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Fast Track Surgery (ERAS) Fast Track Surgery (ERAS)

Fast Track Surgery (ERAS) - PowerPoint Presentation

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Uploaded On 2020-06-17

Fast Track Surgery (ERAS) - PPT Presentation

Surgeons Perspective Dr Vidhyachandra Gandhi DNB GI surgery DNB Gen Surgery FSGE Gastrointestinal ampHPB Surgeon Pune Why is the patient in hospital today Concept of stress in surgery ID: 780441

surgery day remove early day surgery early remove removal increase ambulation analgesia pod postoperative bowel eras amp pre patient

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Presentation Transcript

Slide1

Fast Track Surgery(ERAS)Surgeons Perspective

Dr.

Vidhyachandra

Gandhi

DNB (GI surgery), DNB (Gen Surgery), FSGE

Gastrointestinal &HPB

Surgeon

Pune

Slide2

Why is the patient in hospital today ?

Slide3

Concept of stress in surgeryStimulation of HPA axis - glucocorticoids

Stimulation of sympathetic nervous system - catecholamines

Slide4

`Decrease physiological stress

Decrease psychological stress

Decrease organ dysfunction

Focus …..

Slide5

Slide6

Components

Slide7

FTS – Does not includeFTS and early discharge

One track surgery

– no rigid “one size fits all” protocol

Cost containment

Slide8

Pre op strategies

Patient Education

realistic information

counseling

Slide9

Pre op strategies

Reduce Fasting

Traditional 6 hrs fasting not required

long fasting – increase gastric volume & decrease Ph

Carbohydrate rich drink prior to elective surgery

- conflicting data

Slide10

Pre op Carbohydrate loading …..Early recovery from surgery and shorter length of hospital stay 

Decreases insulin resistance with reduced risk of hyperglycemia in the perioperative period 

Reduction in thirst, headache and hunger sensation

Reduces postoperative nausea and vomiting 

Enhances return of bowel function

Improves postoperative food intake 

Maximizes glycogen reserve to support glucose production through surgery, decreases protein breakdown and improves muscle strength 

 

Slide11

Pre op strategies

Mechanical bowel Preparation

Routine use not recommended

Rectal surgeries and lap surgery

Improve pre op nutrition

Avoid smoking

Slide12

Minimal invasive surgery

FTS = MIS

Synergistic

Complimentary

Slide13

Drains – Early removal

Avoid placement

Detect blood, bile and anastomotic leak – no evidence

Hampers mobilization - cut and bag

Increases SSI, increase pain

Catheters – early removal

discomfort , urosepsis

Nasogastric tubes – early removal

Slide14

ERAS

EARLY FEEDING

Slide15

Myth and Facts

Basal digestive enzyme output is around 5-6 litres

Even if nothing is taken by mouth so much fluid will go across the anastomosis.

“Protection” by keeping NPO is a wrong premise

Slide16

Enteral Feeds

Per oral

Nasogastric

Nasojejunal

Feeding Jejunostomy

Slide17

Early Enteral feeds Wound healing

Better anastomotic healing

Reduces septic complications

Faster return of GI function

Reduces surgical stress

Early discharge

Decreases cost

Patient satisfaction

Slide18

Some patient reactions..

“I threw up most of the night . . . and then they put up a drip to maintain the fluid balance, but they quickly took it down again . . presumably from the understanding that I should pull myself together and get some liquids down me. So I had to force myself to drink”.

Slide19

Middle Path

After your operation you can Eat and Drink whatever appeals to you

But we Don’t advise resuming a normal diet or eating a lot of solid food during the first 2-3 Days.

Slide20

Early Ambulation – Day 0/1Reduce muscle loss

Improve pulmonary function

Improve tissue oxygenation

Avoid venous stasis

GOOD ANALGESIA

Slide21

Implementation - FTS

Slide22

Indian scene

Public sector

Private sector

Insurance sector

Slide23

Barriers to ImplementationLack of awareness

Difficult to accept

More emphasis on surgical technique – MIS

Lack of support, lack of interest

Slide24

Barriers to ImplementationComplications viewed as failure

Cultural beliefs

Slide25

Limitations

Low compliance and adherence to protocol

Applicability in elderly pts

Only colorectal surgery – not true

Slide26

Slide27

Slide28

Length of stay was significantly decreased in ERAS patients in

both all studies and the randomized trial subgroup (P < 0.001 for both).

Slide29

Hospital cost – decreased in ERAS

Time to flatus – shorter in ERAS

Readmission rate – no difference

Slide30

Significant decrease in pulmonary , urinary tract and SSI

Slide31

Slide32

How do I do ?

Lower GI Surgery (Colorectal & Small Bowel)

POD1

Remove ryles tube

All liquids as tolerated.

Supplemental I.V fluids to maintain urine output

Increase liquids in evening , if tolerated well

Ambulation .

Encourage Incentive spirometry every 2 hours for 5 minutes.

Epidural analgesia ,with Diclofenac as rescue analgesic.

Intravenous ondansetron 4mg for any postoperative nausea or vomiting.

Removal of urinary catheter for all who underwent colonic resections and anterior resection.

Slide33

How do I do ? Lower GI Surgery (Colorectal & Small Bowel)

POD 2

Assess tolerance to the previous evening’s feed- Nausea, vomiting, abdominal distention, abdominal cramps and any episode of fever

If patient is comfortable and clinical assessment is satisfactory (no abdominal distention/ fever), then allow patient’s usual daily food intake.

Ambulation to be actively encouraged as the previous day.

Incentive spirometry

Remove epidural catheter.

Oral analgesia

Rescue analgesia if required

Cut and bag the drains if placed

Wound Inspection and dressing change.

Slide34

How do I do ?

Lower GI Surgery (Colorectal & Small Bowel)

POD 3

Remove urinary catheter for those who underwent low anterior resections.

Assess tolerance to feeds the previous day.

Continue allowing usual diet.

Continue ambulation.

Continue incentive spirometry.

Continue analgesia with T. Diclofenac

POD 4/5

Discharged

Slide35

How do I do ? Upper GI Surgery (Gastrectomy)

Nasogastric tube removal on postoperative day 1.

Allow to drink water on postoperative day 1.

Clear liquid diet on POD2.

Solid diet on demand anytime after POD 4.

Drain removal on POD 5.

Slide36

How do I do ? Upper GI Surgery (Esophagectomy)

Jejunostomy feeds day 1 and increase subsequently

Ambulation day 1

Remove ryles tube day 3

Remove neck drain day 3

Remove Foleys day 3

Gastrograffin swallow day 5 and start orally

Slide37

How do I do ? Whipples

Jejunostomy feeds day 1 and increase subsequently

Ambulation day 1

Remove ryles tube day 2

Orals on day 3 and increase subsequently

Remove Foleys day 3

Abdominal drains - cut and bag / removed later depending on output

Slide38

BenefitsEarly discharge

Streamlining in surgical care

Better QOL

Reduce morbidity

Improved institutional efficiency

Slide39

Email : drgandhivv@gmail.com