This document discusses the role of anesthesiologists in Enhanced Recovery After Surgery (ERAS) protocols. ERAS protocols use evidence-based perioperative strategies to speed patient recovery after surgery through decreased complications, length of stay, readmissions and faster return to daily living. The anesthesiologist plays a key role in optimizing patient care through the preoperative, intraoperative and postoperative periods by utilizing techniques like carbohydrate loading, multimodal pain management, early mobilization and rehabilitation. Proper implementation of ERAS requires a team-based approach and anesthesiologist leadership to coordinate perioperative care and improve surgical outcomes.
General anesthesia & obstetrics- c-section part ISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
This document discusses complications that can arise from regional anesthesia. It covers nerve injuries, infections, systemic toxicity from local anesthetics, and issues related to anticoagulation. Specific complications covered include nerve injuries from peripheral nerve blocks, infections from continuous perineural catheters, cardiac and neurological toxicity from local anesthetics, and challenges with anticoagulated patients. Prevention strategies and management approaches are provided.
Acute pain management & preemptive analgesia (3)DR SHADAB KAMAL
This document discusses acute pain management and pre-emptive analgesia. It defines acute pain as pain caused by actual or potential tissue damage that is usually nociceptive in nature. Acute pain management primarily deals with patients recovering from surgery or acute medical conditions. Pre-emptive analgesia aims to prevent central neural sensitization by administering analgesics before a painful stimulus occurs, which can reduce both acute postoperative pain and the risk of chronic postsurgical pain. The document outlines various treatment approaches for acute pain management, including opioids, non-opioid analgesics, regional anesthetic techniques, and multimodal analgesia.
The document discusses the Enhanced Recovery After Surgery (ERAS) protocol. ERAS aims to optimize patient care and recovery through a multidisciplinary, evidence-based approach. It challenges traditional practices like prolonged preoperative fasting and use of drains. The ERAS protocol incorporates recommendations across the preoperative, intraoperative and postoperative periods. This includes carbohydrate loading, minimal fasting, optimized fluid management, multimodal analgesia, early nutrition and mobilization to reduce complications and length of stay while improving outcomes.
This document discusses chronic pain after surgery. It begins with introducing chronic pain as persisting more than 3 months and impacting quality of life. Surgery is recognized as a common cause of chronic pain in pain clinics. The pathophysiology involves central sensitization. Risk factors include surgical technique and nerve injury. Prevention strategies encompass regional anesthesia, preemptive analgesia, and adjuvant drugs like ketamine, gabapentin, and pregabalin. The summary reiterates that perioperative pain can lead to central sensitization and chronic postsurgical pain, while regional blocks may reduce this risk for some surgeries.
This document provides an overview and update on issues in neuroanesthesia. It discusses recurrent issues such as patient positioning, monitoring, fluid management and more that have not changed significantly over time. It also reviews cerebral physiology concepts like blood flow regulation and the effects of anesthetic agents. The document outlines current surgical trends like minimally invasive procedures and equipment trends like intraoperative CT. It concludes by emphasizing the importance of multidisciplinary team training to continually improve neuroanesthesia care.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
Update in anesthesia for non obstetric surgery in pregnencymamunur1
1) Non-obstetric surgery during pregnancy presents challenges as the anesthetist must care for both the pregnant woman and fetus. Regional anesthesia is preferred when possible to minimize fetal drug exposure.
2) The goals of anesthesia management are to optimize maternal physiology and uteroplacental blood flow, avoid unwanted drug effects on the fetus, and prevent preterm labor. General principles include fluid management, thromboprophylaxis, and fetal monitoring.
3) Laparoscopy can be performed safely during any trimester with low pneumoperitoneum pressures and fetal monitoring. Cardiac and neurosurgery also require careful management of hemodynamics and oxygen delivery to maintain uteroplacental perfusion.
General anesthesia & obstetrics- c-section part ISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
This document discusses complications that can arise from regional anesthesia. It covers nerve injuries, infections, systemic toxicity from local anesthetics, and issues related to anticoagulation. Specific complications covered include nerve injuries from peripheral nerve blocks, infections from continuous perineural catheters, cardiac and neurological toxicity from local anesthetics, and challenges with anticoagulated patients. Prevention strategies and management approaches are provided.
Acute pain management & preemptive analgesia (3)DR SHADAB KAMAL
This document discusses acute pain management and pre-emptive analgesia. It defines acute pain as pain caused by actual or potential tissue damage that is usually nociceptive in nature. Acute pain management primarily deals with patients recovering from surgery or acute medical conditions. Pre-emptive analgesia aims to prevent central neural sensitization by administering analgesics before a painful stimulus occurs, which can reduce both acute postoperative pain and the risk of chronic postsurgical pain. The document outlines various treatment approaches for acute pain management, including opioids, non-opioid analgesics, regional anesthetic techniques, and multimodal analgesia.
The document discusses the Enhanced Recovery After Surgery (ERAS) protocol. ERAS aims to optimize patient care and recovery through a multidisciplinary, evidence-based approach. It challenges traditional practices like prolonged preoperative fasting and use of drains. The ERAS protocol incorporates recommendations across the preoperative, intraoperative and postoperative periods. This includes carbohydrate loading, minimal fasting, optimized fluid management, multimodal analgesia, early nutrition and mobilization to reduce complications and length of stay while improving outcomes.
This document discusses chronic pain after surgery. It begins with introducing chronic pain as persisting more than 3 months and impacting quality of life. Surgery is recognized as a common cause of chronic pain in pain clinics. The pathophysiology involves central sensitization. Risk factors include surgical technique and nerve injury. Prevention strategies encompass regional anesthesia, preemptive analgesia, and adjuvant drugs like ketamine, gabapentin, and pregabalin. The summary reiterates that perioperative pain can lead to central sensitization and chronic postsurgical pain, while regional blocks may reduce this risk for some surgeries.
This document provides an overview and update on issues in neuroanesthesia. It discusses recurrent issues such as patient positioning, monitoring, fluid management and more that have not changed significantly over time. It also reviews cerebral physiology concepts like blood flow regulation and the effects of anesthetic agents. The document outlines current surgical trends like minimally invasive procedures and equipment trends like intraoperative CT. It concludes by emphasizing the importance of multidisciplinary team training to continually improve neuroanesthesia care.
CPSP is a new emerging disease but can be a silent epidemic.
Optimal perioperative management may reduce the incidence of CPSP.
Minimal invasive surgical techniques
Agressive perioperative multimodal analgesia, inluding epidural or nerve blocks.
Appropriate management of acute pain is therefore not only a humane obligation, but also may prevent of chronic pain!
Update in anesthesia for non obstetric surgery in pregnencymamunur1
1) Non-obstetric surgery during pregnancy presents challenges as the anesthetist must care for both the pregnant woman and fetus. Regional anesthesia is preferred when possible to minimize fetal drug exposure.
2) The goals of anesthesia management are to optimize maternal physiology and uteroplacental blood flow, avoid unwanted drug effects on the fetus, and prevent preterm labor. General principles include fluid management, thromboprophylaxis, and fetal monitoring.
3) Laparoscopy can be performed safely during any trimester with low pneumoperitoneum pressures and fetal monitoring. Cardiac and neurosurgery also require careful management of hemodynamics and oxygen delivery to maintain uteroplacental perfusion.
This document discusses acute perioperative pain management. It defines pain and its classification, and explains why treating pain is important for patient outcomes and recovery. It covers pain assessment methods, non-pharmacological and pharmacological treatment options including the WHO analgesic ladder and multimodal analgesia. Specific pain medications like acetaminophen, NSAIDs, opioids, gabapentin and regional anesthesia techniques are described. Management of side effects and opioid overdose is also summarized.
Preventive analgesia:
Broader definition of preemptive analgesia
Perioperative analgesic regimen that able to control pain-induced sensitization
Not the timing of the analgesic treatment but the duration and efficacy of an analgesic intervention are more important for an effective postoperative pain relief
Adequate preventive analgesia should include multimodal techniques and with a sufficient duration of tretment
Enhanced recovery after surgery (eras)Sanjay Dange
This document outlines the components of an Enhanced Recovery After Surgery (ERAS) protocol presented by Dr. Sanjay Dange. The goals of ERAS are to decrease postoperative stress, maintain physiological function, and enable early mobilization to reduce recovery time and length of stay without increasing complications. Key elements include preoperative education and optimization, minimally invasive surgery when possible, goal-directed fluid management, multimodal analgesia including epidural anesthesia, early feeding and mobilization within 24 hours of surgery.
A presentation by Kim Ekelund at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Postoperative pain is harmful and leads to both acute and chronic negative effects if poorly controlled. A multimodal approach to pain management is recommended, utilizing both pharmacological and non-pharmacological techniques. This includes the use of opioids, non-opioid analgesics like NSAIDs and gabapentinoids, and regional analgesic techniques such as epidurals, peripheral nerve blocks, and trigger point injections to provide superior pain relief with fewer side effects than systemic opioids alone. The goal is to control pain and facilitate early recovery after surgery.
The document discusses the history and current practices of pain management during childbirth. It notes that historically, childbirth pain was seen as divine punishment. Non-pharmacological techniques like acupuncture and hypnosis were used. Queen Victoria popularized using chloroform for pain relief in the 1800s. Now, over 90% of women receive some form of analgesia, mainly neuraxial techniques like epidurals that are considered very safe when administered properly. The document provides details on various analgesic options and their risks and benefits.
This document provides information about total intravenous anesthesia (TIVA). It begins with a definition of TIVA as a technique of general anesthesia that uses intravenous agents exclusively without inhalational gases.
It then discusses the history of TIVA, types of TIVA, indications, advantages, disadvantages, common drugs used and their properties, drug combinations, and methods of administration including single syringe, manually controlled infusion, target controlled infusion, and closed loop systems. Specific TIVA protocols, dosages, and drug mixtures are also outlined. The document aims to provide an overview of TIVA for educational purposes.
This document provides information on brachial plexus nerve blocks. It discusses the various techniques for brachial plexus blocks including interscalene, supraclavicular, infraclavicular, and axillary blocks. The advantages of nerve blocks are outlined as avoidance of general anesthesia, early recovery, and excellent postoperative pain relief. Potential complications include nerve injury, local anesthetic toxicity, hematoma, and diaphragmatic paralysis. Proper patient preparation and use of ultrasound or nerve stimulation techniques can help accurately place the local anesthetic and minimize complications.
The document discusses anesthesia considerations for orthopedic joint replacement surgeries, which are commonly performed in elderly patients. It outlines various challenges in caring for geriatric patients including co-morbidities and decreased organ function. However, improvements in monitoring, techniques, analgesia, and early mobilization have led to better outcomes. The document compares regional versus general anesthesia and discusses intraoperative concerns like blood loss, hypotension from bone cement, and fat embolism. Postoperative concerns include pain, delirium, hypoxemia, and infection risk, emphasizing the need for multimodal pain control and early mobilization.
Fast Track surgery from the orthopedic point of view
How to apply FTS in orthopedics specially in Arthroplasty surgery. Evidence based practice in orthopedics
This document discusses anesthesia considerations for orthopedic surgery. It begins by outlining the learning objectives which are to describe general considerations and goals related to orthopedic surgery, specific considerations and their anesthetic implications, and special orthopedic conditions. It then discusses pre-operative, intra-operative, and post-operative goals and considerations including patient positioning, bone cement implantation syndrome, pneumatic tourniquets, fat embolism, deep vein thrombosis, and regional anesthesia techniques.
This document discusses patient selection criteria and preoperative assessment and preparation for ambulatory anesthesia. It covers suitable procedures, duration limits, patient characteristics, contraindications, preoperative evaluation, and both nonpharmacologic and pharmacologic preparation. For patient selection, it recommends considering factors like procedure type, duration, medical history, age and contraindications. It also discusses anxiolysis, sedation, preemptive analgesia and preventing nausea for premedication. The goal is to safely perform procedures as outpatients and facilitate early recovery.
Olle Ljungqvist discussed improving perioperative care worldwide through the ERAS Society. He summarized evidence showing variations in outcomes between countries and hospitals, and how implementing ERAS guidelines can reduce variations and complications. Sustaining ERAS requires a multidisciplinary team approach, ongoing training, and continuous auditing to maintain compliance over time. While complex to implement initially, ERAS has been shown to reduce costs and complications globally when properly established.
The ERAS protocol was developed in 2001 to improve surgical recovery through evidence-based practices. It utilizes a multidisciplinary team and multimodal interventions including preoperative education and carbohydrate loading, intraoperative fluid management and opioid-sparing techniques, and postoperative early nutrition, ambulation and defined discharge criteria. Implementation of ERAS has been shown to reduce length of hospital stay by 35-40% and complications rates while lowering healthcare costs. While initially developed for colorectal surgery, ERAS has been applied to other specialties and demonstrated benefits but faces barriers to widespread adoption including resistance to changing traditional practices.
The document discusses the role of anesthesiologists in Enhanced Recovery After Surgery (ERAS) protocols, which are multimodal perioperative care pathways designed to achieve early recovery after surgery through interventions in the preoperative, intraoperative, and postoperative periods to minimize physiological stress and complications. Key anesthesiologist interventions include opioid-sparing anesthesia, regional analgesia, fluid management, prevention of hypothermia and nausea/vomiting, and avoiding unnecessary tubes or lines. ERAS protocols have been shown to reduce complications, hospital stay, and improve quality of life outcomes compared to traditional care.
Fetal surgery involves procedures performed on fetuses while still in the uterus to treat conditions that could cause irreversible harm if left untreated. For a condition to be considered for fetal surgery, it must cause ongoing damage that can be mitigated by early intervention and occur before the fetus can survive outside the womb. Fetal surgery can be open or minimally invasive. Open fetal surgery requires general anesthesia for the mother and high concentrations of volatile anesthetic agents to achieve uterine relaxation, while minimally invasive techniques use local anesthesia. Proper maternal anesthesia management and fetal monitoring are needed to balance risks to the mother and fetus.
The post operative period begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon. The post operative care is provided by – PACU
Capt Shoaib Bin kashem shares his experience with paediatric anaesthesia at Dhaka Shishu (Children) Hospital, the largest children's hospital in Bangladesh. Key points:
- Children have different anatomy, physiology, pharmacology and psychology compared to adults which impacts anaesthesia. Their airways are smaller and more susceptible to obstruction.
- Monitoring and equipment must be appropriately sized for paediatric patients. Uncuffed endotracheal tubes are generally preferred for children under 8 years old.
- Drug dosing is weight-based and many medications are more potent in paediatric patients due to differences in metabolism and distribution. Regional anaesthesia is commonly used.
- Perioperative fluid management and
The document discusses ambulatory and fast-track anesthesia. It notes the growth of ambulatory surgery from less than 10% to over 70% of elective procedures. Benefits include patient preference, efficiency and lower costs. Suitable procedures include dental, dermatological, gynecological, orthopedic and others less than 3 hours. Patient selection focuses on ASA I-III. Preparation includes education, anxiolysis and preemptive analgesia/anti-emetics. General anesthesia, regional techniques and MAC are described.
This document discusses anesthesia considerations for functional endoscopic sinus surgery (FESS). It notes that general anesthesia is typically used to provide an immobile surgical field and airway protection. Techniques to minimize bleeding include controlled hypotension, use of propofol, positioning, preoperative steroids, local vasoconstrictors, normothermia, and careful extubation using techniques like intravenous lidocaine to reduce coughing. The LMA is an alternative to endotracheal intubation that provides less airway protection but better hemodynamics and recovery.
This document discusses acute perioperative pain management. It defines pain and its classification, and explains why treating pain is important for patient outcomes and recovery. It covers pain assessment methods, non-pharmacological and pharmacological treatment options including the WHO analgesic ladder and multimodal analgesia. Specific pain medications like acetaminophen, NSAIDs, opioids, gabapentin and regional anesthesia techniques are described. Management of side effects and opioid overdose is also summarized.
Preventive analgesia:
Broader definition of preemptive analgesia
Perioperative analgesic regimen that able to control pain-induced sensitization
Not the timing of the analgesic treatment but the duration and efficacy of an analgesic intervention are more important for an effective postoperative pain relief
Adequate preventive analgesia should include multimodal techniques and with a sufficient duration of tretment
Enhanced recovery after surgery (eras)Sanjay Dange
This document outlines the components of an Enhanced Recovery After Surgery (ERAS) protocol presented by Dr. Sanjay Dange. The goals of ERAS are to decrease postoperative stress, maintain physiological function, and enable early mobilization to reduce recovery time and length of stay without increasing complications. Key elements include preoperative education and optimization, minimally invasive surgery when possible, goal-directed fluid management, multimodal analgesia including epidural anesthesia, early feeding and mobilization within 24 hours of surgery.
A presentation by Kim Ekelund at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Postoperative pain is harmful and leads to both acute and chronic negative effects if poorly controlled. A multimodal approach to pain management is recommended, utilizing both pharmacological and non-pharmacological techniques. This includes the use of opioids, non-opioid analgesics like NSAIDs and gabapentinoids, and regional analgesic techniques such as epidurals, peripheral nerve blocks, and trigger point injections to provide superior pain relief with fewer side effects than systemic opioids alone. The goal is to control pain and facilitate early recovery after surgery.
The document discusses the history and current practices of pain management during childbirth. It notes that historically, childbirth pain was seen as divine punishment. Non-pharmacological techniques like acupuncture and hypnosis were used. Queen Victoria popularized using chloroform for pain relief in the 1800s. Now, over 90% of women receive some form of analgesia, mainly neuraxial techniques like epidurals that are considered very safe when administered properly. The document provides details on various analgesic options and their risks and benefits.
This document provides information about total intravenous anesthesia (TIVA). It begins with a definition of TIVA as a technique of general anesthesia that uses intravenous agents exclusively without inhalational gases.
It then discusses the history of TIVA, types of TIVA, indications, advantages, disadvantages, common drugs used and their properties, drug combinations, and methods of administration including single syringe, manually controlled infusion, target controlled infusion, and closed loop systems. Specific TIVA protocols, dosages, and drug mixtures are also outlined. The document aims to provide an overview of TIVA for educational purposes.
This document provides information on brachial plexus nerve blocks. It discusses the various techniques for brachial plexus blocks including interscalene, supraclavicular, infraclavicular, and axillary blocks. The advantages of nerve blocks are outlined as avoidance of general anesthesia, early recovery, and excellent postoperative pain relief. Potential complications include nerve injury, local anesthetic toxicity, hematoma, and diaphragmatic paralysis. Proper patient preparation and use of ultrasound or nerve stimulation techniques can help accurately place the local anesthetic and minimize complications.
The document discusses anesthesia considerations for orthopedic joint replacement surgeries, which are commonly performed in elderly patients. It outlines various challenges in caring for geriatric patients including co-morbidities and decreased organ function. However, improvements in monitoring, techniques, analgesia, and early mobilization have led to better outcomes. The document compares regional versus general anesthesia and discusses intraoperative concerns like blood loss, hypotension from bone cement, and fat embolism. Postoperative concerns include pain, delirium, hypoxemia, and infection risk, emphasizing the need for multimodal pain control and early mobilization.
Fast Track surgery from the orthopedic point of view
How to apply FTS in orthopedics specially in Arthroplasty surgery. Evidence based practice in orthopedics
This document discusses anesthesia considerations for orthopedic surgery. It begins by outlining the learning objectives which are to describe general considerations and goals related to orthopedic surgery, specific considerations and their anesthetic implications, and special orthopedic conditions. It then discusses pre-operative, intra-operative, and post-operative goals and considerations including patient positioning, bone cement implantation syndrome, pneumatic tourniquets, fat embolism, deep vein thrombosis, and regional anesthesia techniques.
This document discusses patient selection criteria and preoperative assessment and preparation for ambulatory anesthesia. It covers suitable procedures, duration limits, patient characteristics, contraindications, preoperative evaluation, and both nonpharmacologic and pharmacologic preparation. For patient selection, it recommends considering factors like procedure type, duration, medical history, age and contraindications. It also discusses anxiolysis, sedation, preemptive analgesia and preventing nausea for premedication. The goal is to safely perform procedures as outpatients and facilitate early recovery.
Olle Ljungqvist discussed improving perioperative care worldwide through the ERAS Society. He summarized evidence showing variations in outcomes between countries and hospitals, and how implementing ERAS guidelines can reduce variations and complications. Sustaining ERAS requires a multidisciplinary team approach, ongoing training, and continuous auditing to maintain compliance over time. While complex to implement initially, ERAS has been shown to reduce costs and complications globally when properly established.
The ERAS protocol was developed in 2001 to improve surgical recovery through evidence-based practices. It utilizes a multidisciplinary team and multimodal interventions including preoperative education and carbohydrate loading, intraoperative fluid management and opioid-sparing techniques, and postoperative early nutrition, ambulation and defined discharge criteria. Implementation of ERAS has been shown to reduce length of hospital stay by 35-40% and complications rates while lowering healthcare costs. While initially developed for colorectal surgery, ERAS has been applied to other specialties and demonstrated benefits but faces barriers to widespread adoption including resistance to changing traditional practices.
The document discusses the role of anesthesiologists in Enhanced Recovery After Surgery (ERAS) protocols, which are multimodal perioperative care pathways designed to achieve early recovery after surgery through interventions in the preoperative, intraoperative, and postoperative periods to minimize physiological stress and complications. Key anesthesiologist interventions include opioid-sparing anesthesia, regional analgesia, fluid management, prevention of hypothermia and nausea/vomiting, and avoiding unnecessary tubes or lines. ERAS protocols have been shown to reduce complications, hospital stay, and improve quality of life outcomes compared to traditional care.
Fetal surgery involves procedures performed on fetuses while still in the uterus to treat conditions that could cause irreversible harm if left untreated. For a condition to be considered for fetal surgery, it must cause ongoing damage that can be mitigated by early intervention and occur before the fetus can survive outside the womb. Fetal surgery can be open or minimally invasive. Open fetal surgery requires general anesthesia for the mother and high concentrations of volatile anesthetic agents to achieve uterine relaxation, while minimally invasive techniques use local anesthesia. Proper maternal anesthesia management and fetal monitoring are needed to balance risks to the mother and fetus.
The post operative period begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon. The post operative care is provided by – PACU
Capt Shoaib Bin kashem shares his experience with paediatric anaesthesia at Dhaka Shishu (Children) Hospital, the largest children's hospital in Bangladesh. Key points:
- Children have different anatomy, physiology, pharmacology and psychology compared to adults which impacts anaesthesia. Their airways are smaller and more susceptible to obstruction.
- Monitoring and equipment must be appropriately sized for paediatric patients. Uncuffed endotracheal tubes are generally preferred for children under 8 years old.
- Drug dosing is weight-based and many medications are more potent in paediatric patients due to differences in metabolism and distribution. Regional anaesthesia is commonly used.
- Perioperative fluid management and
The document discusses ambulatory and fast-track anesthesia. It notes the growth of ambulatory surgery from less than 10% to over 70% of elective procedures. Benefits include patient preference, efficiency and lower costs. Suitable procedures include dental, dermatological, gynecological, orthopedic and others less than 3 hours. Patient selection focuses on ASA I-III. Preparation includes education, anxiolysis and preemptive analgesia/anti-emetics. General anesthesia, regional techniques and MAC are described.
This document discusses anesthesia considerations for functional endoscopic sinus surgery (FESS). It notes that general anesthesia is typically used to provide an immobile surgical field and airway protection. Techniques to minimize bleeding include controlled hypotension, use of propofol, positioning, preoperative steroids, local vasoconstrictors, normothermia, and careful extubation using techniques like intravenous lidocaine to reduce coughing. The LMA is an alternative to endotracheal intubation that provides less airway protection but better hemodynamics and recovery.
This document discusses ambulatory and fast track anesthesia. It covers topics such as the benefits of ambulatory surgery including lower costs and greater efficiency. It describes different facility designs for ambulatory surgery and lists many common procedures that can be done on an outpatient basis. The document outlines considerations for patient selection and preoperative preparation including pharmacologic and non-pharmacologic techniques. It also discusses various anesthetic techniques for ambulatory surgery like general anesthesia, regional anesthesia, and monitored anesthesia care. Fast tracking approaches to minimize side effects like PONV are also summarized.
The document discusses postoperative care and chest complications. It covers several key points:
1) Respiratory complications occur in up to 15% of major surgeries and can negatively impact outcomes through increased mortality, morbidity, hospitalization duration, and costs.
2) Patients face respiratory risks in the immediate postoperative period from issues like atelectasis, pulmonary edema, and respiratory failure due to changes in lung volumes and function.
3) Preventing postoperative pulmonary complications requires evaluating patient risk factors, optimizing pre- and postoperative pulmonary status through measures like smoking cessation, treating infections, and encouraging deep breathing exercises.
Summary:
Regional anesthetic techniques are increasing in popularity because of the improved recovery profiles
Intravenous adjuvants can provide patient comfort
Titrated infusion of rapid and short acting sedative drugs should enhance patient safety
Vigilant monitoring, supplemental oxygen, and the availability ressucitation equipment are strongly recommended
Prevention of complications of general anaesthesia post abdominalAkhilaNatesan
This document discusses the effects of general anesthesia on respiratory function after abdominal surgeries and methods to prevent postoperative pulmonary complications (PPCs). General anesthesia can cause restrictive lung defects from reduced lung volumes and mucociliary dysfunction. It also decreases respiratory muscle function. Physiotherapists can assess risk factors for PPCs and implement prehabilitation with exercise and breathing techniques to improve lung function before surgery. Post-surgery, early mobilization, chest physiotherapy, and incentive spirometry help rehabilitate respiratory function and prevent clinically significant PPCs.
- Laparoscopic surgery utilizes carbon dioxide insufflation to create space in the abdomen for visualization, but this causes various physiological effects.
- General anesthesia with endotracheal intubation is the standard to allow ventilatory control and protect the airway during positioning.
- Potential complications include hemodynamic issues, pulmonary complications from gas absorption or positioning, and injuries related to surgical instrumentation or patient positioning. Close communication with the surgeon is important if complications occur to potentially reduce intra-abdominal pressure or convert to an open procedure.
This document provides an overview of critical care management for patients in an Intensive Care Department (ICD). It discusses admission procedures, monitoring, daily clinical management, and specific organ system support that may be required including circulatory, respiratory, renal, gastrointestinal, hepatic, and neurological support. Mechanical ventilation, tracheostomy, renal replacement therapy, sedation, and management of conditions like delirium are also covered.
Preoperative preparation in surgical patientsOwoyemiOlutunde
The document outlines principles of preoperative preparation, including:
1. The goal is to stratify surgical risk and optimize patient medical status through detailed evaluation, testing, and treatment of comorbidities.
2. Key aspects of preparation involve assessing cardiac, pulmonary, nutritional, and other organ system risks and instituting interventions to reduce risks of perioperative complications.
3. Preparation requires a multidisciplinary approach including medical optimization, counseling, and consent to improve surgical outcomes.
This document discusses the anesthetic management considerations for laparoscopic surgery. Some key points include: carbon dioxide is used to create pneumoperitoneum during laparoscopy due to its solubility in blood; positioning and carbon dioxide absorption can affect hemodynamics and respiration; careful fluid management and monitoring are important due to physiologic effects; and complications may include subcutaneous emphysema, capnothorax, or cardiovascular issues if not properly managed. A multimodal approach is recommended to minimize complications and optimize outcomes.
The document discusses a clinical trial that evaluated the effects of treating ARDS patients with the neuromuscular blocking agent (NMBA) cisatracurium for 48 hours. The randomized, double-blind study of 340 ARDS patients found that those receiving cisatracurium had improved oxygenation and a decreased trend in ICU mortality compared to controls. However, the primary outcome of reduced 90-day mortality was not statistically significant between the groups. The authors conclude that NMBAs may provide clinical benefits for ARDS, but further research is still needed.
This document discusses the role of anesthesiologists during cath lab procedures and the types of anesthesia used. It outlines the necessary equipment, medications, monitoring, and considerations for different procedures. Anesthesiologists must plan carefully with cardiologists and be prepared to manage airways and treat potential complications while patients are sedated or anesthetized for cath lab exams and interventions.
Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection that prolongs mechanical ventilation and ICU stays. It has a high mortality rate of 20-50%. Risk factors include prolonged mechanical ventilation, supine positioning, and use of sedatives. Diagnosis is difficult due to non-specific signs. New tools like LUPPIS aim to aid early diagnosis. Prevention strategies recommended by guidelines include early mobility, oral care, subglottic secretion drainage, and selective decontamination in some settings.
This document outlines key aspects of anaesthesia including definitions, pre-operative management, induction, intraoperative management, special patient circumstances, and regional anaesthesia. Pre-operative management involves assessment, optimization of medical conditions, preparation including premedication, and management of fasting state and fluid balance. Induction methods include intravenous and inhalational agents. Intraoperative monitoring standards are outlined. Special considerations are given to patients with full stomach, shock, head injury, or airway obstruction. Regional anaesthesia techniques like spinal, epidural and peripheral nerve blocks are also discussed.
Daycare surgery involves operations where the patient is discharged on the same day. General anaesthesia is commonly used, while central neuraxial blocks are discouraged due to delayed discharge from motor block. Local and plexus blocks are good options. Anaesthetic goals include smooth onset, adequate intraoperative analgesia/amnesia, and rapid recovery. Common daycare surgeries include hernia repair, hemorrhoidectomy, laparoscopic procedures, otoplasty, and cystoscopy. Monitored anaesthesia care involves anaesthesiologist oversight during planned procedures. Non-operating room anaesthesia presents challenges due to unfamiliar environments but can be addressed through thorough patient evaluation, appropriate monitoring, and careful planning for procedures such as cardiac catheter
How do I safely ventilate my patient inOT.pptxchandra talur
There are several key points regarding safe ventilation of patients in the operating theatre:
1. Mechanical ventilation can cause harm if not done properly, so the goal is to open just enough lung to provide adequate oxygen while avoiding ventilator-induced lung injury.
2. Large tidal volumes, low PEEP, and high FiO2 have been shown to increase the risk of postoperative pulmonary complications, so a lung protective strategy is recommended.
3. Surrogates like plateau pressure, driving pressure, and static compliance can help assess lung stress and strain in the absence of direct measurements and guide ventilation settings to prevent overdistention and volutrauma.
Procedural sedation and analgesia (PSA) involves using short-acting sedatives and analgesics to enable medical procedures while closely monitoring the patient. It is commonly performed by emergency clinicians and other specialists. PSA aims to reduce pain and anxiety while allowing procedures to be performed effectively. Key considerations include patient assessment, informed consent, appropriate practitioner training and experience, monitoring, equipment, medications, and responding to potential complications. Common medications used for PSA include propofol, etomidate, ketamine, and short-acting opioids, with the choice dependent on the specific situation and patient characteristics.
Post anaesthesia discharge criteria and complicationsssuserd0f8ec
The document discusses standards of post-anesthesia care in the post-anesthesia care unit (PACU), including continually monitoring patients' vital signs, oxygenation, and level of consciousness. It also covers potential physiological disorders that can manifest in the PACU, such as respiratory complications, hemodynamic instability, and residual neuromuscular blockade. Guidelines for safe discharge from the PACU include using standardized scoring systems to evaluate patients' status and readiness for discharge.
This document discusses day case or ambulatory surgery. It notes that over the last 30 years, there has been rapid expansion in the use of day-case surgery, with the percentage of patients going home the same day increasing from less than 10% to approximately 65%. Suitable procedures are those that take less than 90 minutes, do not cause excessive bleeding or pain, and have minimal postoperative physiological disturbances. The growth of ambulatory surgery has been facilitated by improved anesthetic techniques and shorter-acting drugs that allow for faster recovery.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Travel Clinic Cardiff: Health Advice for International TravelersNX Healthcare
Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Nano-gold for Cancer Therapy chemistry investigatory projectSIVAVINAYAKPK
chemistry investigatory project
The development of nanogold-based cancer therapy could revolutionize oncology by providing a more targeted, less invasive treatment option. This project contributes to the growing body of research aimed at harnessing nanotechnology for medical applications, paving the way for future clinical trials and potential commercial applications.
Cancer remains one of the leading causes of death worldwide, prompting the need for innovative treatment methods. Nanotechnology offers promising new approaches, including the use of gold nanoparticles (nanogold) for targeted cancer therapy. Nanogold particles possess unique physical and chemical properties that make them suitable for drug delivery, imaging, and photothermal therapy.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Spontaneous Bacterial Peritonitis - Pathogenesis , Clinical Features & Manage...Jim Jacob Roy
In this presentation , SBP ( spontaneous bacterial peritonitis ) , which is a common complication in patients with cirrhosis and ascites is described in detail.
The reference for this presentation is Sleisenger and Fordtran's Gastrointestinal and Liver Disease Textbook ( 11th edition ).
Debunking Nutrition Myths: Separating Fact from Fiction"AlexandraDiaz101
In a world overflowing with diet trends and conflicting nutrition advice, it’s easy to get lost in misinformation. This article cuts through the noise to debunk common nutrition myths that may be sabotaging your health goals. From the truth about carbohydrates and fats to the real effects of sugar and artificial sweeteners, we break down what science actually says. Equip yourself with knowledge to make informed decisions about your diet, and learn how to navigate the complexities of modern nutrition with confidence. Say goodbye to food confusion and hello to a healthier you!
“Psychiatry and the Humanities”: An Innovative Course at the University of Mo...Université de Montréal
“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal Expanding the medical model to embrace the humanities. Link: https://www.psychiatrictimes.com/view/-psychiatry-and-the-humanities-an-innovative-course-at-the-university-of-montreal
The Children are very vulnerable to get affected with respiratory disease.
In our country, the respiratory Disease conditions are consider as major cause for mortality and Morbidity in Child.
1. ERAS :
THE ROLE OF
ANESTHESIOLOGIST
S
Susilo Chandra
Department of Anesthesiology and Intensive Care
Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo Hospital
2. “Enhanced Recovery After Surgery (ERAS) protocols are
combinations of evidence based peri-operative
strategies which work synergistically to markedly speed
recovery after surgery.
3. ENHANCE RECOVERY
AFTER SURGERY
➤ Decreased
perioperative
complications
➤ Decreased length of
stay
➤ Reduced postop
readmission rates
➤ Early return to daily
living
➤ Reduced healthcare
cost
4. Pre-Operative
Counselling and Training Reduced fasting and
preoperative carbohydrate
loading
Avoidance of mechanical
bowel preparation
Deep Vein Thrombosis
Prophylaxis
Antibiotic Prophylaxis
High Inspired
Oxygen
Concentrations
Preventive Hypothermia
Goal Directed Intra-
Operative Fluid Therapy
Surgical Approach
and Incisions
Avoidance of Post-
Operative Drains and
Nasogastric Tubes
Short Duration of
Epidural
Analgesia and
Local Blocks
Multimodal
Analgesia
Early post-operative Diet
Early postoperative
Mobilization
Restricted amounts of
Intravenous Fluids
Audit
ERACS
6. PREOPERATIVE ASSESSMENT
➤ Screening and optimization of comorbidities
➤ Assessment of chronic medication use
➤ Beta-blocker, ACE inhibitor, anti-platelet drugs, anti-
coagulants, anti-diabetic drugs, statins
➤ Education and psychological preparation of the patient
➤ Reduced anxiety and fear
➤ Improved patient satisfaction
9. PREOPERATIVE CARBOHYDRATE
LOADING
➤ Major surgery induces numerous metabolic changes, including
insulin resistance -> hyperglycemia
➤ Preoperative carb loading modifies insulin resistance,
improves patient comfort and well being, minimizes protein
losses, and improve postoperative muscle function
➤ Key aspect of “enhanced recover” protocols
➤ Does not increase the risk of pulmonary aspiration
➤ Reduced length of stay and complications
10. PREOPERATIVE LAB TESTS
➤ Routine screening tests = no clinical benefit
➤ Preop period is not for screening asymptomatic disease
➤ Unnecessary tests -> anxiety, increased delays and
cancellations, potential harm, increased costs, false-negative
or false-positive results
➤ Should be guided by clinical status, comorbidity and
invasiveness of surgical procedures
11. PREMEDICATION : AVOID
BENZODIAZEPINE
➤ Avoid routine preop sedative-hypnotics, include in patients
with significant anxiety
➤ Increased cognitive dysfunction
➤ Increased pharyngeal/laryngeal dysfunction
➤ Midazolam to reduce awareness? No evidence
16. NEUROMUSCULAR BLOCKADE
➤ Residual paralysis in postop period is frequent and difficult to
recognize clinically
➤ TOF < 0.9 increases postoperative complications and ICU
admission
➤ Avoid/minimize muscle relaxants
➤ Reverse blockage unless there is unequivocal evidence of
adequate function
➤ Neostigmine dose based on the degree of blockade
17.
18. OPIOID
➤ Opioid reduce propofol
dose synergistically
(~40-80%)
➤ Ceiling effect
➤ Moderate opioid doses
reduce MAC
synergistically (~75%)
Type to enter a caption.
19. FRONT LOADING OPIOIDS
➤ Not acceptable
➤ Increases post-induction
hypotension
➤ Increases potential for acute
tolerance
20. MECHANICAL VENTILATION
➤ Optimal lung protective ventilation
➤ Low TV 6-8 ml/kg
➤ PEEP 5-10 cmH2O
➤ Initial respiratory rate 8x/min
➤ Maintain ETCO2 ~ 40 mmHg
➤ Mild hypercapnia will improve tissue O2
➤ Improved respiratory function
➤ Reduced lung and systemic inflammation
21. FLUID THERAPY
➤ Excessive fluid = increased morbidity and mortality
➤ Avoid fluid administration based upon static indicators
➤ Goal-directed fluid therapy
➤ Follow up postop
26. EMERGENCE CONSIDERATIONS
➤ Primary aim = Washout
inhaled anesthetic, not build-
up CO2
➤ Pressure support ventilation
to maintain FRC
➤ Nasal ventilation is more
superior
➤ Semi-upright (30-40 deg)
position
– Liang Y et al: Anesthesiology 2008; 108: 998
• Semi-upright (30-40o) position
27. FAST TRACK REHABILITATION
➤ Avoid tubes, catheters, drains, restrictions
➤ Early mobilization and physical therapy
➤ Optimize pain relief
➤ Respiratory therapy
➤ Improve sleep
➤ Early oral feeding
➤ Early detection of complications
28.
29. SUMMARY
➤ ERAS improves outcomes and
recovery
➤ Involves pre, intra and postop
➤ Anesthesiologists should take
leadership in development and
implementation of clinical
pathway
➤ Communication and team
work
Protokol ERAS pertama kali diperkenalkan oleh Profesor Henrik Kehlet di Denmark pada tahun 1990. Penerapan lanjutan protokol ini telah berkembang lebih jauh pada operasi abdomen, thorax dan vaskular. Protokol ERAS telah dievaluasi dan terbukti dapat menurunkan lama waktu perawatan hingga 30 persen, dan menurunkan angka komplikasi hingga 50 persen.
ERAS mencakup berbagai protokol panduan tatalaksana perawatan perioperatif, dirancang untuk mencapai perbaikan pasca operasi yang cepat, dengan cara menjaga fungsi organ perioperatif dan mengurangi respon stress pasca operasi. Faktor utama dalam protokol ERAS mencakup konseling pra operasi, optimalisasi pemberian nutrisi , pemberian analgesia dan anestesia yang baku, serta mobilisasi dini. Melalui penerapan protokol ERAS, diharapkan dapat dicapai kualitas kesembuhan pasien yang baik, penurunan angka kejadian komplikasi pasca operasi, pemendekan lama rawat pasien (length of stay) dan penurunan biaya perawatan pasien.
Seiring dengan perkembangan ilmu pengetahuan pengobatan bersadarkan kepada bukti (evidence based medicine), dikembangkanlah protokol tatalaksana pasien dengan harapan meningkatkan kualitas hasil pengobatan pasien, terutama terkait dengan penilaian kualitas hidup dan pembiayaan pengobatan lanjutan.
Pendekatan ERAS dalam evaluasi preoperatif ditujukan untuk menurunkan angka komplikasi perioperatif, mengurangi lama perawaran, menurunkan angka readmisi, meningkatkan waktu pulih pasien dan menurunkan cost perawatan di rumah sakit.
Pendekatan ERAS dimulai sejak kunjungan praoperatif. Berbagai penilaian risiko dilakukan sejak dini yang bertujuan untuk mengoptimalkan keadaan pasien sebelum operasi. Persiapan juga dilanjutkan menjelang operasi dengan puasa yang cukup dan pemberian loading karbohidrat Sebelum operasi. Tatalaksana intraoperatif yang baik juga membutuhkan kerjasama yang baik antara dokter spesialis anestesiologi dan dokter bedah.
Terdapat berbagai macam metode dalam menilai risiko pembedahan perioperatif. Hal ini dapat dikaitkan dengan jenis pembedahan ataupun pasien sendiri mengenai risiko serta outcome yang dapat dinilai dalam tindakan operasi elektif. Faktor risiko terkait jenis pembedahan termasuk prosedur pembedahan itu sendiri dan apakah prosedur tersebut dilakukan dalam keadaan elektif atau darurat.
Penggunaan obat-obatan kronik sebaiknya dilakukan pencatatan dengan baik. Hal ini terutama pada pasien geriatri dengan polifarmasi, dimana dapat ditemukan interaksi obat antara satu dengan yang lainnya. Penggunaan obat kronik harus dicatat dengan baik dalam rekam medik pasien untuk mengurangi risiko interaksi obat.
Edukasi dan persiapan psikis pasien juga sebagiknya dilakukan semenjak penilaian preoperatif. Hal ini dimaksudnya untuk mengurangi rasa cemas dan takut pasien dan pada akhirnya meningkatan kepuasan pasien terhadap prosedur yang akan dilakukan.
Konsep prehabilitasi diperkenalkan untuk meningkatan kekuatan otot preoperatif. Hal ini ditujukan untuk menurunkan disabilitas pascaoperasi. Selain melatih sistem muskuloskeletal, prehabilitasi juga dilakukan pada sistem organ lain, termasuk sistem kardiovaskular. Nutrisi pasien juga diperbaiki sebelum pasien menjalani operasi sehingga pasien berada dalam kondisi paling optimal Sebelum dilakukan operasi.
Konsep prehabilitasi dilakukan dengan berbagai cara : latihan fisik, perbaikan status nutrisi, suplementasi protein, dan teknik mengatas ansietas. Data menyebutkan bahwa prehabilitasi dapat memperbaiki kapasitas fungsional pada pasien yang menjalani bedah kolorektal. Grafik di atas menunjukkan bahwa pada pasien yang dilakukan prehabilitas sebelum operasi dapat kembali ke keadaan dasar sebelum dilakukan prehabilitas pada 8 minggu pascaoperasi. Sedangkan pada pasien yang tidak mendaptkan prehabiliasi belum dapat kembali ke baseline pada 8 minggu setelah operasi.
Proses pembedahan menyebabkan respon stres yang dapat mengakibatkan berbagai perubahan hormonal dan metabolik, termasuk salah satunya resistensi insulin. Hal ini dapat menyebabkan hiperglikemia yang reaktif terhadap stres pembedahan. Protokol ERAS memperkenalkan konsep pemberian loading karbohidrat 2 jam preoperasi. Pemberian karbohidrat ini dalam bentuk cair yang dapat dikonsumsi pasien Sebelum operasi.
Loading karbohidrat dapat memodifikasi resitensi insulin, meningkatkan rasa nyaman dan keamanan pasien, mengurangi hilangnya protein intraoperatif dan meningkatkan fungsi otot.
Loading karbohidrat ini disebut sebagai salah satu bagian penting dari protokol ERAS. Pemberian loading karbohidrat ini merupakan
Pemeriksaan penunjang merupakan hal yang cukup rutin dilakukan sebelum tindakan operasi. Bahkan banyak pemeriksaan penunjang yang sering dilakukan berulang kali walaupun tidak ada tanda dan gejala klinis yang mendukung. Protokol ERAS menyebutkan bahwa pemeriksaan skrining rutin tidak memiliki keuntungan yang bermakna. Selain itu disebutkan bahwa pemeriksaan preoperatif tidak ditujukan untuk penyakit asimptomatik.
Pemeriksaan penunjang yang berlebihan menambah ansietas, meningkatkan delay dan angka pembatalan serta menyebabkan “harm”. Selain itu pada pasien dengan jaminan kesehatan tentunya pemeriksaan penunjang yang berlebihan menyebabkan biaya yang sangat besar. Hasil false negative atau false positive juga dapat mempengaruhi persiapan preoperatif.
Permintaan pemeriksaan preoperatif sebaiknya dilakukan sesuai dengan kebutuhan, status klinis dan komorbiditas pasien berdasarkan anamnesis dan pemeriksaan fisik. Selain itu tidakan operasi yang akan dilakukan juga dapat menjadi dasar pemilihan pemeriksaan penunjang.
Pasien yang akan menjalani pembedahan pada umumnya mengalami kondisi anxietas. Kondisi ini memiliki korelasi terhadap intepretasi dan persepsi nyeri pasca operasi. Pemberian obat-obat anxiolisis dapat dipertimbangkan melalui penialaian praoperatif. Pemberian anxiolitik dan anallgesia dengan waktu paruh singkat dapat diberikan untuk memfasilitasi tindakan regional anestesia dan insersi jalur intravena. Pemberian benzodiazepin kerja singkat harus dihindari pada pasien usia lanjut/geriatri. Pemberian sedasi dan opioid dg paruh waktu lam harus dihindari karena dapat mengganggu penyembuhan, memperlama mobilisasi pasca operasi,menyembabkan pemanjangan waktu rawat pasien.
Komponen penting yang disebutkan dalam protokol ERAS untuk intraoperatif adalah balanced anesthesia. Komponen yang termasuk didalamnya Adalah stabilitas hemodinamik, ditandai dengan pemeriksaan monitoring yang sesuai standar, relaksasi otot, serta lack of recall, yang ditandai dengan monitor kedalaman anestesia.
Salah satu isu yang menjadi masalah pasca anestesia umum adalah adanya efek residu dari obat anestesia. Residu obat dapat menyebabkan waktu pulih sadar yang lebih lama dari prosedur anestesia yang dapat menyebabkan durasi waktu pulih di PACU atau readmisi di ICU lebih tinggi. Residu obat anestesia yang berlebihan juga dapat mengganggu patensi jalan nafas, meningkatkan disfungsi faring dan risiko aspirasi. Selain itu hal ni juga dapat menyebabkan penurunan respons ventilasi terhadap adanya hipoksia atau hiperkarbia. Hal ini tentunya akan mengakibatkan instabilitas hemodinamik pasien pascaoperasi.
Penggunaan pelumpuh otot pada tindakan pembedahan dalam protokol ERAS mendapatkan porsi perhatian tersendiri. Penelitian terbaru pada teknik pembedahan laparoskopik menyebutkan penggunaan pelumpuh otot bertujuan untuk mejaga kedalaman anestesia dan menciptakan kondisi yang optimal untuk pembedahan. Namun, penggunaan NMB dalam jumlah besar dimana tidak terdapat sediaan sugamadex, dapat meningkatkan risiko terjadinya paralisis residu. Pada pasien yang menjalani pembedahan terbuka abdomen, penggunaan pelumpuh otot tidak terlalu dibutuhkan. Pencapaian level analgesi yang adekuat lebih mampu memberikan kemudahan untuk mendapatkan lapangan pandang operasi yang lebih baik.
Penilaian kondisi bebas pelumpuh otot pada akhir pembiusan penting untuk dilakukan karena paralisis otot residual dapat menyebakan ketidakcukupan perspirasi, hipoksia, aspirasi hingga distres nafas. Pada khirnya dapar menyebabkan gangguan mobilisasi dini. Hipotermia terbukti juga dapat mempengaruhi lama metabolism obat pelumpuh otot dan menyebabkan pemanjangan lama kerja obat dan waktu pulih dari pelumpuh otot. Beberapa penelitian menunjukkan bahwa uji klinis dan penilaian kuantitatif fungsi neuromuscular (TOF, simulasi tetani) tidak cukup dan tidak dapat diandalkan untuk mendeteksi rekurarisasi residual, bahkan ketika digunakna sugamadex sebagai agen reversal.
Penggunaan opioid juga sebaiknya diberikan dengan pertimbangan sesuai kebutuhan pasien. Opioid terbukti dapat menurunkan dosis propofol dan MAC gas secara sinergistik. Opioid disebutkan memiliki ceiling effect yang menjadi salah satu hal yang unik dalam pemberian opiod.
Salah satu konsep yang disebutkan adalah mengenai pemberian opioid dosis tinggi di awal untuk mengurangi nyeri pascaoperasi. Namun hal ini ternytaa tidak sesuai. Front-loading opioid ternyata dapat menyebabkan hipotensi pascainduksi yang meningkat serta dapat menyebabkan potensi toleransi akut opioid.
Pada pasien yang membutuhkan ventilasi mekanik maka hal yang perlu diperhatikan untuk proteksi paru yang optimal adalah pemberial TV 6-8 ml/kg, PEEP 5-10 cmH2O dengan initial respiratory rate 8x/min. Salah satu hal yang disebutkan juga adalah mengenai hiperkapnia ringan (~40 mmHg) yang ternyata dapat meningkatkan oksigenasi jaringan dan meningkatkan fungsi respirasi.
Tujuan dari terapi cairan perioperative adalah untuk menjaga hemostasis cairan, mencegah kelebihan cairan dan hipoperfusi organ. Pemberian cairan pra, intra dan pasca operasi harus didasarkan kepada respon masing-masing pasien dan kebutuhan secara klinis, dan bukan terpaku kepada rekomendasi tertulis. Pemberian cairan pra operasi pada pasien yang menjalani pembedahan elektif lebih dipilih melalaui jalur enteral dibandingkan dengan parenteral. Namun harus tetap mempertimbangkan kebutuhan dan kondisi klinis pasien, jenis cairan, dan kemungkinana aspirasi terutama pada pasien dengan masalah perlambatan waktu pengosongan isi lambung.
Pemberian cairan intra operatif dengan menggunakan cairan kristaloid bertujuan untuk menggantikan kekurangan cairan yang lebih didasarkan kepada hemostasis air-garam. Hal ini berbeda dengan kondisi resusitasi yaitu pemberian cairan kristaloid dengan teknik bolus yang bertujuan untuk menggantikan volume cairan ketika dijumpai kondisi dengan tanda hypovolemia, sehingga dapat memperbaikan volume intravascular dan aliran sirkulasi. Pemberian terapi cairan intraoperative harus merujuk kepada target balans cairan seimbang (hampir nol) dan harus dihindari peningkatan masa tubuh substansial hinggal 2.5 kg. Pemberian cairan intraoperative dapat menggunakan perkiraan basal rerata infus kristaloid 2-3 ml/kg/jam (pendekatan restriktif), dengan mengacu kepada komplikasi kelebihan pemberian cairan kristaloid dapat mengakibatkan risiko komplikasi pulmoner, prolong ileus, dan memanjangan waktu pulih. Cairan kristaloid isotonic seimbang menjadi pilihan utama dibandingkan dengan cairan salin 0.9%. Penggunaan cairan salin 0.9% dihubungkan dnegan peningkatan risiko hiperkloremia dan gangguan renal , pemanjangan waktu perawatan, dan peningkatan angka mortalitas dalam 30 hari perawatan. Pemberian terapi cairan intraoperative harus diberikan dengan teknik bolus yang berdasarkan kepada bukti klinis kondisi hypovolemia. Goal-directed fluid therapy (GDFT) bertujuan untuk menjaga kondisi normovolemia pasien untuk tetap pada kurva Frank-Starling mereka masing-masing, dengan mengandalkan pengukuran perubahan isi volume sekuncup (stroke volume) melalui teknik pemantauan cardiac output dengan teknik minimal invasif.
Standar tatalaksana nyeri pada pasien pasca operasi harus multimodal, evidence-based dan menggunakan regimen analgesia dengan prosedur spesifik dengan tujuan utama mendapatkan kondisi analgesi yang optimal dengan efek samping minimal dan untuk mencapai target pencapaian ERAS antara lain mobilisasi dan asupan oral dini.
Infus kontinu anestesi lokal pada luka operasi (Continuous wound infusion, CWI) pad apasien yang menjalami pembedahan abdomen terbuka terbukti dapat memberikan analgesia pasca operasi yang adekuat dan mengurangi konsumsi opioid namun pengaruhnya pada pemulihan fungsi saluran cerna masih belum diketahui. Penggunaan CWI dibandingkan dengan TEA pada pasien yang menjalani pembedahan abdomen per laparoskopik menunjukkan bahwa intensitas nyeri pasca operasi pasien pada kedua kelompok relative sama. Walaupun demikian, masih terdapt beberapa hambatan dalam penerapan teknik ini, terutama dalam hal cara pemberian.
RESULTS: All three groups had similar VAS scores during the first 48 h after surgery. Group CWI and group EA, compared with group PCIA, had lower morphine consumption (P < 0.001), less postoperative nausea and vomiting (1.20 ± 0.41 vs 1.96 ± 0.67, 1.32 ± 0.56 vs 1.96 ± 0.67, respectively, P < 0.001), earlier extubation (16.56 ± 5.24 min vs 19.76 ± 5.75 min, P < 0.05, 15.48 ± 4.59 min vs 19.76 ± 5.75 min, P < 0.01), and earlier recovery of bowel function (2.96 ±1.17dvs3.60±1.04d,2.80±1.38dvs3.60± 1.04 d, respectively, P < 0.05). The mean length of hospitalization after surgery was reduced in groups CWI (8.20 ± 2.58 dvs 10.08 ± 3.15 d,P < 0.05) and EA (7.96 ± 2.30 dvs 10.08 ± 3.15 d,P < 0.01) compared with group PCIA. All three groups had similar patient satisfaction and wound healing, but group PCIA was prone to higher sedation scores when compared with groups CWI and EA, especially during the first 12 h after surgery. Group EA had a lower mean arterial pressure within the first postoperative 12 h compared with the other two groups.
CONCLUSION: CWI with ropivacaine yields a satisfactory analgesic effect within the first 48 h after open gastrectomy, with lower morphine consumption and accelerated recovery.
PONV merupakan salah satu kondisi pasca operasi yang paling tidak nyaman dirasakan oleh pasien. Tatalaksana dan pencegahan kejadian PONV saat ini masih sangat rendah, walaupun telah di lakukan berbagai penelitian dan ulasan serta perkembangan penggunaan obat-obatan untuk tatalaksana PONV. Faktor predisposisi untuk terjadinya PONV sangat banyak. Sistem penilaian telah dikembangkan oleh Apfel dkk dengan menggunakan 4 faktor risiko, yaitu jenis kelamin wanita, riwayat gangguan keseimbangan dan PONV sebelumnya, tidak ada riwayat merokok sebelumnya dan penggunaan opioid pasca operasi. Pendekatan berbagai sisi tatalaksana PONV dalam ERAS mencakup penggunaan antiemetic dan anestesis intravena total menggunakan propofol dibangding dengan penggunaan agen anestesi volatile. Penggunaan nitrit oksida juga dihindari. Teknik regional anestesia dan penggunaan obat NSAID dalam tatalaksana nyeri pasca operasi menjadi salah satu upaya pencegahan PONV
Hal yang menjadi esensial saat proses emergens Adalah washout dari seluruh anestetik inhalasi dan menurunkan jumlah CO2 dalam tubuh. Perlu diingat bahwa residu obat anestesia dapat menyebabkan tingginya morbiditas pascaoperasi maka perlu diyakinkan bahwa pada saat tindakan selesai maka tidak ada residu obat yang masih ada.
Untuk menjaga Functional Residual Capacity maka dibutuhkan ventilasi dengan pressure support untuk menjaga ventilasi terjaga dengan baik. Salah satu jurnal menyebutkan bahwa penggunaan nasal ventilation lebih superior dibandingkan combined oral nasal ventilation pada saat anestesia umum. Posisi yang ideal pasca emergens Adalah dijaga semi-upright position.
Nyeri dan penggunaan drain menjadi salah satu pengambat mobilisasi. Oleh karena itu, idealnya terdapat tim tatalaksana nyeri khusus dalam menjalankan protokol ERAS. Analgesia epidural mampu memberikan kecukupan analgesia yang optimal setelah tindakan pembedahan abdominal atau thorakal namun memiliki hubungan yang erat dengan kejadian hipotensi dan kelemahan anggota gerak bawah. Terdapat tendensi bahwa pasien yang menjalani tirah baring lama akan mengalami hipotensi orthostatic, dan penggunaan epidural dianggap sebagai salah satu faktor yang dapat memicu. Namun, penggunaan epidural lebih sedikit menyebabkan kejadian hipotensi orthostaik dibandingkan dengan penggunaan opioid sistemik.
Mobilisasi dini merupakan salah satu komponen program ERAS dalam upaya menjaga fungsi otot, mencegah komplikasi akibat tirah baring lama, serta mengikutsertakan pasien secara aktif dalam proses penyembuhan pasca operasi.
Berikut adalah salah satu rangkuman dari protokol ERAS yang diterapkan di Johns Hopkins Hospital yang dilakukan pada pasien yang akan menjalani pembedahan kolorektal.
Protokol ERAS memiliki berbagai kelebihan yang signifikan dibandingkan praktik rutin/konvensional
Protokol ERAS membutuhkan komitmen dan kerjasama dari berbagai pihak (staf pre-admisi, dietisien, perawat, fisioterapi, petugas sosial, hingga dokter)
Informasi lebih lanjut mengenai protokol ERAS dapat di akses melalui website www.erassociety.org