protocol to improve perioperative patient care. It discusses preoperative, intraoperative, and postoperative interventions including prehabilitation, minimizing fasting times, multimodal analgesia, early mobilization and nutrition to reduce stress, complications and length of stay. Key elements are preoperative counseling and optimization, short-acting anesthesia, fluid balance, prevention of hypothermia, early removal of tubes/drains and promotion of gut motility. Special considerations for different surgeries like colorectal, rectal and liver procedures are also covered. The conclusion emphasizes communication, preparing patients physically and mentally for surgery and auditing outcomes.

1. HOW TO IMPROVE QUALITY
OF PERIOPERATIVE PATIENT
CARE BY USING ERAS:
ENHANCED RECOVERY
AFTER SURGERY
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2. INTRODUCTION
• Enhanced Recovery After Surgery (ERAS): the care delivered by surgical team
• Before
• During
• After surgery
• Multidisciplinary team: anesthesiologist, surgeons, nurses
• Designed to reduce perioperative stress, maintain postoperative physiologic
function, and accelerate recovery after surgery
• Using multimodal stress-minimizing approach reduces rate of morbidity, improves
recovery, and shortens length of stay

3. INTRODUCTION
• ERAS on general surgery:
• Elective colorectal
• Elective rectal/pelvic
• Gastrectomy
• liver
• Others:
• Gynecologic
• TKA/THA

5. PREOPERATIVE PHASE
• Preadmission counseling
• Fluid and carbohydrate loading
• No prolonged fasting
• No/selective bowel preparation
• Antibiotic prophylaxis
• Thromboprophylaxis
• No premedication

6. PREADMISSION COUNSELING
• Information
• Education
• Counseling
• Reduce anxiety and subsequent pain
• Patient-centered

7. PREOPERATIVE OPTIMIZATION
• Risk assessment
• Alcohol cessation: > 4 weeks
• Smoking cessation: > 4 weeks

8. PREOPERATIVE OPTIMIZATION:
RISK ASSESSMENT
• Heart: in cardiac and non-cardiac surgery  ASA classification
• Lung: Asthma and COPD
• Kidney: 1% of non-cardiac surgery develop AKI
• Hypertension: target at 80 = 110% baseline
• DM: blood sugar 80 – 180 mg/dL is accepted
• Anemia: Hb 6 – 10 g/dL and > 8 g/dL in higher risk are accepted
• Malnutrition: nutritional support for 7 – 10 days

9. PREHABILITATION
• Aerobic and resistance exercise together
• Protein supplement
• Relaxation strategies

10. PREVENTION OF PONV
• PONV = postoperative nausea and vomiting
• It can develop 30 – 50% postoperatively and can cause dehydration and delayed
adequate nutritional intake
• Risk factors:
• patient-related: female, Hx of motion sickness
• Anesthesia-related: TIVA, propofol, liberal use of opioids
• Surgery-related: GI surgery

11. PREVENTION OF PONV
• Use of preoperative antiemetic drugs can reduce PONV:
• First line: droperidol, ondansetron, dexamethasone
• Second line: promethazine, scopolamine, metroclopramide
• Gabapentin, pregabalin
• IV paracetamol

12. PRE-ANESTHETIC MEDICATION
• Pre-and post-operative anxiety may increase analgesic requirement
and complication rates
• Use benzodiazepine with caution in elderly
• Melatonin
• Paracetamol, NSAIDS, and gabapentinoids (gabapentin and
pregabalin) in combination

13. ANTIMICROBIAL PROPHYLAXIS AND
SKIN PREPARATION
• Hair removal does not reduce SSI – use clippers if needed
• Chlorhexidine antiseptic – reduce SSI
• IV antibiotics: 60 min prior to skin incision
• No evidence on antiseptic shower and drapes

14. FLUID AND ELECTROLYTE THERAPY
• Avoid prolonged preoperative fasting
• Patient can drink clear liquid diet up to 2 h prior to induction
• Euvolemia before induction

15. PREOPERATIVE FASTING AND
CARBOHYDRATE LOADING
• Clear liquid: 2 h
• Light meal: 6 h
• complex CHO-maltodextrin, 12.5%, 285 mOsm/kg,
800 ml in the evening before surgery and 400 ml 2–3 h
before induction of anaesthesia: reduce insulin resistance and prevent
protein breakdown
• Not proper in patients with DGE, GI motility disorder, emergency
surgery – fast for 8 h

16. INTRAOPERATIVE PHASE
• Short-acting anesthetic agents
• Mid-thoracic epidural anesthesia/analgesia
• No drains
• Avoid salt and water overload
• normothermia

17. STANDARD ANESTHETIC PROTOCOL
• Avoid benzodiazepine
• Use short-acting general anesthetic drugs
• Cerebral monitoring
• monitoring of the level and complete reversal of neuromuscular block

18. INTRAOPERATIVE FLUID AND
ELECTROLYTE THERAPY
• Most patients require crystalloid 1 – 4 ml/kg/hr to maintain fluid
homeostasis
• Avoid excessive fluid and organ hypoperfusion  euvolemia
• Near zero fluid balance should be preferred
• Inotropes should be considered in patient with poor contractility

19. PREVENTING INTRAOPERATIVE
HYPOTHERMIA
• Keep 36oC or over

20. SURGICAL ACCESS
• MIS has shown to improve and more rapid recovery, reduced general
complications, reduced incisional hernia rate reduced adhesion
• Laparoscopic, hand-assisted, robotic

21. DRAINAGE
• It used to be used for drain collection and detect anastomotic leakage
• Should not be routinely used

22. NASOGASTRIC INTUBATION
• Postoperative NG intubation should NOT be used routinely: remove
before reversal

23. POSTOPERATIVE PHASE
• Analgesia
• No NG tube
• Prevention of PONV
• Prevention of POI
• Avoid salt and water overload
• Early catheter removal
• Early oral nutrition
• Early mobilization
• Stimulation of gut motility
• Audit of compliance and outcome

24. POSTOPERATIVE ANALGESIA
• Multimodal analgesia
• Opioid sparing: reduce PONV, POI, sedation, respiratory depression
• Paracetamol and NSAIDS: basic
• Lidocaine and dexmedetomidine infusion
• Surgical site infiltration
• Epidural analgesia and TAP block

25. THROMBOPROPHYLAXIS
• Mechanical: well-fitting compression stocking and/or intermittent
pneumatic compression until discharge
• Pharmacological: LMWH OD x 28 days

26. POSTOPERATIVE
FLUID AND ELECTROLYTE THERAPY
• Near-zero fluid and electrolyte balance
• Hypotonic solution should be used (to prevent high NaCl)

27. URINARY DRAINAGE
• Use for 2 main reasons: prevention of AUR and monitoring UO
• Early removal is recommended (1-3 days)

28. PREVENTION OF POSTOPERATIVE ILEUS
• Using multimodal analgesia – limiting opioid administration
• MIS
• Eliminating NG placement
• Maintaining fluid balance
• Gum chewing – not recommend for colorectal surgery

29. POSTOPERATIVE GLYCEMIC CONTROL
• Insulin use is okay
• CDC recommended < 200 mg/dl

30. POSTOPERATIVE NUTRITIONAL CARE
• Prolonged NPO
• Increased risk of infectious complications
• Delayed recovery
• 4 h after surgery is safe

31. EARLY MOBILIZATION
• Prolonged bed rest:
• Increased pulmonary complication
• Decreased muscle strength
• Thromboembolic complication
• Insulin resistance
• For ICU, sitting and standing is suitable

32. SPECIAL CONSIDERATION IN
SPECIFIC PROCEDURES

33. COLORECTAL SURGERY
• Oral antibiotics + systemic antibiotics + mechanical bowel preparation
= reduce SSI
• Mechanical bowel preparation:
• Can cause dehydration and electrolyte imbalance
• No routine used in colon surgery but may be used in rectal surgery

34. RECTAL AND PELVIC SURGERY
• Preoperative counseling: don’t forget stoma care!!
• Role of urinary catheter removal
• Increased risk of AUR
• Risk factors of AUR: male, epidural analgesia, pelvic surgery
• Role of ‘no drain’ is still debated
• Laparoscopic surgery in benign cases

35. GASTRECTOMY
• Malnourished patients should be optimized with oral or enteral
nutrition

36. LIVER SURGERY
• malnourished patients should be optimized by oral supplement at
least 7 days or 14 days in severe malnutrition

37. CONCLUSION…
• Communication skill is important for ERAS protocol
• The patient should be both physical and mental ready for surgery
• Let’s start with shorten NPO time
• Multimodal analgesia should be used to reduce opioid use and
improve outcome of POI, PONV, early ambulation
• Audit is important to evaluate what we have done