ERAS! THE ROLE OF ANAESTHESIOLOGIST
-
Upload
perundurai-vijayakumar -
Category
Healthcare
-
view
159 -
download
0
Transcript of ERAS! THE ROLE OF ANAESTHESIOLOGIST
![Page 1: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/1.jpg)
ERAS! THE ROLE OF ANAESTHESIOLOGIST
DR.P.C.VIJAYAKUMARPRESIDENT-IAPEN- TAMILNADU CHAPTER
SOORIYA HOSPITALCHENNAI,TAMILNADU,INDIA.
![Page 2: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/2.jpg)
TRADITIONAL PERIOPERATIVE CARE
![Page 3: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/3.jpg)
•1.STARVE!!IATROGENIC STARVATION
![Page 4: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/4.jpg)
2.STRESS!! INCISION,PAIN,IMMOBILIZATION
![Page 5: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/5.jpg)
3.DROWN! DROWNING IN THE I.V.FLUIDS!
![Page 6: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/6.jpg)
CHANGE THE TRADITION !
![Page 7: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/7.jpg)
Enhanced recovery after surgery
Surgery Multi-modal intervention
Traditional care
Days Weeks
![Page 8: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/8.jpg)
EVIDENCE TO SAY NO TO STARVATION!
![Page 9: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/9.jpg)
Mendelson's syndrome
2006 saw the 60th anniversary of the publication of New York obstetrician Curtis Lester Mendelson's classic paper, ‘The aspiration of stomach contents into the lungs during obstetric anesthesia’.
Mendelson went on to show that acid was responsible for this asthma-like syndrome. He instilled into the respiratory tracts of rabbits a variety of substances including 0.1N hydrochloric acid and vomitus (both untreated and neutralized) from pregnant women.
He concluded that gastric retention of solid and liquid material is prolonged during labour, and that aspiration of vomitus into the lungs can occur while laryngeal reflexes are abolished.
‘Respiratory failure secondary to aspiration pneumonitis during anaesthesia’ became synonymous with Mendelson's syndrome, and its prevention a cornerstone of anaesthetic practice.
![Page 10: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/10.jpg)
![Page 11: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/11.jpg)
Key pointsResidual gastric volume (RGV) and pH (two surrogate end-points of aspiration risk) are determined by oral intake, gastric secretion and gastric emptying. A 2 h fasting interval (vs. midnight) for fluids neither increases RGV nor decreases pH.
Gastric emptying of liquids is an exponential process. The half-time for water is about 10 min. It is wrong to regard the stomach as either ‘empty’ or ‘full’, and induction of anaesthesia ‘safe’ or ‘unsafe’.
Current accepted fasting intervals for elective cases are 2 h for water and clear fluids, 4 h for breast milk, and 6 h for food (including milky drinks). ‘Nil by mouth from midnight’ has no place in modern perioperative practice.
Gastric emptying is impaired by trauma, labour and opioid analgesia. Fasting intervals assume limited importance compared with other aspects of the anaesthesia regimen (e.g. choice of airway management) in the prevention of aspiration.
The ‘top 3’ risk factors for aspiration are emergency surgery, light anaesthesia/unexpected response to stimulation and upper/lower gastrointestinal pathology.
![Page 12: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/12.jpg)
CHO LOADING
What is it?• 100G ;12.5% ;CHO
PREVIOUS DAY NIGHT• 50G ;12.5% ;CHO 2 HOURS
BEFORE SURGERY• CHO MUST BE COMPLEX
MALTODEXTRINS AND NOT THE PLAIN GLUCOSE!!!
• NEED A COMMERSIAL FEED FOR THIS PURPOSE!
Advantages• Gives satisfaction • Decreases stress• Decrease insulin resistance• No increase in GRV• No increase in aspiration
![Page 13: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/13.jpg)
• CAN HAVE NORMAL ORAL DIET 2 HOURS AFTER REGIONAL AND 4 HOURS AFTER GENERAL ANAESTHESIA
• DON’T EVER RESIST THE NATURAL APPETITE!
![Page 14: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/14.jpg)
SAY NO TO PREMEDICATION
• ADMISSION ON THE DAY OF SURGERY
• NO NEED TO PREMEDICATE• SEDATIVES DELAYS RECOVERY• NO ROLE FOR PROPHYLACTIC
ANTIEMETICS• GASTRIC ACID SUPPRESSION
DELAYS APPETITE• GLYCO TAKES OUT THE
TASTE /DYSPHAGIA
PREMED• SEDATIVE
DIAZEPAM
• H2 BLOCKER/PROTON INHIBITORS RANITIDINE/OMEPERAZOLE
• ANTISIALOGOUGE ATROPINE/GLYCOPYRROLATE
![Page 15: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/15.jpg)
PONV-PREVENTION
• PREOP RISK FACTORS MILD/MODERATE/SEVERE YOUNGER/FEMALE/OBESE/ANXIETY/MOTION SICKNESS/PREVIOUS PONV
• TIVA INSTEAD OF GA IN HIGH RISK• AVOID NARCOTICS/VOLATILES/N2O/REVERSAL• LIBERAL ANTIEMETICS
MULTIMODAL STEROIDS/5HT ANTAGONIST/METACLOPROMIDE/DOMPERIDONE
![Page 16: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/16.jpg)
![Page 17: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/17.jpg)
PAIN RELIEF!• REGIONAL ANALGESIA MIDTHORASIC-
T8/T9; EPIDURAL LUMBAR EPIDURAL TAB-TRANSVERSUS ABDOMINIS BLOCK
• ONLY LA ; HIGH VOLUME/LOW CONCENTRATION
• NO NARCOTICS ;PREFERABLY SHORT ACTING FENTANYL; NAUSEA/ILEUS/IMMOBILITY
• BUT CLONIDINE/DEXMED IN RA
• GENEROUS USE OF NSAIDS PARENTERAL PARACETAMOL NSAID SUPPOSITORIES
![Page 18: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/18.jpg)
Why epidural analgesia ?
![Page 19: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/19.jpg)
EPIDURAL MANAGEMENT• IT ATTENEUATES THE STRESS RESPONSE (TETRAD OF
ANAESTHESIA) OF SURGERY/DECREASES CATACHOLAMINES
• EPIDURAL ANALGESIA IN LAPAROSCOPIC SURGERIES????
• MANAGE HYPOTENTION WITH VASOPRESSORS
• DON’T INFUSE MORE VASOPRESSORS
• USE LESS FLUID CHALLENGES
• AVOID LIMB PARESIS
• BALANCE ANALGESIA AND HYPOTENTION
![Page 20: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/20.jpg)
INTRA-OP HYPOTHERMIA
HYPOTHERMIA PREVENTION• TEMPERATURE
MONITORING• HYPOTHERMIA MORE
COMMON WITH REGIONAL ANAESTHESIA
• O.T ROOM TEMPERATURE• EXTERNAL WARMER• FLUID WARMER
ILL EFFECTS OF HYPOTHERMIA • INFECTION• POST OP SHIVERING/STRESS• BLEEDING• MI• ARRYTHMIA
![Page 21: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/21.jpg)
![Page 22: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/22.jpg)
EARLY MOBILIZATION
• WALKING EPIDURAL• SEGMENTAL EPIDURAL WITH PRESERVED
BLADDER SENSATION• NO SEDATIVES• NO NARCOTICS
![Page 23: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/23.jpg)
HIGH INSPIRED OXYGEN 80%-BAG&MASK
• OXYGEN IS REQUIRED BY IMMUNE CELLS TO PRODUCE FREE RADICALS-A DEFENCE AGAIST PATHOGENS
• NEED FOR COLLAGEN SYNTHESIS / ANGIOGENESIS
• IMPROVES ANASTAMOTIC HEALING• DECREASE SURGICAL SITE INFECTIONS• REDUCE PONV
![Page 24: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/24.jpg)
NO DROWNING IN SURGERY!!
![Page 25: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/25.jpg)
GOAL DIRECTED INTRAOP FLUID THERAPY
• EXCESS FLUIDS DELAYS GUT FUNCTION/CARDIAC MORBIDITY
• LiDCO/PICCO DEVICES/OESOPHAGEAL ECHO
• CO/SV/TLW ARE THE GOAL PARAMETERS
• MINIMAL GOALS-UO/MAP/CVP
• POST OP FLUIDS NOT MORE THAN 2.5 L/DAY
![Page 26: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/26.jpg)
RESUSCITATION ELECTIVE SURGERY
WET IS BEST BALANCED IS BETTER
![Page 27: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/27.jpg)
MAINTAIN I/O CHART AVOID POSITIVE BALANCE
![Page 28: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/28.jpg)
=
POISON
![Page 29: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/29.jpg)
9g Sodium Chloride = 36 Bags of Chips,or 1L Bag of Saline
The ability of the patient to get rid of the accumulated sodium is greatly curtailed in the postop period!
![Page 30: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/30.jpg)
THE VERDICT ON SALINECompared with balanced crystalloids, saline use is associated with:• Increased mortality1
• Hyperchloremic acidosis1,2,3,4
• Adverse effects on the kidney1,2
• Increased morbidity1
• Increased resource consumption1
• DELAYED GUT FUNCTION-PARALYTIC ILEUS
1. Shaw AD, et al., Ann Surg. 2012 May; 255(5):821-9 2. Chowdhury AH et al. Ann Surgery 2012 ;256(1):18-24 3: McFarlane C. & Lee A . Anaesthesia 1994;49:779-81.4: Hadimioglu N. et al. Anesth Analg. 2008;107:264-9
The future of IV Fluid Management: Balanced Crystalloids
![Page 31: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/31.jpg)
HOW DO I LIMIT IV FLUIDS/SODIUM?
TAKE THE DRIP DOWN ON THE
FIRST POST-OP DAY
![Page 32: ERAS! THE ROLE OF ANAESTHESIOLOGIST](https://reader037.fdocuments.net/reader037/viewer/2022110122/55a83f6c1a28ab824f8b4805/html5/thumbnails/32.jpg)
LET US SEE WHEATHER THIS FIRE WORKS!
THANK YOU!!
T