ERAS Concept

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

Law CJ, et al: Br J Anaesth 2014; 112: 675-80

 Choice of anesthetic agent
• Avoid benzodiazepines and use of short-acting
general anaesthetic agents in an opioid-sparing
ERAS Pathway
• Induction : propofol + short-acting opioids
(fentanyl, alfentanil, sufentanil or remifentanil
infusions)
• Maintain anesthesia : no strong data to support
the recommendation of either anaesthetic gases or
TIVA using propofol infusions
• GOAL : rapid awakening with minimal residual
effects
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 (ERAS)
Society Recommendations: 2018 . World Journal of Surgery. 2018
Short-acting inhalation agents versus
Propofol TIVA : Which is better?
• No strong data to support the recommendation of
either short acting anaesthetic gases or TIVA using
propofol infusions to maintain anaesthesia
• Propofol TIVA
• lower incident of PONV in certain patients
• have a beneficial effect on cancer outcomes, but no
definitive recommendation can be made for this
currently [1].
• Desflurane or sevoflurane (in O2-enriched air) is
standard practice around much of the world to
maintain anesthesia in intubated patients[2].
1. Wigmore TJ, Mohammed K, Jhanji S (2016) Long-term survival for patients undergoing volatile versus IV anesthesia for
cancer surgery: a retrospective analysis. Anesthesiology 124:69–79
2. Martin DS, Grocott MP (2015) Oxygen therapy and anaesthesia: too much of a good thing? Anaesthesia 70:522–527
 Inhaled Anesthetics : Partition Coefficients
Blood : Gas Brain : Blood Fat : Blood Muscle : Blood

Nitrous Oxide 0.47 1.1 2.3 1.2

Desflurane 0.42 1.29 27.2 2.02

Sevoflurane 0.69 1.7 47.5 3.13

Isoflurane 1.43 1.57 44.9 2.92

Yasuda N et al. Anesth Analg. 1989; 69[3]: 370-373

Eger EI et al.Pharmacoeconomics 2000 Mar; 17 (3): 245-262
 Recovery process to light anesthesia may be
slower with more soluble inhaled anesthetics
Recovery of protective airway reflex
 Speed of recovery to normal ventilation
60

55

Sevoflurane (n=28)
PaCO2 50
(Mean ± SD) *
45 *
40

35 *P<0.05 Desflurane (n=28)

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)

Time to eye opening (min) 2.8 (1-8) 7 (3-12)**

Time to orientation (min) 4.8 (2-11) 9.8 (5-16)**
Ready to leave PACU (min) 15.5 (6-30) 23.7 (13-60)**
Ready to go home (hr) 3.0 (2-4.4) 3.5 (2.1-4.5)*
Full activity next day 28/31 15/29

* P<0.01,
** P<0.0001 (Mann-Whitney)

Mahmoud, N.A., et al. Anesthesia, 2001, 56, 171-182

Mahmoud NA et al. Anesthesia, 2011.56:171-182

 P<0.01

Mahmoud et al

Mahmoud NA et al. Anesthesia, 2011.56:171-182

 Desflurane reduced average extubation time and
variability of extubation time by 20%–25%

Meta-
analysis

Translate to a 75 % reduction in the incidence of prolonged

extubation times ( 95% CI 68% to 84%)

Dexter F et al. Anesth Analg 2010; 110:570-80

 Mayo Clinic Study
Anesthesia Technique Influences Recovery

Pre-implementation n=2936
Post-implementation n=3137

Weingarten TN, et al: BMC Anesthesiology 2015; 15: 54

 Nitrous Oxide
• Avoiding N2O reduced risk of PONV, but
overall impact was modest (1,2)
• Systematic review and meta-analysis of RCTs
from 30 studies (2)
• Propofol induction negate emetic effects of N2O
• Prophylactic antiemetic therapy further negate
emetic effects of N2O

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)

• Etiology : a combination factors including

medical condition and medical procedures
that include anesthesia
• Characteristic :
• confusion
• change in mental function within 24-72 hours of
surgery

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

BIS reduced anesthetic usage :

• Propofol 21% less
• Volatile 30% less
Faster emergence (4.3 minutes)
Shorter PACU stays (12.5
minutes) P=0.01
Odds Ratio 0.58 (0.41-0.80)

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

first 7 days of hospital stay

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)

1. 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.

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

Pediat ric Sensor

T
M
Ext end Sensor

BIS™ Complet e 4-Channel

BIS™ Complet e 2-Channel
M onit oring Syst em
M onit oring Syst em
BIS consciousness assessment enhanced Bilat eral
Full f eat ured st and-alone solut ion w it h bi-hemispheric capabilit ies Sensor

2
5

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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

• All intermediate acting

NMBA, particularly io n
vecuronium, exhibit lat
mu
accumulation due to
c cu
redistribution h a
wit
• Infusion rate had to be ed
i a t
decreased with time,
s o c in
s
long duration asurgery,
to maintainB is
same
degreeNM of NM blockade

Miller DR et al.Can J Anaesth 2000;47:943-49

• Residual block was present in 186 patients
(31%) on admission to the PACU
• Adverse respiratory events were more
frequent in patients with residual block
(21% vs 14%, P = 0.033)
 Routine “full”
full” dose reversal with
neostigmine not appropriate…
appropriate…
Neostigmine cause muscle weakness
when given after complete
neuromuscular recovery
• Eikermann M et al: Anesthesiology 2007; 107: 621-9
• Herbstreit F et al: Anesthesiology 2010; 113: 1280-8
• Grosse-Sundrup M et al: BMJ 2012; 345: e6329
How much Neostigmine dose should be given ?

Joshi GP et al. IARS 2013 Review course Lecture

Fuchs-Buder T, et al. Anesthesiology 2010; 112:34-40
 AAGBI Guideline

AAGBI 2015 Standards recommends that a

nerve stimulator must be available
whenever a NM blocker is used during
anesthesia & it must also be immediately
available in the PACU

Checketts et al. Standards of monitoring. Anaesthesia 2015

Inappropriate monitoring of residual
block increased complication..

Sasaki N, et al: Anesthesiology 2014; 121: 959-68

What should we do if don’t have
TOF monitoring ?
• Avoid or minimize NMBA, if possible
• Don’t administer NMBA by the clock
• Closed monitoring should be done in
first hours in PACU
 The need of muscle relaxation in
bariatric surgery
• Laparoscopic and robotic surgery requires insufflation
of the peritoneum to create space for operating.
• High intra-abdominal pressure
worsen cardiac
function, impede ventilation & reduce RBF [1].
• Reducing the intra-abdominal pressure < 10–12
mmHg
reduce physiological effects of
pneumoperitoneum
decrease aortic afterload,
improvement in RBF and lower peak airway ventilator
pressures
• ‘Deep block’ may allow operating at lower pressure
while maintaining intra-abdominal space for surgery [2],
but increase the need of NMBA
accumulation
1. Demyttenaere S, Feldman LS, Fried GM. Effect of pneumoperitoneum on renal perfusion and function: a systematic review.
Surg Endosc 21:152–160. 2007
2. 137. Bruintjes MH, van Helden EV, Braat AE et al. Deep neuromuscular block to optimize surgical space conditions during
laparoscopic surgery: a systematic review and meta- analysis. Br J Anaesth 118:834–842. 2017
 Goal of fluid administration
• to maintain intravascular volume, cardiac
output and tissue perfusion while avoiding
salt and water overload.
• to treat objective evidence of
hypovolaemia, and consequently improve
intravascular volume and circulatory flow
• most patients require crystalloids at a rate of
1–4 ml/kg/h to maintain homoeostasis
1. 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
2. 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
 Goal fluid management in ERAS
Reduce the need of fluid administration

Minimize hemodynamic changes

•Avoidance of deep general anesthesia
•General use of lung protective ventilation

Elimination of fluid preload before

epidural analgesia
Joshi GP, Kehlet H. CON: Perioperative goal-directed fluid therapy is an essential element of an
enhanced recovery protocol? Anesthesia and analgesia 2016;122(5):1261-1263.
Intraoperative Goal-Directed Fluid
Therapy (GDFT)
Relatively small-volume (200-250 mL) boluses of
fluid (usually a colloid) over background crystalloid
infusions have been used to increase stroke volume
and cardiac output, improve gut perfusion, and
decrease gut mucosal acidosis
Giglio MT, Marucci M, Testini M, et al. Goal-directed haemodynamic therapy and gastrointestinal
complications in major surgery: a meta-analysis of randomized controlled trials. Br J
Anaesth;103:637–646 2009

Stroke volume and CO measurement
TED, lithium

dilution, arterial pulse contour analysis, thoracic electrical
bioimpendance, partial non-rebreathing systems, and trans-
pulmonary thermodilution
ERAS or GFDT?

Despite the NICE Guidance which recommends that

GDFT technology should be used ‘‘in patients
undergoing major or high-risk surgery’’, but this study
suggests that GDFT may not be of use to all elective
patients undergoing major abdominal surgery

GDFT may be more of use in the intraoperative care

of high-risk patients, however, as yet, there are no
definitive data to support this belief.
 GDFT in ERAS Protocol
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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

Chatterjee S, Rudra A, Sengupta S. Current

concepts in the management of postoperative
nausea and vomiting. Anesthesiology research
and practice 2011. doi:10.1155/2011/748031
 PONV in ERAS Protocol
Preemptive, multimodal antiemetic prophylaxis
should be used in all at-risk patients to reduce PONV.
Avoid Minimize
Regional TIVA Adequate
emetogenic opioid and
anesthesia Propofol Hydration
stimuli neostigmine

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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