35
Objectives • Is ERAS a new thing or a reinvention? • Applications and Teamwork • Anesthesia Concerns • Co$$$$$$$$$t • Where can improvements be made?

ork Co$$$$$$$$$t •on?Slowly sip this drink on your way to the hospital. You must finish the drink 2 hours before your scheduled surgery time. For instance- if surgery is at 9 a.m.,

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  • Obj

    ectiv

    es•I

    s ERA

    S a

    new

    thin

    g or

    a re

    inve

    ntio

    n?•A

    pplic

    atio

    ns a

    nd T

    eam

    wor

    k•A

    nesth

    esia

    Con

    cern

    s•C

    o$$$

    $$$$

    $$t

    •Whe

    re c

    an im

    prov

    emen

    ts be

    mad

    e?

  • ERA

    S by

    Defi

    nitio

    n (A

    AN

    A)

    •Enh

    ance

    d R

    ecov

    ery

    afte

    r Sur

    gery

    (ER

    AS®

    ) ref

    ers t

    o pa

    tient

    -cen

    tere

    d,ev

    iden

    ce-b

    ased

    , mul

    tidis

    cipl

    inar

    y te

    am d

    evel

    oped

    pat

    hway

    s for

    asu

    rgic

    al sp

    ecia

    lty a

    nd fa

    cilit

    y cu

    lture

    to re

    duce

    the

    patie

    nt’s

    surg

    ical

    stre

    ss re

    spon

    se, o

    ptim

    ize

    thei

    r phy

    siol

    ogic

    func

    tion,

    and

    faci

    litat

    ere

    cove

    ry. T

    hese

    car

    e pa

    thw

    ays f

    orm

    an

    inte

    grat

    ed c

    ontin

    uum

    , as t

    hepa

    tient

    mov

    es fr

    om h

    ome

    thro

    ugh

    the

    pre-

    hosp

    ital /

    pre

    adm

    issi

    on,

    preo

    pera

    tive,

    intra

    oper

    ativ

    e, a

    nd p

    osto

    pera

    tive

    phas

    es o

    f sur

    gery

    and

    hom

    e ag

    ain.

  • Fast

    Tra

    ck S

    urge

    ry

    •Hen

    rik K

    ehle

    t pio

    neer

    ed th

    eco

    ncep

    t in

    the

    1990

    s with

    an

    initi

    ativ

    e or

    igin

    ally

    kno

    wn

    as“f

    ast-t

    rack

    surg

    ery”

  • Old

    idea

    s app

    lied

    toda

    y•T

    he fi

    rst E

    nhan

    ced

    Reco

    very

    Afte

    r Sur

    gery

    (ERA

    S) p

    roto

    col w

    ases

    tabl

    ished

    in 2

    001

    by a

    gro

    up o

    f sur

    geon

    s fro

    m N

    orth

    ern

    Euro

    pe.

    Thei

    r prim

    ary

    goal

    was

    to o

    ptim

    ize

    surg

    ical

    out

    com

    es th

    roug

    h th

    eim

    plem

    enta

    tion

    of e

    vide

    nce-

    base

    d m

    edic

    ine

    and

    best

    prac

    tices

    inpa

    tient

    s und

    ergo

    ing

    colo

    nic

    rese

    ctio

    ns.

    •The

    cur

    rent

    pro

    pone

    nts o

    f ERA

    S en

    cour

    age

    the

    proc

    ess o

    ne st

    epfu

    rther

    by

    conc

    entra

    ting

    on th

    e qu

    ality

    of p

    atie

    nt c

    are

    and

    impr

    ovin

    gpa

    tient

    s' fu

    nctio

    nal c

    apac

    ity, t

    here

    by e

    xped

    iting

    the

    retu

    rn to

    bas

    elin

    efu

    nctio

    n.

  • App

    licat

    ions

    and

    Tea

    mw

    ork

    •The

    prim

    ary

    goal

    s of t

    he m

    ultim

    odal

    , mul

    tidis

    cipl

    inar

    y, a

    ndco

    mpr

    ehen

    sive

    ER

    AS

    path

    way

    s are

    to b

    lunt

    the

    resp

    onse

    to su

    rgic

    alst

    ress

    thro

    ugh

    optim

    izat

    ion

    of n

    utrit

    iona

    l and

    func

    tiona

    l sta

    tus,

    limita

    tion

    of p

    reop

    erat

    ive

    fast

    ing,

    indi

    vidu

    aliz

    ed fl

    uid

    man

    agem

    ent,

    opio

    id-s

    parin

    g an

    alge

    sia,

    min

    imal

    ly in

    vasi

    ve su

    rger

    y, a

    nd e

    arly

    post

    oper

    ativ

    e am

    bula

    tion

    and

    feed

    ing.

    The

    se c

    ompo

    nent

    s hav

    efa

    cilit

    ated

    a fa

    ster

    retu

    rn to

    the

    patie

    nt's

    preo

    pera

    tive

    func

    tiona

    l sta

    te.

    Thou

    gh g

    uide

    lines

    var

    y, th

    ere

    are

    roug

    hly

    20 e

    lem

    ents

    incl

    uded

    inea

    ch p

    athw

    ay. M

    ultid

    isci

    plin

    ary

    team

    s of p

    rofe

    ssio

    nals

    mus

    t wor

    kto

    geth

    er

  • App

    licat

    ions

    •You

    nam

    e it…

    ……

    …..

    •Col

    orec

    tal

    •Orth

    o•G

    YN

    •PED

    S•G

    U•C

    -Sec

    tion

    •Spi

    ne

  • Stre

    ss R

    espo

    nse

  • You

    Are

    Goi

    ng to

    Drin

    k W

    hat W

    hen?

    ???

  • •Man

    y stu

    dies

    hav

    e de

    mon

    strat

    ed th

    at u

    nder

    goin

    g su

    rger

    y in

    aca

    rboh

    ydra

    te-fe

    d sta

    te (b

    y w

    ay o

    f a c

    arbo

    hydr

    ate

    clea

    r liq

    uid

    drin

    k)ve

    rsus

    a fa

    sting

    stat

    e re

    sults

    in im

    prov

    ed p

    atie

    nt sa

    tisfa

    ctio

    n an

    dcl

    inic

    al b

    enefi

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    e to

    the

    redu

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    n in

    pos

    tope

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    sulin

    resis

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    e.26

    ,27

    ERA

    S gu

    idel

    ines

    reco

    mm

    end

    800

    mL

    of a

    12.

    5%ca

    rboh

    ydra

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    rink

    with

    a p

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    fety

    pro

    file

    the

    nigh

    t bef

    ore

    surg

    ery

    and

    400

    mL

    2 ho

    urs b

    efor

    e su

    rger

    y.28

    In p

    atie

    nts

    with

    type

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    ere

    type

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    iabe

    tes,

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    com

    men

    dsav

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    ese

    patie

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    re in

    sulin

    defic

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    , not

    insu

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    sista

    nt.2

    9 Th

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    tiss

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    infe

    ctio

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    tes,

    decr

    ease

    dLO

    S in

    maj

    or su

    rger

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    and

    redu

    ced

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    ea a

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    miti

    ng.3

    0,31

  • Are

    as fo

    r Im

    prov

    emen

    t

  • •Sch

    mid

    t P, R

    ao S

    . Effe

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    and

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    ulat

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    •Man

    ag. 2

    018;

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    .• •C

    aval

    cant

    e A

    N, S

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    r DR

    , Wei

    ngar

    ten

    TN. M

    ultim

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    •Ana

    lges

    ic T

    hera

    py W

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    and

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    iatio

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    125(

    1):1

    41-

    •146

    .• •