![Back To The Past
PREOPERATIVE PROLONG FASTING
MECHANICAL BOWEL PREPARATION
NASOGASTRIC TUBE
DRAIN TUBE, [ in any GIT surgery ]
PROLONG BED REST](https://image.slidesharecdn.com/erasprotocol3-200130193949/85/Eras-protocol-3-2-320.jpg)
![Evolution of Surgical Principles replaces the dogma
and brought the concept of
THIS CONCEPT WAS FIRST
DESCRIBED BY Dr Henrik Kehlet [1990]
E R A S](https://image.slidesharecdn.com/erasprotocol3-200130193949/85/Eras-protocol-3-3-320.jpg)
![ERP –KEY ELEMENT
2. Pre operative nutrition
In adequate nutrition independly increase risk and hospital stay
ESPN criteria[european society of parenteral and enteral nutrition] of severe
nutritional risk
weight loss> 10-15%.
BMI <18.5
Serum Albumin<30 gm/lit
MANAGEMENT:
Appropriate input
Standerd whole protein liquid nutritional
supplement](https://image.slidesharecdn.com/erasprotocol3-200130193949/85/Eras-protocol-3-9-320.jpg)
![ERP –KEY ELEMENT
• AVOID Drain tube
increases hospital stay
increase risk of infection
PREVENTION OF PONV[POST OP NAUSEA & VOMITING]
ONDENSATRON](https://image.slidesharecdn.com/erasprotocol3-200130193949/85/Eras-protocol-3-17-320.jpg)
Eras protocol (3)
- 1. ERAS PROTOCOL Enhance Recovery After Surgery Dr Asik Hossain Mallick, JR, 1ST Year
- 2. Back To The Past PREOPERATIVE PROLONG FASTING MECHANICAL BOWEL PREPARATION NASOGASTRIC TUBE DRAIN TUBE, [ in any GIT surgery ] PROLONG BED REST
- 3. Evolution of Surgical Principles replaces the dogma and brought the concept of THIS CONCEPT WAS FIRST DESCRIBED BY Dr Henrik Kehlet [1990] E R A S
- 4. ERP • Integrated, Evidence Based, Multimodal,Consensus on perioperative care
- 5. ERAS GOAL 1 Reduction of stress response to surgery 2 Accleration of Recovery
- 6. Team Member of successfull ERP • NURSES • DIETITIANS • PHYSIOTHERAPIST • PAIN MANAGEMENT TEAM • ANESTHETIST • SURGEON • HOSPITAL MANAGEMENT • AUDIT TEAM
- 7. ERP COMPONENT PRE ADMISSION •OPTIMISATION •COUNSELLING •ORAL SUPPLIMENT •Peri operative nutrition PRE OPERATIVE • Admission on day of surgery • Pre op nutrition • Reduce preoperative fasting and carbohydrate loading • Selective bowel preparation • Prophylaxis of DVT and Antibiotic • Perioperative opoid sparing analgesic Anesth esia • Normothermia •Thoracic epidural anesthesia and short acting anesthetic gas • Avoid fluid overload • Non opiate analgesia SURGICAL • Approach- Laproscopic/Transverse incision/Short incision • Avoid surgical Drain And Nasogastric tube POST OPERATIVE • Hydration •Active Multimodal PAIN Control • Aggressive Management of Nausea vomiting • Early oral feeding and Mobilisation • Nutritional support • Catheter Drain Omit
- 8. ERP –KEY ELEMENT • 1. Pre Admission Counselling Clear explanation regarding hospitalisation Role of patient about food intake, nutrition supplement,
- 9. ERP –KEY ELEMENT 2. Pre operative nutrition In adequate nutrition independly increase risk and hospital stay ESPN criteria[european society of parenteral and enteral nutrition] of severe nutritional risk weight loss> 10-15%. BMI <18.5 Serum Albumin<30 gm/lit MANAGEMENT: Appropriate input Standerd whole protein liquid nutritional supplement
- 10. ERP –KEY ELEMENT • 3 Admission on day of surgery • 4 Reduction of Prolong Fasting as NPO: increases thirst no gurentee of empty stomach very less impact upon gastric volume PROLONG Fasting stress glucose & insulin resistence
- 11. ERP –KEY ELEMENT • 5 CARBOHYDRATE LOADING Tissue injury Hypovolemia HPA AXIS CORTISOL Gluconeogeneasis INFECTION Hypoxia weight loss BETA CELL BLOCK INSULIN PRODUCTION Management: Clear carbohydrate drink the day prior to surgery up to 2 hr before surgery acclerate recovery and reduce hospital stay
- 12. ERP –KEY ELEMENT 6 .Selective bowel preparation Avoid MBP 6 Hr Fast for solid and Particulate food Clear fluid until 2 hr before induction
- 13. ERP –KEY ELEMENT • 7.PREVENTION OF POST OP ILEUS Normal GI peristalsis is maintained by 1. Enteric Bowel handling & surgical stress 2. CNS opioid 3Hormonal influence intra op fluid overload
- 14. POST OP ILEUS MANAGEMENT 1 Epidural anaesthesia 2 Non opiate analgesia 3 Avoid short term NSAID 4 Minimal invassive surgery 5 Gentle tissue handling 5 Avoidance of fluid overload avoid Na and Fluid overload Oesophageal Doppler monitoring 6 Early feeding 7 Use of chewing gum presence of sorbitol and hexitol saliva &pancreatic secretion cephalovagal stimulation 8 Early Mobilisation Bed rest insulin resistance
- 15. ERP –KEY ELEMENT AVOIDANCE OFNASOGASTRIC TUBE Increases risk of ATELECTASIS FEVER PNEUMONIA THORACIC EPIDURAL ANAESTHESIA Decreases GA risk Block Stress hormone release
- 16. ERP –KEY ELEMENT • SHORT ACTING ANESTHETIC AGENT PROPOFOL, Remifentanyl Short acting inhalational agent NORMOTHERMIA Hyperthermia causes dehydration Hypothermia increase risk of bleeding wound infection tranfusion requirment
- 17. ERP –KEY ELEMENT • AVOID Drain tube increases hospital stay increase risk of infection PREVENTION OF PONV[POST OP NAUSEA & VOMITING] ONDENSATRON
- 18. ERP –KEY ELEMENT • DISCHARGING CRITERIA Good pain control Solid food intake Independendly mobile or same level as prior to admission willing to go home
- 19. Thank you