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1. HOW TO IMPROVE QUALITY
OF PERIOPERATIVE PATIENT
CARE BY USING ERAS:
ENHANCED RECOVERY
AFTER SURGERY
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2. INTRODUCTION
• Enhanced Recovery After Surgery (ERAS): the care delivered by surgical team
• Before
• During
• After surgery
• Multidisciplinary team: anesthesiologist, surgeons, nurses
• Designed to reduce perioperative stress, maintain postoperative physiologic
function, and accelerate recovery after surgery
• Using multimodal stress-minimizing approach reduces rate of morbidity, improves
recovery, and shortens length of stay

3. INTRODUCTION
• ERAS on general surgery:
• Elective colorectal
• Elective rectal/pelvic
• Gastrectomy
• liver
• Others:
• Gynecologic
• TKA/THA

5. PREOPERATIVE PHASE
• Preadmission counseling
• Fluid and carbohydrate loading
• No prolonged fasting
• No/selective bowel preparation
• Antibiotic prophylaxis
• Thromboprophylaxis
• No premedication

6. PREADMISSION COUNSELING
• Information
• Education
• Counseling
• Reduce anxiety and subsequent pain
• Patient-centered

7. PREOPERATIVE OPTIMIZATION
• Risk assessment
• Alcohol cessation: > 4 weeks
• Smoking cessation: > 4 weeks

8. PREOPERATIVE OPTIMIZATION:
RISK ASSESSMENT
• Heart: in cardiac and non-cardiac surgery  ASA classification
• Lung: Asthma and COPD
• Kidney: 1% of non-cardiac surgery develop AKI
• Hypertension: target at 80 = 110% baseline
• DM: blood sugar 80 – 180 mg/dL is accepted
• Anemia: Hb 6 – 10 g/dL and > 8 g/dL in higher risk are accepted
• Malnutrition: nutritional support for 7 – 10 days

9. PREHABILITATION
• Aerobic and resistance exercise together
• Protein supplement
• Relaxation strategies

10. PREVENTION OF PONV
• PONV = postoperative nausea and vomiting
• It can develop 30 – 50% postoperatively and can cause dehydration and delayed
adequate nutritional intake
• Risk factors:
• patient-related: female, Hx of motion sickness
• Anesthesia-related: TIVA, propofol, liberal use of opioids
• Surgery-related: GI surgery

11. PREVENTION OF PONV
• Use of preoperative antiemetic drugs can reduce PONV:
• First line: droperidol, ondansetron, dexamethasone
• Second line: promethazine, scopolamine, metroclopramide
• Gabapentin, pregabalin
• IV paracetamol

12. PRE-ANESTHETIC MEDICATION
• Pre-and post-operative anxiety may increase analgesic requirement
and complication rates
• Use benzodiazepine with caution in elderly
• Melatonin
• Paracetamol, NSAIDS, and gabapentinoids (gabapentin and
pregabalin) in combination

13. ANTIMICROBIAL PROPHYLAXIS AND
SKIN PREPARATION
• Hair removal does not reduce SSI – use clippers if needed
• Chlorhexidine antiseptic – reduce SSI
• IV antibiotics: 60 min prior to skin incision
• No evidence on antiseptic shower and drapes

14. FLUID AND ELECTROLYTE THERAPY
• Avoid prolonged preoperative fasting
• Patient can drink clear liquid diet up to 2 h prior to induction
• Euvolemia before induction

15. PREOPERATIVE FASTING AND
CARBOHYDRATE LOADING
• Clear liquid: 2 h
• Light meal: 6 h
• complex CHO-maltodextrin, 12.5%, 285 mOsm/kg,
800 ml in the evening before surgery and 400 ml 2–3 h
before induction of anaesthesia: reduce insulin resistance and prevent
protein breakdown
• Not proper in patients with DGE, GI motility disorder, emergency
surgery – fast for 8 h

16. INTRAOPERATIVE PHASE
• Short-acting anesthetic agents
• Mid-thoracic epidural anesthesia/analgesia
• No drains
• Avoid salt and water overload
• normothermia

17. STANDARD ANESTHETIC PROTOCOL
• Avoid benzodiazepine
• Use short-acting general anesthetic drugs
• Cerebral monitoring
• monitoring of the level and complete reversal of neuromuscular block

18. INTRAOPERATIVE FLUID AND
ELECTROLYTE THERAPY
• Most patients require crystalloid 1 – 4 ml/kg/hr to maintain fluid
homeostasis
• Avoid excessive fluid and organ hypoperfusion  euvolemia
• Near zero fluid balance should be preferred
• Inotropes should be considered in patient with poor contractility

19. PREVENTING INTRAOPERATIVE
HYPOTHERMIA
• Keep 36oC or over

20. SURGICAL ACCESS
• MIS has shown to improve and more rapid recovery, reduced general
complications, reduced incisional hernia rate reduced adhesion
• Laparoscopic, hand-assisted, robotic

21. DRAINAGE
• It used to be used for drain collection and detect anastomotic leakage
• Should not be routinely used

22. NASOGASTRIC INTUBATION
• Postoperative NG intubation should NOT be used routinely: remove
before reversal

23. POSTOPERATIVE PHASE
• Analgesia
• No NG tube
• Prevention of PONV
• Prevention of POI
• Avoid salt and water overload
• Early catheter removal
• Early oral nutrition
• Early mobilization
• Stimulation of gut motility
• Audit of compliance and outcome

24. POSTOPERATIVE ANALGESIA
• Multimodal analgesia
• Opioid sparing: reduce PONV, POI, sedation, respiratory depression
• Paracetamol and NSAIDS: basic
• Lidocaine and dexmedetomidine infusion
• Surgical site infiltration
• Epidural analgesia and TAP block

25. THROMBOPROPHYLAXIS
• Mechanical: well-fitting compression stocking and/or intermittent
pneumatic compression until discharge
• Pharmacological: LMWH OD x 28 days

26. POSTOPERATIVE
FLUID AND ELECTROLYTE THERAPY
• Near-zero fluid and electrolyte balance
• Hypotonic solution should be used (to prevent high NaCl)

27. URINARY DRAINAGE
• Use for 2 main reasons: prevention of AUR and monitoring UO
• Early removal is recommended (1-3 days)

28. PREVENTION OF POSTOPERATIVE ILEUS
• Using multimodal analgesia – limiting opioid administration
• MIS
• Eliminating NG placement
• Maintaining fluid balance
• Gum chewing – not recommend for colorectal surgery

29. POSTOPERATIVE GLYCEMIC CONTROL
• Insulin use is okay
• CDC recommended < 200 mg/dl

30. POSTOPERATIVE NUTRITIONAL CARE
• Prolonged NPO
• Increased risk of infectious complications
• Delayed recovery
• 4 h after surgery is safe

31. EARLY MOBILIZATION
• Prolonged bed rest:
• Increased pulmonary complication
• Decreased muscle strength
• Thromboembolic complication
• Insulin resistance
• For ICU, sitting and standing is suitable

32. SPECIAL CONSIDERATION IN
SPECIFIC PROCEDURES

33. COLORECTAL SURGERY
• Oral antibiotics + systemic antibiotics + mechanical bowel preparation
= reduce SSI
• Mechanical bowel preparation:
• Can cause dehydration and electrolyte imbalance
• No routine used in colon surgery but may be used in rectal surgery

34. RECTAL AND PELVIC SURGERY
• Preoperative counseling: don’t forget stoma care!!
• Role of urinary catheter removal
• Increased risk of AUR
• Risk factors of AUR: male, epidural analgesia, pelvic surgery
• Role of ‘no drain’ is still debated
• Laparoscopic surgery in benign cases

35. GASTRECTOMY
• Malnourished patients should be optimized with oral or enteral
nutrition

36. LIVER SURGERY
• malnourished patients should be optimized by oral supplement at
least 7 days or 14 days in severe malnutrition

37. CONCLUSION…
• Communication skill is important for ERAS protocol
• The patient should be both physical and mental ready for surgery
• Let’s start with shorten NPO time
• Multimodal analgesia should be used to reduce opioid use and
improve outcome of POI, PONV, early ambulation
• Audit is important to evaluate what we have done