1.Mandatory guidelines for taking up the case of Exploratory laparotomy 2.What is the fluid of choice? 3. Is ABG mandatory? 4. What is sepsis? Septic shock? SIRS? Severe sepsis?

1. ERAS
Enhanced recovery after
surgery
PRESENTED BY: DR M.KARTHIK EMMANUEL
MODERATOR : DR NIKHIL MUDGALKAR

2. Preoperative phase guidelines

3. Early identification of physiological derangement and
intervention
• Resuscitation and correction of underlying physiological derangement
should begin immediately and should continue during diagnostic
pathway
• Rapid assessment of the patient for physiological derangement using
a validated method such as an APACHE II scoring system
• Abnormal score should be a trigger to act immediately

5. Screen and monitor for sepsis and accompanying
physiological derangement
• All patients for emergency laprotomy should be assessed with a
validated sepsis score as early in their presentation. This should be
repeated at appropriate intervals in line with severity of signs and
sepsis risk
• If SIRS,sepsis or septic shock is diagnosed,treatment should begin
immediately in line with the surviving sepsis campaign including
measurement of lactate

6. Prompt antibiotic administration should occur
1. Signs of sepsis
2. High risk of infection
3. Peritonitis , hollow viscous perfoation
NOTE :
Delay to antibiotic administration in patients with sepsis increases mortality
Monitoring of blood lactate as a marker of risk and in monitoring of response to
resuscitation should be considered even in the absence of sepsis

8. Signs of end organ damage

11. Early imaging,surgery and source control of
sepsis
• Delay to surgery increases mortality in patients with sepsis and septic
shock. All patients with septic shock should receive source control
with surgery Or interventional radiology as soon as possible and with
in 3hrs
• For patients with sepsis without septic shock source control should
within 6hrs
NOTE:
Perform a CT scan with IV contrast as soon as possible if indicated
Acquiring a CT scan should not cause a delay to surgery if surgery is very urgent

12. Risk Assessment
• A risk score using a validated model should be performed on all the
patients prior to surgery and at the end of surgery
• The score can be used to guide pathways of care and facilitate
discussion between team members

13. Age related evaluation of frailty & cognitive
assessment
• All patients over 65yrs of age and others at high risk( cancer patients)
should be assessed for frailty using a validated frailty score & min-cog
assessment for cognitive function
• For patients who are at risk for delirium and postoperative cognitive
dysfunction take steps to keep the patients oriented &avoid drugs
known to cause harm ( Moderate evidence, strong recommendation)

15. 1 = VERY FIT
2 = FIT ( No active disease symptoms,
but are less fit than category 1)

16. 3 = MANAGING WELL ( Medical
problems are well controlled)
4 = LIVING WITH VERY MILD FRAILTY(
Not dependent on others often
symptoms limit activities)

17. 5 = LIVING WITH MILD FRAILTY ( need
help with high order instrumental
activities of daily living
6 = LIVING WITH MODERATE
FRAILTY(need help in all outside
activities & have problem with stairs)

18. 7 = LIVING WITH SEVERE FRAILTY(
completely dependent for personal
care)
8 = LIVING WITH VERY SEVERE FRAILTY

19. 9 = TERMINALLY ILL ( life expectancy <6
months)

20. REVERSAL OF ANTITHROMBOTIC
MEDICATIONS
• Strongly consider reversal of anticoagulation medications when major
surgical intervention is planned. This decision should be based on
both the patients risk of procedure related bleeding & the risk of
thromboembolism ( Moderate evidence)
• Consider platelet transfusion in patients taking antiplatelet therapy
when the planned procedural bleeding risk is high( Low evidence)

21. Assessment of venous thromboembolism risk
• Patient should be risk assessed for VTE risk on admission. If
pharmaceutical prophylaxis is not possible mechanical prophylaxis
should be used. Reassessment should occur daily postoperatively
PRE-ANESTHETIC MEDICATION – Anxiolysis and analgesia
• Sedative medication should be avoided preopeartively to avoid the risk of
micro aspiration, hypoventilation and delirium( Moderate evidence,strong
recommendation)
• Analgesia should be given to alleviate the patients pain and stress
• Multi modal opioid sparing analgesia should be titrated to maximize comfort
and minimize side effects

22. Preoperative glucose and electrolyte
management
• Hyper & hypoglycemia are the risk factors for adverse postoperative
outcomes.Preoperatively,glucose levels should be maintained at 144-
180mg/dl. A variable rate insulin infusion should be used judiciously
to maintain blood glucose in this range with appropriate monitoring
of blood glucose to avoid hypoglycemia ( Moderate evidence,weak
recommendation)
• Correction of potassium and magnesium prior to surgery should be
done using the i.v route with appropriate monitoring. However , it
should not delay the patient being taken to the operating room(
Moderate evidence, weak recommendation)

23. PREOPERATIVE NG tube
Should be considered on an individual basis assessing for the risk of aspiration
and gastric distension depending on the pathology and patient factor(
Moderate evidence, strong recommendation)
PATIENT AND FAMILY EDUCATION AND SHARED
DECISION MAKING
Patients and families should have the opportunity to
discuss(clear,concise,written informed decision with verbal patient
education) the risk with a senior physician prior to surgery( Low
evidence, strong recommendation)

24. Intra and postoperative phase guidelines

25. INTRA-ABDOMINAL DRAINS
Routine,prophylactic use of intra abdominal surgical drains is discourgaed given
a lack of evidence to their benefit in clean and clean/contaminated cases
PREVENTION OF INFECTION – Perioperative Antibiotics
1. Perioperative broad spectrum intravenous antibiotics should be
administered within 60min before skin incision unless tne patient is already
receiving appropriate antibiotic therapy.
2. Some agents such as fluoroquinolones & vancomycin require
adiministration over 1-2hrs, and therefore administration should begin if
possible within 120min
3. Local and national guidelines should be followed for choice of antibiotic
dosing and administration
4. Continuation of antibiotics should be based on pathology and
contamination during surgery

26. SKIN ASEPSIS
Preopeartive skin antisepsis with alcohol based solutions Or
chlorhexidineshould be used
FASCIAL WOUND PROTECTOR IRRIGATION & GLOVE CHANGE IN
ABDOMINAL CLOSURE
Routine use of a fascia abdominal wound protector, abdominal irrigation & new
gloves and closure instruments is recommended to reduce SSI (Moderate
evidence, strong recommendation)
RAPID SEQUENCE INDUCTION OF ANESTHESIA
To minimize the risk of aspiration after induction of anesthesia,rapid control of
the airway with intubation using a fast acting muscle relaxant such as
succinylcholine 1-2mg/kg Or rocuronium 0.9-1.2mg/kg for placement of an
endotracheal tube should be used. Drugs for induction of anesthesia should be
selected and dosed appropriately to maintain hemodynamic stability(Moderate
evidence strong recommendation)

27. MAINTENANCE ANAESTHETIC AGENT & DEPTH OF ANESTHESIA
MONITORING
There is no evidence to recommend one anesthetic agent over another for
maintenance of anesthesia
Consider using depth of anesthesia monitoring in patients over 60yrs of age at
risk of postoperative delirium and anesthesia induced hypotension
PONV REDUCTION
All patients undergoing emergency laparotomy are at high risk of PONV due to
physiological derangement and gastrointestinal insult. A multimodal approach
to reducing PONV should be utilized,minimizing triggers and opioids
TEMPERATURE MANAGEMENT
Active warming devices & warming of intravenous fluids should be used to
maintain normothermia

28. LUNG VENTILATION STRATEGY
Routine use of low tidal volume(6-8ml/kg) and PEEP <=5cm H20 with titration
according to flow volume loops and clinical evaluation is recommended
MONITORING & REVERSAL OF NMB
1. Neuromuscular blockade should be monitored to ensure adequate reversal
before endotracheal extubation
2. Reversal of NMB using a selective relaxant binding agent( if available)as
compared with neostigmine is recommended ( Moderate evidence, strong
recommendation)

29. IV FLUID & ELECTROLYTE REPLACEMENT
1. Patients should have onging treatment to correct electrolyte disturbances
throughout the Perioperative period
2. Balanced crystalloids should be used in preference to 0.9%NS for
resuscitation and to maintain intravascular volume
3. Use of arterial & or central venous pressure catheters should be considered
at an early stage to aid in physiological assessment and to deliver and titrate
vasopressors and fluid therapy
4. GDHT should be considered during surgery in high risk patients to optimize
cardiac index. A MAP of 60-65mmHg and cardiac index
>2.2L/min/m2,individualized to the patient, should be maintained during
surgery using appropriate vasopressors and inotropes as needed

30. MANAGEMENT OF BLOOD GLUCOSE
Patients should have their glucose closely monitored and controlled ( Preferably
with the use of a variable rate insulin infusion )
BLOOD PRODUCT MANAGEMENT
Transfusion of red blood cells should be restrictive( trigger Hb 7-9),with
exceptions based on individualized clinical status and comorbidities
MULTIMODAL SYSTEMIC ANALGESIA
1. Each patient should be assessed for the optimal Perioperative analgesic
regimen,considering the presence of sepsis and coagulation abnormalities
2. Multimodal management should include acetminophen and NSAIDS if there
are no contraindications
3. Use of wound cathers and Or local abdominal wall blocks and catheters
should be considered to reduce postoperatively opioid demand but may
have variable efficacy

31. • Thoracic epidural analgesia and spinal anesthesia should be used only
after assessment for sepsis and abnormal coagulation
• Hypotension necessitates appropriate monitoring, volume and
vasopressor therapy
END OF SURGERY,EVALUATION AND ET EXTUBATION
A multidisciplinary discussion at the end of surgery should be used to assess
suitability for endotracheal extubation as the risk of postoperative pulmonary
complications and reintubation is high

32. PREVENTION OF POSTOPERATIVE
PULMONARY COMPLICATIONS
• Patients who have undergone emergency laprotomy and show
evidence of hypoxemia,should receive continuous postive airway
pressure or noninvasive positive pressure ventilation rather than the
standard oxygen therapy ,if the risk of aspiration is considered to be
low. This should occur in an environment where staff are skilled in
these techniques continous physiological monitoring is available and
arterial blood gases can be sampled
• Respiratory physiotherapy involving the training & supervision of
patients sputum clearance,developing inspiratory muscle strength
and deep breathing exercises should be used in emergency
laprotomy patients in postoperative period

33. ADMISSION TO THE ICU Or HIGHER LEVEL OF
CARE POSTOPERATIVELY
• Health systems should establish protocols for determining the
appropriate location for postoperative care based on a validated
preoperative risk score,impact of the surgical procedure,ongoing
physiological instability and continuing supportive and therapeutic
requirements
POSTOPERATIVE DELIRIUM SCREENING AND PREVENTION
Patients over 65ysof age should receive regular postoperative
delirium screening. At risk patients should be managed with non-
pharmaceutical interventions such as regular orientation,sleep
hygiene approaches and cognitive stimulation to prevent delirium
and medication triggers minimized

34. CONTINUOUS OF VENOUS THROMBOEMBOLISM
RISK ASSESSMENT AND TREATMENT
• Patients should be assessed with a validated tool for VTE risk on
admission and throughout their hospital stay. If pharmacological
prophylaxis is not possible,mechanical prophylaxis should be
administered. For very high risk patients(many emergency laprotomy
patients will fall into this category),pharmacological combined with
mechanical prophylaxis should be given. Reassessment should occur
daily postoperatively

35. URINARY CATHETER REMOVAL
Urinary catheteruse should be evaluated daily and the catheter should be
removed as early as possible
PERI AND POSTOPERATIVE NG TUBE USE
NG tube use should be considered on an individual basis,taking into account the
risk of gastric stasis and aspiration related to gut dysfunction.Daily revaluation
of the need for NG should occur and it should be removed as early as possible
POSTOPERATIVE NUTRITION
1. Early tube feeding(within 24hr)should be initiated in patients in whom early
oral nutrition cannot be started and in whom oral intake will be
inadequate(<50% of caloric requirement)for more than 7days
2. If enteral feeding is contraindicated early parenteral nutrition is indicated to
mitigate the period of inadequate oral/enteral intake.Enteral or oral
nutrition may be reinitiated as gastrointestinal function recovers

36. POSTOPERATIVE ILEUS MINIMIZATION
A multifaceted approach to minimizing postoperative ileus,including minimally
invasive surgery,optimized fluid management, opioid-sparing analgesia early
mobilization,early postoperative food intake,laxative administration and
omission/early removal of NG tube
EARLY MOBILIZATION
Patients should be assisted to mobilize as soon as possible after surgery