Enhanced Recovery from Anesthesia and Surgery An Ambulatory Surgery Perspective D. John Doyle MD PhD Chief, Department of General Anesthesia Cleveland Clinic Abu Dhabi Professor of Anesthesiology Cleveland Clinic COI Disclosure: Pfizer speakers bureau 25 minutes

Objectives List the central principles upon which ERAS programs are based. Explain how the choice of anesthetic technique influences surgical outcomes. Describe how multimodal pain therapy impacts on surgical outcomes. Identify the steps to setting up a local ERAS program.

Discuss what is special about ERAS in the ambulatory surgery setting.

ERAS goals Reduce surgical stress / inflammatory processes Maintain postoperative physiological function Early mobilization after surgery Faster recovery Reduced complications (morbidity, mortality) Reduced length of stay Reduced expenses

17 Elements to ERAS Example ERAS Study Laparoscopic Colorectal Surgery Navel Example ERAS Study International Journal of Surgical Research 2013; 2(5): 57-62. Enhanced Recovery after

Surgery (ERAS) in Patients Undergoing Colorectal Surgeries doi:10.5923/ In a study of 222 patients undergoing elective colorectal surgery 106 cases and 116 controls - there was no significant difference between the ERAS and control group for morbidity and mortality. Regular feeding was tolerated much earlier in ERAS group (3days vs 7days). Bowel function returned earlier in the ERAS group (2.9 days vs 5.3 days). Readmission within 30 days of discharge was higher for the ERAS group (6.6% vs 0%). 8 ERAS Elements Pertain Specifically to Anesthesia ERAS & Anesthesia

Prevention of PONV

Optimal Fluid Therapy No Opiates / Multimodal Pain Therapy Keeping the Patient Warm No Premedication Short-acting Anesthetics Carbohydrate Loading Mid-thoracic Epidurals Lack of Benefit for Routine Premedication Among patients undergoing elective surgery under general anesthesia,

sedative premedication with lorazepam compared with placebo or no premedication did not improve the self-reported patient experience the day after surgery, but was associated with modestly prolonged time to extubation and a lower rate of early cognitive recovery. The findings suggest a lack of benefit with routine use of lorazepam as sedative premedication in patients undergoing general anesthesia. Maurice-Szamburski A, Auquier P, Viarre-Oreal V, Cuvillon P, Carles M, Ripart J, Honore S, Triglia T, Loundou A, Leone M, Bruder N; for the PremedX Study Investigators. Effect of Sedative Premedication on Patient Experience After General Anesthesia: A Randomized Clinical

Trial. JAMA. 2015 Mar 3;313(9):916-925. doi: 10.1001/jama.2015.1108. PubMed PMID: 25734733. American Society of Anesthesiologists Sues BevMD, Maker of Clearfast, for False Claims of Product Endorsement Society seeks relief from damages to its reputation as

an unbiased scientific organization Released: 27-Jan-2015 Nonopiate Pain Management

Local and regional anesthesia Systemic lidocaine Acetaminophen NSAIDS (e.g., ketorolac)

Corticosteroids Ketamine Magnesium 2 Adrenoceptor Agonists (clonidine and dexmedetomidine ) Gabapentinoids (gabapentin and pregabalin) Corticosteroids Lidocaine

Recent literature suggests that an adjunctive intraoperative lidocaine infusion (100 mg intravenously prior to incision and then 12 mg/kg/hour ) aids in patient recovery after surgery, presumably as a result of its newly discovered anti-inflammatory properties.

Ketamine Ketamine is an NMDA receptor antagonist, but it also acts at other sites (including opioid receptors and monoamine transporters). Ketamine comes as a racemic mixture consisting two enantiomers, Rand S-ketamine. Pure S-ketamine (availabale in Europe) is reported to be less prone to psychomimetic side effects, such as derealisation and hallucinations. Posterior spine fusion study Give 0.2 mg/kg on induction of general anesthesia and

then 2 mcg/kg/hour for the next 24 hours. Perioperative infusion of subanesthetic ketamine was effective in reducing pain in narcotic-tolerant patients after posterior spinal fusions. It reversed unacceptable levels of pain in patients resistant to conventional narcotic treatment. Gabapentin and Pregabalin Gabapentinoids mainly act on the -2--1

subunit of pre-synpatic calcium channels and inhibit neuronal calcium influx. This results in a reduction in the release of excitatory neurotransmitters such as glutamate, substance P, and calcitonin gene-related peptide from primary afferent nerve fibres thus suppressing neuronal excitability after nerve or tissue injury.

able 2. Summary of clinical benefits Drug Summary of clinical benefits Ketamine Useful adjuvant in painful procedures: upper abdominal, thoracic, and major orthopaedic surgeries (Level I) 5 Useful adjuvant to PCA analgesia (Level I)1 Patients with chronic pain issues and on high-dose opioidsdecreases pain intensity and opioid consumption lasting

much beyond the perioperative period (Level II)17 Opioid-resistant painrescue analgesia (mixed evidence; Level II)1 Has preventive but not pre-emptive analgesic effect (Level I). Studies looking at the role of ketamine in preventing CPSP have shown only mixed effects (Level II)1 Pregabalin Riskbenefits probably more acceptable for painful procedures resulting in acute neuropathic pain, requiring large doses of opioids (e.g. cardiothoracic surgery, arthroplasty, or spine surgery) in order for the reduction in opioid-related side-effects to outweigh the side-effects. The evidence for this is limited and needs further research. Risks for minor,

laparoscopic, or day-care procedures probably outweigh the benefits 7 Useful preventive analgesic effect9 Gabapentin Benefits similar to pregabalin, but being an older drug has more literature evidence Improved analgesia at rest and movement (Level I) Improved functional recovery with better range of movements and pulmonary function (Level II) 10 Analgesic effect comparable and synergetic with NSAIDS and superior to tramadol10 Useful adjuvant to epidural analgesiadecreased pain scores, epidural analgesic consumption, and patient

satisfaction despite an increase in dizziness1 In established acute postoperative pain, single-dose gabapentin is superior to placebo but worse than other commonly used analgesic. The NNT was 11 (Cochrane review)18 Useful preventive analgesic effect9 A small RCT (60 patients undergoing abdominal hysterectomy) showed gabapentin was superior to ketamine in preventing CPSP9 I.V. lidocaine Useful in visceral pain and improves postoperative bowel function after abdominal surgeryreduces pain and opioid

requirements, nausea, vomiting, duration of ileus, resulting in decreased time to pass flatus, faeces and earlier intake of enteral food, rehabilitation, and discharge (Level I)12,13 Benefit seen even in patients undergoing laparoscopic colectomy as part of acute rehabilitation programme 12,13 No proven use in non-abdominal surgeries12 Probably has a preventive effect after major abdominal and breast surgery (Level II)14,15 Systemic 2 agonist Moderate analgesic benefitprobably better than paracetamol but less than that of ketamine and NSAIDS as

inferred from non-systematic indirect comparison16 All these beneficial effects may come at a price of significant hypotension and bradycardia 19 Useful adjuvant in perioperative care in adults and children because of several useful extra analgesic benefits such as sedation, anxiolysis, analgesia, postoperative shivering, PONV, agitation, mitigation of stress response to surgery and tracheal intubation, anaesthetic-sparing effect, and as supplement to neuraxial and peripheral nerve blocks 16 Decreased perioperative mortality and myocardial infarction especially in high-risk vascular surgeries 19 No evidence for preventive analgesia16

Magnesium Systemic administration of perioperative magnesium reduces postoperative pain and opioid consumption. De Oliveira GS Jr, Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2013 Jul;119(1):178-90.

Dexamethasone Single dose IV dexamethasone at doses over 0.1 mg/kg is an effective adjunct to reduce postoperative pain and opioid consumption after surgery. De Oliveira GS Jr, Almeida MD, Benzon HT, McCarthy RJ. Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2011 Sep;115(3):575-88.

Fluid Therapy Intravenous fluid therapy in the perioperative period is undergoing a reassessment crisis with a trend towards giving less fluid volumes and a smaller salt load. Third spacing has been debunked! This means more use of pressors like phenylephrine.

Third-Spacing is a Myth In summary, a classic third space was never localized and only quantified with one specific method using certain conditions regarding sampling and equilibration times, implying serious concerns and weaknesses. All other methods using various tracers, multiple sampling techniques, longer equilibration times, or analysis of kinetics contradict the existence of a fluid-consuming third space. Taking all this into account, we have to conclude that a classic third space per

se quantitatively does not exist. It is currently not more than an ill-defined compartment thought to reflect an otherwise unexplainable perioperative fluid shift. Therefore, we suggest abolishing this mystery and sticking to the given facts: Fluid is perioperatively shifted within the functional extracellular compartment, from the intravascular toward the interstitial space Chappel D et. al. Anesthesiology 109, 723: 2008 Perils of Aggressive Fluid Resuscitation

New evidence suggests that aggressive fluid resuscitation leads to severe tissue edema that compromises organ function and leads to increased morbidity and mortality Marik PE: Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care 2014; 4:21 Kelm DJ, Perrin JT, Cartin-Ceba R, et al: Fluid overload in patients with severe sepsis and septic shock treated with early goal-directed therapy is associated with increased acute need for fluid-related medical interventions and hospital death. Shock 2015; 43:6873

Performance Monitoring Special Considerations for Ambulatory Surgery Cases Spinals and epidurals are sometimes not practical in ambulatory surgery but other forms of regional anesthesia sometimes are.

Special emphasis on Pain control PONV prevention Discharge readiness (several dimensions) Conclusions ERAS programs are a particularly effective way of providing improved surgical care. Clinical trials evaluating various ERAS

protocols have been published. All ERAS programs have important anesthetic components, especially with respect to pain management. The ERAS Society has many valuable resources to help interested clinicians. Selected References 1: Rasmussen LS, Steinmetz J. Ambulatory anaesthesia and cognitive dysfunction. Curr Opin Anaesthesiol. 2015 Dec;28(6):631-5. doi: 10.1097/ACO.0000000000000247. PubMed PMID: 26308519.

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surgery (ERAS) protocols for colorectal cancer in Japan. BMC Surg. 2015 Jul 28;15:90. doi: 10.1186/s12893-015-0079-0. PubMed PMID: 26215107; PubMed Central PMCID: PMC4517644. 13: Gravante G, Elmussareh M. Enhanced recovery for non-colorectal surgery. World J Gastroenterol. 2012 Jan 21;18(3):205-11. doi: 10.3748/wjg.v18.i3.205. PubMed PMID: 22294823; PubMed Central PMCID: PMC3261537. 14: Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J. Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery. Colorectal Dis. 2012 Sep;14(9):1045-51. doi: 10.1111/j.14631318.2011.02856.x. Review. PubMed PMID: 21985180. 15: Hoffmann H, Kettelhack C. Fast-track surgery--conditions and challenges in postsurgical treatment: a review of elements of translational research in enhanced recovery after surgery. Eur Surg Res. 2012;49(1):24-34. doi: 10.1159/000339859. Epub 2012 Jul 11. Review. PubMed PMID: 22797672. 16: Varadhan KK, Lobo DN, Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Crit

Care Clin. 2010 Jul;26(3):527-47, x. doi: 10.1016/j.ccc.2010.04.003. PubMed PMID: 20643305. 17: Nelson G, Kalogera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014 Dec;135(3):586-94. doi: 10.1016/j.ygyno.2014.10.006. Epub 2014 Oct 12. Review. PubMed PMID: 25316179. 18: Keane C, Savage S, McFarlane K, Seigne R, Robertson G, Eglinton T. Enhanced recovery after surgery versus conventional care in colonic and rectal surgery. ANZ J Surg. 2012 Oct;82(10):697-703. doi: 10.1111/j.14452197.2012.06139.x. Epub 2012 Aug 9. PubMed PMID: 22882553. More Information (15 sets of educational slides)


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