ENHANCED RECOVER AFTER SURGERY

ENHANCED

RECOVER AFTER

SURGERYIMPROVED

SAFETY

DISCLOSURES

TELEFLEX CONSULTANT AND ADVISORY BOARD

B BRAUN CONSULTANT AND ADVISORY BOARD

NO DIRECT CONFLICTS

10/13/2018

Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major

abdominal surgery. West Islip, NY Professional Communication Inc. 2016.

3

Redo

Start in your area

Add more areas

HOURHAPPY

Implement

C-Sections

START

Corner

SlotEDUCATE

FREE

TURN

TEAM

Design

Protocols

Provide

Updates

specific

procedure

Enhanced Recovery

10/13/2018

• The concept of enhanced recovery started 1990s with FAST TRACKING.

• The ERAS Society in Europe was formed in 2010.

• The first international ERAS Society Congress was held in France in 2012.

• In the United States (US) interest in enhanced recovery has been growing since the late 2000s.

• The Duke University Medical Center Enhanced Recovery Program started in 2010

• The first US Enhanced Recovery Congress organized by the Duke University Department of Anesthesiology and Surgery was held in Washington DC in 2013. The 2nd US Enhanced Recovery program was held in New Orleans in October 2014, and marked the official launch of the American Society of Enhanced Recovery (ASER).

Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc. 2016. Gustafsson U. O., Scott M. J., Schwenk, W., et. al. Guidelines for perioperative care in elective colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. 2013; 37 (2): 259-284.

6

LET THE ERAS GAME

BEGIN

Build a team!

Caution

Selecting

Members

Getting Started

Choose a Specific Case

Colorectal

TEAM

Protocols

Educate

• Nursing staff

• Surgeons

• Anesthesia

• Journal Club

Negative PeopleTreat with Evidence!!

Enhanced recovery

10/13/2018

• Reduce care time by more than 30%

• A recent study demonstrated that ERAS programs allow patients to recover much faster after their operation and this reduces the need for hospital stay by about 30% or more than 2 days after major abdominal surgery. Despite earlier discharge from the hospital, readmissions did not increase

• (Greco et al. World Journal of Surgery 2014 38:1531-1541).

Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc. 2016.

Gustafsson U. O., Scott M. J., Schwenk, W., et. al. Guidelines for perioperative care in elective colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. 2013; 37 (2): 259-284.

10

Enhanced Recovery

• Reduce complications by up to 50%

• ERAS reduce major complications after abdominal surgery by as much as 40%. In particular non-cardiac complications, such as those from the lungs and cardiovascular systems are markedly reduced

• (Greco et al. World Journal of Surgery 2014 38:1531-1541)

Preoperative-Preanesthesia clinic

Preoperative Patent Education

Preoperative Assessment and

Optimization

Minimize Starvation Times

Oral Carbohydrate Drink up to 2 hours before

surgery

Bowel Prep

Anesthesia Plan

Decreased Delays And Day of SurgeryCancellations

Success in Clinic Negative

SURGEON! AND

ANESTHESIA

PROVIDERS

Preoperative Patient Education

• Shame free educational Environment

• Allow for questions!

• Appropriate literacy level

• Check for Health Literacy

• Do they know their medications and what they do?

• Reliable electronic teaching and websites

• Integration of Meaningful images

• Set Goals and Expectations for Ambulation and Discharge

Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc. 2016. 10/13/2018 14

Preoperative Assessment and Optimization

• Medical Optimization Prior to Surgery

• Be Mindful of time constraints!

• Preoperative optimization and risk stratification

• May need to consult with Patients Primary Care or specialist if Clinical judgement of a improvable condition.

• ACC/AHA Risk Assessment

• >4 Mets

• Active CHF, Unstable Angina, Unstable Arrhythmia, Major Valve Lesion, Pulmonary HTN, and Cardiomyopathy


Preoperative Assessment

and Optimization

• Preoperative Testing

• Lancet 2003 article by Garcia et al. 60-70% preoperative testing was not necessary if a good preoperative assessment was completed.

• CBC and Chemistry indicated within 30 days

• ACC/AHA METS <4 plus 2 or more risk factors: CAD, CHF, Insulin DM > 20 years, CVA, Renal Insufficiency

• Feely et al. 2013 recommend test due to medical necessity “indicated test” that will change management or better assess risk/anesthesia choice.

• Screening vs Surveillance or targeted indicated test due to status change

Preoperative Assessment and Optimization• Pulmonary Risk and Optimization

• Smoking history and promotion of cessation

• Incentive Spirometry one week prior to surgery 10 times per hour while awake- Caution with COPD Patients!!

• Severe COPD ABG for CO2 Retention.

• 6 minute walk test

• Preanesthesia Clinic Upstairs and long hallway

• Obtain previous ABG’s and Pulmonary Function Studies

10/13/2018 Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc. 2016. 17


10/13/2018

• Optimization in Hemoglobin, HTN, and DM

• Hemoglobin preferred Iron correction

• HTN <180 mmHg Systolic and < 110 mmHg Diastolic

• ACE inhibitors and Angiotension II Receptor antagonist higher risk for Hypotension hold am of surgery but resume postoperative if euvolemic and normal renal function

Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc. 2016. 18



• DM A1c and glucose control and optimization preoperative to prevent surgical infections! Most common complications

• Hold oral hypoglycemic agents consult with primary care or endocrinologist for insulin recommendations. Usually ½ lacking insulin the night before and Short acting sliding scale..

Optimization in Hemoglobin, HTN, and DM

Improved cardiopulmonary Fitness

Recovery for Chemotherapy

Minimize Starvation times


Clear Fluids up to 2 hours before Anesthesia Induction

Clinical Judgement

Elevated A1c

Significant GERD

BMI > 40

Gastroparesis/Peripheral Neuropathy

Oral Carbohydrate Drink up to 2 hours before surgery

Clearfast ( 21g monosaccharides, 38g polysaccharides, 230 calories per 12 oz)

More stable Glycemic control perioperative

Preoperative carbohydrate drink mimics breakfast and promotes insulin release. This

will help decrease the peripheral insulin resistance secondary to surgical stress.

Bowel Prep- To Prep or Not?

• Current Evidence supports Mechanical Bowel Prep with Oral Antibiotics!

• Types of Mechanical

• Isosmotic Balanced Electrolyte Solutions-PEG(polyethylene glycol)

• 4 liters Due to HIGH molecular weight nonabsorbable passes through GI tract without net absorption or secretion

• Avoids Electrolyte and fluid shifts

• Most common Side Effect? Nausea


Bowel Prep- To Prep or Not?

• Current Evidence supports Mechanical Bowel Prep with Oral Antibiotics!

• Types of Mechanical

• Hyperosmotic( Magnesium Citrate & Sodium Phosphate)

• They draw water into intestines and cause fluid and electrolyte shifts. Could result in Renal Issues

• Not Recommended by Enhanced Recovery Protocols


Anesthesia Plan


• Female, Hx PONV or Motionsickness, Nonsmoker, younger age, use of inhaled anesthetics, opioids, duration of anesthesia and type of surgery (abdominal/laparoscopic surgery)

Preoperative Antiemetic Risk Assessment and

Utilization of Two Agents

• ASA 1&2 Fluid Restrictive Technique Any system least invasive Cheetah, Esophageal Doppler, pleth variability, etc.

• ASA 3 Volume Cardiac Optimization- SV analysis Esophageal Doppler or FloTrac

• ASA 4 Volume Cardiac Optimization not on Enhanced Recovery Protocol Sv Analysis Esophageal Doppler, TEE, and/or FloTrac- consider ScVo2.

Hemodynamic Monitoring for

Either Fluid Restrictive or Volume and

Cardiac Optimization

Techniques- Goal Directed Therapy

Anesthesia Plan

• Analgesic Management

• Intrathecal Morphine plus Single or Continuous TAP Blocks

• Epidural low thoracic

• Multimodal Opioid Reduction Techniques

Anesthesia Plan- PONV

10/13/2018Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major

abdominal surgery. West Islip, NY Professional Communication Inc. 2016.26

Drugs Dosage Timing

Dexamethasone 4-8mg IV At induction

Ondansetron 4mg IV End of Case

Scopolamine Transdermal Patch Prior Night or 2 hour Prior to surgery

PONV Rescue

10/13/2018Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major

abdominal surgery. West Islip, NY Professional Communication Inc. 2016.27

Drugs Dosage Instructions

Promethazine 2.5mg IV Dilute 25mg to 2.5/ml

Droperidol 0.625 mg IV

Haloperidol 0.5mg-<2mg Dilute 1mg/ml caution not IM only

Preoperative Pain ManagementMultimodal

10/13/2018Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal

surgery. West Islip, NY Professional Communication Inc. 2016.28

Drug Dosage Timing

Acetaminophen 1000mg IV Induction

Gabapentin 600mg PO 2 Hours Prior to Surgery

Celecoxib 400mg PO 2 hrs prior to surgeryCaution with Elderly and Renal

Intrathecal Morphine orLow Thoracic Epidural

200mcg Immediately Preop

Alvimopan Entereg 12mg PO 2 hours prior to surgery if not on Opioids for 2 weeks

Antibiotic Prophylaxis

• More aggressive dosages and more frequent Re-dosing to improve plasma level at closure.

• Surgical Infection the most common complication

• Cefazolin 1g <80kg, 2g>80kg, 3g >120kg. Redose in 3-4 hours to avoid nadir during closure.

• Clindamycin 600mg, 900mg, and 1200mg

• Closure is cleaner with hand assisted barriers used.

Normothermia


Maintain:Warming blankets in the preoperative setting. Do not make them sweat!

Monitor:Temperature should be monitored during the perioperative period

Prevent: Increasing Room Temperature

Increasing Surgical Team awareness

Treatment:Forced air warmers and fluid warmers for ALL Enhanced Recovery Cases

Intraoperative Period

• SCD’s

• Administer Antibiotics- Not 5 seconds or 59 minutes prior to incision

• Administer Multimodal Analgesia Protocol

• AVOID OPIOIDS!!!!!

• Goal Directed Fluid Therapy

• Maintain Normothermia

• Minimize Tubes



• Multimodal Utilizing Non-Opioid Techniques

• Primary Goal AVOID OPIOIDS

• TIVA with Propofol or as adjunct to Inhaled Anesthetics

• 15 mg ketorolac IV at the end of case if ok with surgeon and not contraindicated

• IV 1000mg Acetaminophen with induction


Magnesium 30-50mg/kg bolus over 30minutes

then 20mg/kg/hr

intraoperative infusion. D/C at closure Avoid If

QTc >0.45

Ketamine 0.2mg/kg one

dose

IV Lidocaine 1mg/kg bolus followed by 0.5-1mg/kg

infusion stop at the end of

surgery. Consider

lidoderm patch

Bilateral TAP Blocks either continuous or Single Injection

• 15-20 ml 0.2-0.5% Ropivacaine


• Fluid Management

• Should be Goal Directed by dynamic flow related parameters

• Cardiac Output, Stroke Volume, Stroke Volume Variation with Ventilation, pulse pressure variations, and pleth variability index.

• Equipment: Arterial line related such as LiDCO, PiCCO, FloTrac, or Pleth technology, Esophageal Doppler, TEE, ScVo2, and others.

• Not necessary the amount of fluids but the timing will change with these parameters

• Improved Outcomes with Goal Directed Therapy

• Shorter length of stays and lower complication rates


Intraoperative Fluid Management Low Risk Patients


ASA 1-2 Restrictive Protocol ELECTIVE ONLY!

Non-complicated colorectal procedures on relatively healthy adults

Non-Invasive Cardiac Output Monitoring

Mechanical Ventilation 6-8ml /kg

Especially if utilizing ventilation variations (SVV or PVI)

Intraoperative Fluid Management Low Risk Patients


Fluids D5LR, LR, D5Normosol 3ml/kg/hr Crystalloids not Saline Goal is to reduce Salt Loading

MAP < 65mmHg 250ml of Crystalloids or colloids like voluven NOT NS after two boluses and not improved start phenylephrine

EBL over 500ml replace with colloid 1:1

Intraoperative Fluid

Management Moderate Risk

Patients without

arterial line

• ASA 2 or 3 Blood loss expected <1,500ml

• PIV access 2 +- central line with or without SCVO2.

• Mechanical Ventilation 6ml/kg

• Non-Invasive cardiac monitoring

• Esophageal Doppler, Cheetah, PVI, etc.

• Cardiac Optimization and fluid management

Intraoperative Fluid Management Moderate Risk Patients without arterial line


Fluids D5LR, LR, D5Normosol 3ml/kg/hr Crystalloids not Saline Goal is to reduce Salt Loading

MAP < 65mmHg 250ml of Crystalloids or colloids like voluven NOT NS after two boluses and not improved start phenylephrine


Intraoperative Fluid Management High Risk Patients with Arterial Line

10/13/2018

• ASA 3 or 4 Blood loss expected 1,500 or more.

• PIV access 2 plus central line with SCVO2?

• Arterial line Placement

• Mechanical Ventilation 6ml/kg

• Non-Invasive cardiac monitoring

• Esophageal Doppler, FloTrac, LiDCO, PiCCO, TEE

• Cardiac Optimization and fluid management

Reference:Gan T, Thacker J, Miller T, Scott M, Holubar S, Enhanced recovery for major abdominal surgery. West Islip, NY Professional Communication Inc. 2016. 39

Intraoperative Fluid Management High Risk Patients with Arterial Line



MAP < 65mmHg 250ml of Crystalloids NOT NS after two boluses and not

improved start phenylephrine

Fluids D5LR, LR, D5Normosol 3ml/kg/hr Crystalloids not Saline Goal

is to reduce Salt Loading

Cardiac Optimization

• Improved Cardiac Performance:

• Increased SV by > 10% from fluid bolus

• Maximize Cardiac performance and delivery of oxygen

• SCVO2 or SVO2 are you meeting the demand

• Titration of Vasopressors or Inotropic therapies

Enhanced Recovery Pathway: Elective Laparoscopic Hand Assisted Colorectal Cases

*Contraindications: Oral Carbohydrate (AM of Surgery): A1c>6.5, BMI>40, neuropathy, gastro paresis, uncontrolled GERD, large bowel prep Scopolamine: History of Glaucoma, urinary retention, psychiatric Lidocaine and Magnesium: QTC>0.45 Esmolol: SINUS BRADYCARDIA, heart block greater than first-degree, sick sinus syndrome, IV verapamil therapy, or pulmonary HTN

E. Buckley, M. Burns, T. Hickey, A. A. Taylor, & D. Voight

Phelps County Regional Medical Center Rolla, Missouri USA

Webster University St. Louis , Missouri USA

INTRODUCTION: The reduction of opioids during the postoperative period is the focus of most enhanced recovery protocols. Many of these protocols for laparoscopic colorectal surgery utilize truncal blocks such as single injection bilateral transversus abdominis plane blocks instead of low thoracic epidurals.

CONCLUSION(S) Continuous transverse abdominis plane blocks significantly decreased the opioid consumption during the postoperative period. The substitution of this modality for low thoracic epidurals could assist in decreasing opioid related complications as well as known difficulties with low thoracic epidural such as systemic hypotension, foley catheter placement, delayed ambulation, and interference with anticoagulation.

RESULT(S) The continuous TAP block group received 47% less opioids over 48 hours (p=0.031). This significant decrease was noted during the postanesthesia care unit (p= 0.049) and within the first 24 hours (p=0.006). The opioid consumption for the following 24 hours was not statistically significant (p>0.05).

METHOD(S) A retrospective chart review of elective laparoscopic colorectal procedures was performed (n=34). All patients received intrathecal morphine 200mcg, similar postoperative opioid orders, alvimopan 12 mg PO, and either bilateral single injection transverse abdominis plane blocks with 15ml of 0.5% ropivacaine on each side or continuous bilateral transverse abdominis plane blocks with the same initial bolus. Then a 0.2% ropivacaine infusion at 5ml/hr is started bilaterally for 48 hours. All opioid data was collected and converted to IV morphine equivalents utilizing GlobalRPhprogram.

OBJECTIVE(S) The purpose of this study was to evaluate the effectiveness of single injection versus continuous abdominis plane blocks on postoperative opioid consumption for 48 hours

REFERENCESA. Feldheiser. et. al. Enhanced recovery after surgery for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiology Scand 2016 Mar; 60(3): 289-334.

Continuous Bilateral Transverse Abdominis Plane Blocks Decrease Opioid Consumption by 47 Percent Following Laparoscopics Colorectal Surgery

Contact Information: [email protected]

Next Procedure-Outpatient Shoulder Arthroscopic Repair of Rotator Cuff

• Prior to ERAS 1:4 chance of being admitted or Emergency room visit the day of surgery.

• Respiratory Complications

• Nausea/Vomiting

• Pain

Enhanced Recovery Pathway: Shoulder Arthroscopic Procedures

*Contraindications: Esmolol: SINUS BRADYCARDIA, heart block greater than first-degree, sick sinus syndrome, IV verapamil therapy, or pulmonary HTN

PREOPERATIVE

Low volume continuous ISB. Infuse 0.2% ropivacaine 5 ml/hour with 2 ml/hour PCA until POD 3

Incentive Spirometry 7 days prior, 10 times/hour while awake

INTRAOPERATIVE

• Replace induction opioid dose with esmolol* 0.5 mg/kg. Infuse at 5-30 mcg/kg/min or bolus with 0.2 -0.5 mg/kg if hypertensive/tachycardic with surgical stimulation.

• 8 mg dexamethasone prior to incision

• 4 mg ondansetron prior to close

• 30 mg ketorolac prior to close OR, if contraindicated, 1000 mg IV acetaminophen with induction

• If patient emerges in pain, administer hydromorphone IV PRN

POSTOPERATIVE

Apply

Apply ICE to site ASAP

Advance

Advance diet as soon as patient tolerates

Administer

Administer PO pain medications as first line therapy for post operative pain

Administer

Administer hydromorphone for pain that exceeds above interventions

TOTAL JOINT ARTHROPLASTY

JOINT CAMP

01PLANNED SAME DAY TOTAL SHOULDERS AND KNEES

02GOAL AMBULATION IN THE PACU

03

Enhanced Recovery Pathway: Total Joint Replacement

*Contraindications: Esmolol: SINUS BRADYCARDIA, heart block greater than first-degree, sick sinus syndrome, IV verapamil therapy, or pulmonary HTN TXA: PE or DVT within 12 months of surgery, DVT or PE history treated with anticoagulation, congenital thrombophilia, cardiac stent/ischemic stroke w/i 12 months, creatinine >1.5, severe ischemic heart disease, history of thromboembolic or vascular disease, DIC

PREOPERATIVE

SA: Low volume continuous ISB. Infuse 0.3% ropivacaine 5 ml/hour with 2 ml/hour PCA until POD 3

THA: Single injection fascia iliaca nerve block with 15 ml 0.5% ropivacaine

TKA: Single injection I-Pack block , single injection lateral cutaneous nerve block, continuous Adductor Canal block. Infuse 0.2% ropivicaine 5ml/hour with 2 ml/hour PCA until POD 2

If CR<1.5 and no CHF, PREOP 10 mg oxycontin, 600 mg gabapentin, 200 mg celebrex

Incentive Spirometry 7 days prior, 10 times/hour while awake

Blocks

Continuous Adductor Canal

Single Injection Lateral Femoral Nerve of the Thigh.

Single Injection I-PACK

• Infiltration area between the Popliteal Artery and Capsule of the knee.

• LSU Medical Center 2017 reported a study supporting this technique on 106 patients.

• They compared Continuous Femoral Nerve block with I-PACK vs Just Femoral vs Continuous Adductor with I-PACK

• Continuous Adductor with I-Pack less opioids, shorter length of stay, and longer gait distance POD#1.

• Thobhani S, Scalercio L, Elliott C. et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients: Ochsner Journal 2017;17 (1): 233-238.

INTRAOPERATIVE

• Replace induction opioid dose with esmolol* 0.5 mg/kg. Infuse at 5-30 mcg/kg/min or bolus with 0.2 -0.5 mg/kg if hypertensive/tachycardic with surgical stimulation.

• 8 mg dexamethasone prior to incision

• 4 mg ondansetron prior to close

• 15-30 mg ketorolac prior to close OR, if contraindicated, 1000 mg IV acetaminophen with induction

• TXA*: THA & TSA 2 grams prior to incision; TKA 1 gram prior to incision & 1 gram after tourniquet deflated

• If patient emerges in pain, administer hydromorphone IV PRN

POSTOPERATIVE

Apply ICE to site ASAP

Advance diet as soon as patient

tolerates

Administer PO pain medications as first

line therapy for post operative pain

Administered hydromorphone for pain that exceeds

above interventions

Self Assessment-

Honest Feedback

More Feedback

Elective Cesarean Sections

<4mg Morphine 1st 24 hours

Spinal anesthesia/analgesia with 0.75% bupivacaine in 8.25% dextrose and 100 mcg Duramorph

Bilateral single injection TAP blocks with 15 ml 0.5% ropivacaine

Ketorolac 30 mg IV in OR and 15 mg q 6 hours for 24 hours.

Central monitoring of ETCO2 and Pulse Oximeter for 24 hours

Future ERAS…

References

• Enhanced Recovery for Major Abdominopelvic Surgery. Gan T, Thacker J, Miller T, Scott M, & Holubar S 1st ed. 2016. The American Society of Enhanced Recovery

• For orders: 1-800-337-9838 or www.peibooks.com

• Gustafsson U. O., Scott M. J., Schwenk, W., et. al. Guidelines for perioperative care in elective colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. 2013; 37 (2): 259-284.

• Thobhani S, Scalercio L, Elliott C. et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients: Ochsner Journal 2017;17 (1): 233-238.

http://www.peibooks.com/

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ENHANCED RECOVER AFTER SURGERY