Optimizing Perioperative Care: Enhanced Recovery & Chinese Medicine (Surgery 212) PDF

Lecture/PPT |Lecturer| Books & other references OVERVIEW Background COMPONENTS THE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL VTE Prophylaxis Fluid Management Pain Management Ileus Prevention Traditional Chinese Medicine in Surgical Patients Bowel preparation for surgery Background_____________...

Lecture/PPT |Lecturer| Books & other references OVERVIEW Background COMPONENTS THE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL VTE Prophylaxis Fluid Management Pain Management Ileus Prevention Traditional Chinese Medicine in Surgical Patients Bowel preparation for surgery Background_______________________ Professor Henrik Kehlet (1995) ➔ 1st described perioperative regimen for patients following colon surgery Early oral nutrition Early mobilization Epidural anesthesia ➔ Founder of ERAS Prof Ken Fearon and Prof Olle Ljungqvist 2001 – ERAS Study Group Enhanced recovery after surgery Evidence-Based: ERAS_______________ ➔ ➔ Primary goal treat the surgical patient in a multidisciplinary team approach throughout the perioperative course Accelerate functional recovery Optimize patient outcomes based on evidence- based medicine Endpoint Faster recovery Less physiological stress Shorter hospital stay Fewer complications Classical teaching / practice Prolonged fasting post-op until signs of bowel function Excessive fluid administration Delayed postoperative mobilization NGT insertion to prevent anastomotic leaks - COMPONENTS THE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL A. Preoperative preoperative nutrition prehabilitation pt education and counseling smoking and alcohol cessation multidisciplinary team cardiopulmonary assessment venous thrombo-prophylaxis preoperative fasting and carbohydrate-rich loading B. Intraoperative surgical approach anesthetic management perioperative fluid and management prevention of hypothermia C. Postoperative early mobilization early removal of drains early enteral feeding perioperative pain control postoperative nausea and vomiting postoperative glycemic control Early mobilization is beneficial GIT TB: may mimic malignant Acholic stools - chlk colored stools, no bile, - prob in liver/ gall (biliary atresia) In signs of bowel obstruction Persistent vomiting due to risk for aspiration Laarni Early feeding decrease postop ileus (decrease motility) - if put ngt to drain out contents - walang magstimulate lalo na gumalaw GIT 1 of 7 Preoperative Counseling Booklet Home plan Patient expectations Details of surgery Risks and possible complications Expected time of recovery There is still risk for anastomotic leaks Stoma teaching / marking Colorectal surgery Exercise and prehabilitation Prepare for anticipated stress Impairment prevention Prehabilitation Process of enhancing the functional capacity of the individual to enable him/her to withstand a stressful event Optimization: lungs, cardiac, prehabilitation, nutrition Carb loading: no prolonged fast No bowel prep VTE prophylaxis Nutrition ➔ Significant catabolic stress during surgery Inflammation Nutrient depletion ➔ Nutritional Assessment Significant weight loss? BMI? ➔ Enteral or parenteral nutritional supplementation Standard oral nutrition – high protein, vitamins and minerals Immunonutrition - high protein, vitamins and minerals + Arginine + Omega-3 FA ➔ Smoking Cessation To decrease postoperative mortality To decrease post op complications Prolonged ventilation Pneumonia DVT Wound infection Delayed wound healing Reduced bone fusion Laarni ➔ - Carbon monoxide and Nicotine increase HR and body’s demand for O2 Vasoconstriction – reduced perfusion to tissue beds ➔ Preoperative Fasting and CHO Loading Traditional: 6-12 hours fasting before surgery leads to: Insulin resistance Hyperglycemia Failure to achieve a postsurgical anabolic state ERAS: clear liquids up to 2 hours prior to surgery, solids up to 6 hours Except: gastroparesis, intestinal obstruction, dysphagia Carbohydrate intake up to 2 hours does not increase risk for aspiration Reduces preop hunger, thirst, anxiety and nausea 100g CHO evening, 50g 2-3 hrs before surgery ➔ ➔ - 2 of 7 VTE Prophylaxis__________________ Advanced age Multiple medical comorbidities Prolonged procedure time Inflammatory and Hypercoagulable state of surgery Immobility Major general, vascular and orthopedic surgery Severe cardiopulmonary disease Non-pharmacologic Early ambulation Graduated compression stockings Intermittent Pneumatic compression devices Perioperative Pain Management Opioid-sparing, multimodal analgesia ➔ Opioids - Increase N/V, cause respiratory depression, reduce GI motility, worsen urinary retention, induce endocrine dysfunction, suppress the immune system Enhance pain management with reduction of side effects from opioids Acetaminophen NSAIDs Gabapentin Pharmacologic Low dose unfractionated heparin LMWH Perioperative Fluid Management Goal-directed fluid therapy Esophageal Doppler monitors Non-invasive cardiac output monitors Maintain normovolemia Hypovolemia – reduced circulating blood volume, renal perfusion, endothelial dysfunction Hypervolemia - ileus, bowel edema, hemodilution, pulmonary edema, tissue-healing complications (see appendix for larger picture) Laarni Postoperative Prevention Nausea and Vomiting 3 of 7 Early Nutrition and Postoperative Ileus Prevention Factors that enhance postop ileus Open surgery Long surgical procedure Blood transfusion Fasting Fluid overload Opioids Postoperative N/V NGT ERAS ERAS ERAS ERAS ERAS ➔ ➔ ➔ (see appendix for larger picture) ➔ Laarni in in in in in Colorectal Surgery Hepatopancreaticobiliary Surgery Gastrectomy and Esophagectomy Bariatric Surgery Other Surgical Specialties Traditional Chinese Medicine in Surgical Patients Oldest medicine in China that have been used to combat diseases for thousands of years A medical system with unique theory, style diagnoses and treatments – resulted from Chinese philosophy of protecting life shape Important part of the Chinese culture, making outstanding contributions over thousands of years because of its systemic theory, distinctive treatment methods, significant efficacy, and abundant historical documentation Bowel preparation for surgery Large Chengqi decoction or Seasoning Chengqi decoction Increases GI motility and washes GI stagnation Improve visceral blood flow and peritoneal absorption promote early recovery of post op bowel function Prevent superimposed infection of the intestine 4 of 7 ➔ - ➔ ➔ ➔ - Preoperative Optimization During Sepsis and Infection Pure ginseng decoction Supplemented by blood transfusion can rapidly raise BP and provide optimal setting for surgical treatment Perioperative pain management Combined acupuncture and medicine anesthesia Acupuncture enhances the level of endogenous opioid, Encephalin Restrains the pain signal from being transmitted to the CNS Blocks the body’s reaction to pain Increase pain threshold PONV and Postoperative ileus Acupuncture or transcutaneous electroacupuncture Improves stress-induced impairment in gastric motility functions Inhibit the frequency of transient lower esophageal sphincter relaxation Chinese herb decoctions a. b. c. d. acupuncture pure ginseng decoction exercise proper diet 1. 2. 3. 4. 5. ANSWER KEY False - 2 hrs opioid B - hyperglycemia D B NOTES:_______________________ Two ERAS hospital in the Philippines: Philippine general hospital Medical city Carbohydrate sources before surgery C2 + 4T sugar Sunkiss 400cc (2 hours before the surgery) Best time to stop smoking is 2-4 weeks before the surgery. Bowel surgery NGT (at least 3 days) Don’t give morphine only, combine it with other drugs - MULTIMODAL ANALGESIA Best way to prevent ILEUS is early oral feeding Remove drains if not needed already and check for its indications. REVIEW TEST Carbohydrate intake up to 1 hour does not increase risk for aspiration. True or False 2. Increase N/V, cause respiratory depression, reduce GI motility, worsen urinary retention, induce endocrine dysfunction, suppress the immune system 3. Traditional: 6-12 hours fasting before surgery leads to, except a. Insulin resistance b. Hypoglycemia c. Failure to achieve a postsurgical anabolic state d. NOTA 4. Standard oral nutrition a. high protein, b. vitamins and minerals c. Arginine + Omega-3 FA d. AOTA 5. Supplemented by blood transfusion can rapidly raise BP and provide optimal setting for surgical treatment 1. Laarni APPENDIX 5 of 7 Laarni 6 of 7 Laarni 7 of 7