I Putu Pramana ERAS in NeuroAnesthesia
I Putu Pramana ERAS in NeuroAnesthesia
I Putu Pramana ERAS in NeuroAnesthesia
reduce complications
shorter LOS
better long-term survival
Enhanced Recovery After Surgery (ERAS)
• 1990’s Henrik Kehlet
• 2000s’ Colorectal Surgery
• 2010 ERAS Society:
The cornerstones of ERAS®
Evidence-based perioperative care
Multidisciplinary and multi-professional
approach
Teamwork
Continuous interactive audit and reporting
Data-driven change
Readiness to make the next change
ERAS considerations
Clinical Effectiveness
Patient Safety
Patients Satisfactions
Surgery is a stressor
Stress Response Modification:
Modern Approach
No single answer
A number of multimodal approaches that the
anesthesiologist can employ to minimize surgical stress and
the physiological disruption that prevents early recovery
Stress Response Modification:
Decrease the stress of
Surgery
Decrease the Insulin
resistance related to
surgical stress
Avoid prolonged fasting
Carbohidrat loading
Optimal Pain
management
Goal Directed Fluid
Theraphy
ERAS
Intraoperative Phase
Opioid sparing, Normovolemia Nausealvomiting Normothermia Normoglycmia Avoid tubes and
multimodal analgesia prophylaxis drains
Postoperative Phase
Early nutrition Early mobilization Multimodal Nausea/vomiting V No or judicious IV Patient & family
analgesia management fiuid management education
Post-Discharge Phase
Monitor for symptoms or changes in health Follow-up with surgeon, proceduralist, Continue therapy and other
to seek assistance primary care and/or specialty care interprofessional activites as planned
Early Mobilization
Early resumption of Nutrition
ERAS pathways have become the established
standard of care in many areas of surgery.
Preoperative
Preoperative counseling and ERAS protocol and strategy explained in Conventional/routine Patients were
detail. Patients were explained the benefits explained the benefits of counseling and
education of abstaining from alcohol and smoking. reoperative counseling
Relatives were explained the benefits of
early ambulation and discharge from the
ICU. Active involvement with the nursing
team to assist in postoperative feeding and
ambulation under nursing supervision was
encouraged.
Preoperative fasting Preoperative maltodextrin 200ml (380 Kcal) 6-8 hours. For solid food and 2 hrs for water
is given on the night before surgery and
100ml 2 hrs. before surgery
Preemptive analgesia Tab. Fiupiritine maleate (100 mg) given the Nil
night before and 2 hrs. before surgery
Preoperative RBS Measured for all patients Measured only for diabetics
ERAS protocol vs. conventional care
Strategy ERAS Group Control Group
Intraoperative
Scalp blocks with Inj Given shortly after induction for all Routine infiltration with 10-20 ml 1%
Bupivacaine 0.25% patients lignocaine at incision and pin site.
Postoperative
Pain management 1.Paracetamol 1. Paracetamol
2.Tab. Flupiritine maleate 2.Inj. Fentanyl
3.Rescue with Inj. Fentanyl
Oral sips of via RT Encouraged immediately (within 2 Withheld for 4-6 hr. after
hrs.) of extubation extubation
No Difference
Propofol TIVA vs
Sevoflurane
Anesthesia = titration to needs
Pharmacodynamic approach: titrating drugs to effect
Clinical signs, hemodynamics
EEG parameters or other techniques to measure “depth” of
anesthesia
Pharmaceutical approach: choosing “forgiving drug”
Pharmacokinetic approach: knowledge of concentration-
effect relationship
MAC
Therapeutic window concentrations
Dosage schemes that pretend to achieve these concentrations
Target Controlled Infusions
Target Plasma Concentration (µg/ml)
Etomidate - 0.31-0.5
Target concentrations opioids
Multimodal Analgesia
Options
1. Scalp block
2. NSAIDS (Cox2)
3. Dexmedetomidine
4. Lidocaine
5. Gabapentinoids
6. Paracetamol i.v
International Journal of Medical Sciences
Introduction
ERAS Component
Pre Operative
Intra Operative
Post Operative
ERAS in Neurosurgery
TCI Introduction