ERAS Intraoperative ACEH Feb 2020
ERAS Intraoperative ACEH Feb 2020
ERAS Intraoperative ACEH Feb 2020
Intraoperative Optimizing
Strategy of Anesthesia
Bambang Pujo Semedi
Departement of Anesthesiology and Intensive Therapy
Faculty of Medicine Universitas Airlangga – Dr Soetomo Hospital
Surabaya
Intraoperative Items
Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM,
et.al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery
(ERASÒ) Society Recommendations: 2018 . World Journal of Surgery. 2018
Balanced Anesthesia....
deep enough but avoid
awareness
Inhaled anesthetic concentrations
for prevent awareness
• Doses of inhaled
required to prevent
awareness (recall) are
smaller (0.45 MAC)
than those required
for unconsciousness
• It can be achieved by
using 0.6 to 0.8 MAC
of inhaled anesthetics
with or without N2O,
respectively
Dwyer et al: Anesthesiology 1992; 77: 888-96
55
Sevoflurane (n=28)
PaCO2 50
(Mean ± SD) *
45 *
40
Pre 20 40 60
Minutes After Extubation
Adapted from Bilotta F et al. J Neurosurg Anesthesiol.
2009;21:207-213.
Desflurane Sevoflurane
(n=31) (n=29)
* P<0.01,
** P<0.0001 (Mann-Whitney)
Mahmoud et al
Meta-
analysis
Pre-implementation n=2936
Post-implementation n=3137
1. Myles PS, Leslie K, Chan MT et al (2014) The safety of addition of nitrous oxide to general anaesthesia in at-risk
patients having major non-cardiac surgery (ENIGMA-II): a randomised, single- blind trial. Lancet 384:1446–1454
2. Fernandez-Guisasola et al. Association between nitrous oxide and the incidence of postoperative nausea and vomiting in
adults: a systematic review and meta-analysis. Anaesthesia 2010; 65: 379-87
Deep anesthesia monitoring
• Cerebral function monitoring using bi-spectral
index (BIS can reduce the risk of awareness in
high-risk patients [1]
• maintaining target between 40 and 60
• BIS or newer burst suppression monitoring can
be used to avoid overdose of anesthesia
• reduce the risk of postoperative delirium and
postoperative cognitive dysfunction especially in
elderly population [2]
1. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N (2014) Bispectral index for
improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev
2. Chan MT, Cheng BC, Lee TM et al (2013) BIS-guided anes- thesia decreases postoperative
delirium and cognitive decline. J Neurosurg Anesthesiol 25:33–42
17 |
Post operative delirium (POD)
18
POD could be a very serious problem…
19
BIS-guided reduce incidence of delirium
Meta-analysis of these four trials
Odds Ratio
Patient for delirium
Study Group 1 (n) Group 2 (n)
Population Group 1 to
Group 2
Sieber et al. ≥ 65 yo, hip fracture, BIS ≥ 80 (57) BIS ≈ 50 (57) 0.35 (0.15–0.82)
2010 SAB, propofol sedation
Chan et al. > 60 yo, elective major BIS-guided (450) Routine care 0.58 (0.41–0.80)
2013 noncardiac surgery (452)
Radtke et al. > 60 yo, elective major BIS-guided (575) Routine care 0.73 (0.54–0.98)
2013 noncardiac surgery (580)
Whitlock et al. Elective cardiac and BIS-guided (149) ETAC-guided 0.60 (0.35–1.02)
thoracic surgery (161)
Meta-analysis (1231) (1250) 0.56 (0.42–0.73)
of the above
studies
Whitlock E, Torres B, L, N, Helsten D, Nadelson M, Mashour G. Postoperative delirium in a substudy of
cardiothoracic surgical patients in the BAG-RECALL clinical trial. Anesth Analg. 2014;118: 809–17. 20
Sedation Depth During Spinal Anesthesia and the
Development of Postoperative Delirium in Elderly
Patients Undergoing Hip Fracture Repair1
Prospective, randomized, double-blind
53% reduction
trial of ≥ 65 y/o for hip fracture repair
• 114 patients
• Screened out pre-op delirium, but
allowed dementia deemed not
severe (MMSE ≥15)
Protocol
• Midazolam allowed (up to 2mg) for
SAB placement P=0.02
Odds Ratio 2.69 (1.04-6.93)
• Propofol titrated to deep (BIS target
50) or light (BIS ≥ 80) Sieber FE, Zakriya KJ, Gottschalk A, Blute MR, Lee
HB, Rosenberg PB, Mears SC. Sedation depth
Assessed for delirium with CAM/MMSE during spinal anesthesia and the development of
POD 2 → discharge postoperative delirium in elderly patients
undergoing hip fracture repair. Mayo Clin Proc.
2010; 85(1): 18-26.
21
BIS-guided Anesthesia Decreases Postoperative
Delirium and Cognitive Decline1
Delirium predicted POCD
(related??) 35% reduction
Incidental finding
Chan M, Cheng B, Lee, T, Gin, T. BIS-
• BIS group had significantly guided anesthesia decreases
fewer post op infections postoperative delirium and cognitive
(p=0.01) decline. J Neurosurg
22 Anesthesiol. 2013;25:33–42.
Monitoring depth of anesthesia in a randomized
trial decreases the rate of postoperative delirium
but not postoperative cognitive dysfunction1
• 1155 pts ≥ 60 y/o having surgeries
of at least 60 minutes 22% reduction
• Neurologically & cognitively intact
• Routine care (blinded to BIS) vs
BIS-guided (Target BIS 40-60)
• POCD screening at 7 days and 3
months
• Delirium screening AM and PM for P=0.036
Radtke FM, Franck M, Lendner J, Kruger S, Wernecke KD, Spies CD. Monitoring depth of anaesthesia in a
randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. British
Journal of Anaesthesia. 2012; 110 (S1): i98–i105.
23
Postoperative Delirium in a Sub-study of
Cardiothoracic Surgical Patients in the BAG-
RECALL Clinical Trial1
310 cardiac or thoracic surgery pts who went to 32% reduction (NS)
ICU post-op
Sub-analysis of BAG-RECALL study (awareness
with recall)
• BIS group=Titrate to BIS<60
• ETAG=Keep end-tidal anesthetic
concentration 0.7-1.3 (age adjusted)
Delirium assessments with CAM-ICU twice daily
until ICU discharge or 10 days (whichever came Odds ratio 0.60, 95% confidence
interval, 0.35–1.02, P= 0.058
first)
24
BIS™ Complete Monitoring System
BIS technology is available stand-alone and as an
integrated solution with leading OEM patient
monitoring systems.
BIS™ Sensors
Quat ro Sensor
T
M
Ext end Sensor
2
5
|
Neuromuscular blockade monitoring
is paramount….
• Residual paralysis in postop period is frequent and
difficult to recognize clinically
• Even minimal paralysis (TOF < 0.9) increases
postoperative complications and ICU admission
• Reverse blockade unless there is unequivocal
evidence of adequate function
• Use appropriate neostigmine dose based on the
degree of blockade at the time of reversal
• Clinical signs only cannot be used to determine
whether there is a residual block or not
Accumulation : Neuromuscular blockers
Rollins KE, Lobo DN. Intraoperative goal-directed fluid therapy in elective major abdominal surgery: a
meta-analysis of randomized controlled trials. Annals of surgery 2016;263(3):465-476.
Within ERAS programs, it may
not be necessary to offer all
patients GDFT, and this should
be reserved, after risk
stratification, for high-risk
patients or for patients under-
going high-risk procedures
Thiele RH, Raghunathan K, Brudney CS et al (2016) American Society for Enhanced Recovery (ASER) and
Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management
within an enhanced recovery pathway for colorectal surgery. Perioper Med (Lond) 5:24
ERAS Society guidelines recommend
hypotension with epidural anesthesia is
managed with vasopressors, rather than
fluid challenges alone, to avoid
inadvertent fluid overload
Fluid loading using coloid before
performing a neuraxial anesthesia
is severely questionable
• Volume effects of iso-oncotic colloids are
about 100 % when it is used to substitute
acute blood losses
• Fluid administration in normovolemic will
induce hypervolemia tremendous
shift of fluid and colloids towards the
interstitial space
Timing of volume loading is very important
• Volume effect is part of an infused bolus that
does not shift outwards, but remains inside
the vasculature
• What happens during volume loading?
• Infusion of colloids to a primarily normovolemic
circulation without simultaneous blood
withdrawal ≈ 60% of the infused amount
directly loads the interstitial space
• It is more reasonable to infuse fluid not
‘before’ but when “hypovolemia” occurs
Preventing intraoperative
hypothermia
• It is important to maintain normothermia (> 36 °C)
in patients undergoing major surgery [1]
• Even mild inadvertent perioperative hypothermia
(IPH) has been associated with adverse effects
• Both GA and neuroaxial anaesthesia affect
thermoregulation by impairing vasoconstriction
and shivering temperature redistribution from
the core to the periphery heat loss > heat
production [2]
1. Billeter AT, Hohmann SF, Druen D et al (2014) Unintentional perioperative hypothermia is associated
with severe complica- tions and high mortality in elective operations. Surgery 156:1245–1252
2. Sessler DI (2016) Perioperative thermoregulation and heat bal- ance. Lancet 387:2655–2664
Negative effects of hypothermia
• Hypothermia induce vasoconstriction, increased
afterload, myocardial ischaemia and cardiac
arrhythmias, reduction in splanchnic blood flow and
reduced drug biotransformation [1]
• In a meta-analysis with a median temperature of 35.6
°C, blood loss was increased by 16% and blood
transfusion rate by 22% [2]
• In postoperative period [1]
• shivering increase in O2 consumption
• prolonged stay in the PACU
• increase in rates of infection
• prolonged hospital stay
1. Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, et.al. Guidelines for
Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERASÒ) Society Recommendations: 2018 .
World Journal of Surgery. 2018
2. Rajagopalan S, Mascha E, Na J et al (2008) The effects of mild perioperative hypothermia on blood loss and
transfusion requirement. Anesthesiology 108:71–77
Patients at higher risk of IPH
• ASA 2-5
• preoperative hypothermia,
• undergoing combined regional and general
anaesthesia,
• major surgery
• at risk of cardiovascular complications
Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok
TM, et.al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery
After Surgery (ERASÒ) Society Recommendations: 2018 . World Journal of Surgery. 2018
How to conserve body
temperature during surgery
• pre warming before surgery
• warming and humidification of anesthetic gases,
• warming IV and irrigation fluids
• forced air warming blankets and devices
• warmed and humidified CO2 in laparoscopic surgery
was associated with a significant increase in intra-
operative core temperature (mean change 0.3 °C) [1]
• the ambient temperature should be at least 21 °C
while the patient is exposed prior to active warming
starting [2]
1. Dean M, Ramsay R, Heriot A et al. Warmed, humidified CO2 insufflation benefits intraoperative core temperature during
laparoscopic surgery: a meta-analysis. Asian J Endosc Surg 10:128–136. 2017
2. Hypothermia : prevention and management in adults having surgery. National Institute for Health and Care Excellence,
London. 2008
PONV in ERAS Protocol
Antiemetic prophylaxis should be guided by pre-
operative screening for risk factors for post-perative
nausea and vomiting
Simplified Risk Score for PONV in Adults
T. J. Gan, T. A. Meyer, C. C. Apfel et al., “Society for ambulatory anesthesia guidelines for the management of
postoperative nausea and vomiting,” Anesthesia and Analgesia, vol. 105, no. 6, pp. 1615–1628, 2007
Input and Receptor Involved in PONV
T. J. Gan, T. A. Meyer, C. C. Apfel et al., “Society for ambulatory anesthesia guidelines for the management of
postoperative nausea and vomiting,” Anesthesia and Analgesia, vol. 105, no. 6, pp. 1615–1628, 2007
Multimodal Analgesia for ERAS
Opiate-Sparing Analgesia
The rationale of ERAS approach to analgesia is to use
multimodal analgesia combined with regional and local
anesthetic techniques to allow a patient’s opiate
consumption to be minimized.
Systemic Analgesia Regional/ Local Analgesia
NSAID and Paracetamol Thoracic epidural analgesia
Anticonvulsant agent Spinal anesthesia
Calcium channel blockers TAP block
Systemic local anesthetic Local anesthetic Infiltration
Transition from the IV to oral routes should be expedited if
possible to reduce risks from cannula use, cannula site
thrombophlebitis, and facilitate mobility and discharge
Summary : Key Aspects of ERAS Protocol
Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: time to change
practice? Can Urol Assoc J 2011;5(5): 342-8;DOI:10.5489/cuaj.11002
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