29-11-2021

Enhanced Recovery After Surgery

(ERAS)
In Anesthesia Practice Intraoperative

Bara Adithya
DEPARTMENT OF ANESTHESIOLOGY, INTENSIVE CARE AND PAIN
MANAGEMENT, FACULTY OF MEDICINE, HASANUDDIN UNIVERSITY
 Hypothlamus

Nociception CRF
PLASMA CHANGES IN
METABOLISM

Surgical Stress Pituitary

ACTH GH
Adipocyte
Lipolysis

Spinal Cord
Adrenal

Responses Hepatic
Gluconeogenesis
Alferent Epinephrine
Cortisol

Sympathetic
Nociceptive
pathways Skeletal Muscle

nervous
Protein Degradation

system
Hepatic Acute Phase
Glucagon Protein Synthesis

Surgical Pancreas IL-1

Trauma TNF
or Tissue Pyrexia
IL-6
Injury Immune IL-8
system Insulin
IGF-1 Hypermetabolism
Testosterone
T3
 So, what can the
anaesthesiologist should
? do to reduce surgical
stress responses?
Perioperative Management
 Autonomic & Somatic Responses
Analgesia

Balanced Anesthesia
The concept of balanced
anesthesia was
Balanced
introduced by John S. Anesthesia
Lundy in 1926.
Paralysis Sedation
Reflex Consciousness
Movement Awareness/Recall
Intraoperative Consideration

Problems that plagues the practice of anaesthesia

is that the Residual Effects of hypnotic
sedative/opioids/muscle relaxants influence long-
term outcomes
Intraoperative anesthesia technique/drugs influences

1. Not only immediate postoperative outcome (e.g., delayed emergence in OR) -

economic
2. But also increase postoperative morbidity (e.g., postoperative pulmonary
complications in PACU, delayed recovery of cognitive functions) - clinical

We need to optimize usage of intraoperative drugs to overcome clinical

and economic challenges

✓Using appropriate drug and dose

TARGET ✓Avoid residual effects of anesthetic agents
 Anesthesia/Opioid/NMB overdose

Delays emergence from anesthesia

• Increases OT stay, PACU stay, ICU admission

Compromises airway patency

Increases pharyngeal dysfunction, aspiration

Decreases ventilatory response to hypoxia and hypercarbia

Increases cognitive dysfunction

 Avoid Benzodiazepine Premedication

Avoid routine preoperative benzodiazepines

• Allows faster emergence from anesthesia
• La Colla, et al: Br J Anaesth 2007;99:353-8
• Increases emergence delirium
• Lepouse C, et al: Br J Anaesth 2006;97:747-53
• Increases cognitive dysfunction
• Maurice Szamburski, et al: JAMA 2015;313:916-25
• Increases pharyngeal/laryngeal dysfunction and micro aspiration
• Haardemark Cedborg Al, et al: Anesthesiology 2015; 122:125-67

No evidence that pre-induction midazolam reduces awareness

• ASA Prectice Guidelines:Anesthesiology 2006;104:847
Inhaled Anesthetic
 Decreases
ventilatory
response to CO2

Inhaled Anesthetics
Decrease
Respiratory Drive
Decreases
ventilatory May increase
response to PaCO2
hypoxia
 Postop Hypoxemia

Peripheral chemoreceptor reflex loop consists of peripheral

chemoreceptor, carotid body, brain stem and neuro-mechanical
link between brain stem & respiratory muscles

Integrity of the entire loop is need for response to hypoxia

While low-dose inhalational anesthetics affect carotid body,

opioids interfere with the loop at other sites such as brain stem

A dahlan and L Teppema. Influence of low-dose anaesthetic agents on ventilatory control: where do we stand? Br. J. Anaesth. 1999;83:199-201
Subhypnotic Concentrations and Ventilatory Response

MAC of sevoflurane and

MAC of desflurane had
isoflurane depressed
no effect on peripheral
the peripheral CO2
CO2 sensitivity
sensitivity
Desflurane vs Sevoflurane
Inhaled Anesthetics: Partition Coefficient
Recovery to Light Anesthesia May be Less Rapid with
More Soluble Inhaled Anesthetics
Why
Low Flow
Anesthesia ?
• There is no universally accepted
definition for LFA.
• Any technique ; employs an FGF < the
alveolar ventilation
• Monitoring the inspired and end-tidal
concentrations using gas analyser is
more accurate and convenient method
for the safe conduct of LFA
ADVANTAGES OF LOW‐FLOW ANAESTHESIA
REQUIREMENTS OF LFA
FLOW METER A LEAK-PROOF
CALIBRATED CYCLE

GAS MONITORING VAPOURIZER

SYSTEM CALIBRATED

MINIMAL INTERNAL
VOLUME
BREATHING SYSTEM
LFA techniques are not suitable :
• Anaesthesiologist not familiar with LFA
• Short-term anaesthesia with a face mask
• Use of technically unsatisfactory equipment with a high gas leakage
• Inadequate monitoring (i.e., malfunction of the gas analyser) or lack of
machine/equipment suitable for leak-free closed breathing systems

• When other clinical issues like haemodynamic instability require the attention of the
anaesthesia provider
The Practice of Low Flow Anesthesia
• Initial high flow rate
• A high FGF (2-3 lpm) has to be used in the initial 10-15 min
with 6-8% desflurane, 2,5% sevoflurane or 1,5% isoflurane
(MAC 0,7-0,8)
• Flow reduction
• After 10 min, FGF reduced to 1 lpm
• The lower the flow —> need higher fresh gas oxygen
fraction
Kaohsiung J Med Sci. 2020;1–7.
wileyonlinelibrary.com/journal/kjm2
Termination of LFA
• The vaporizer dial setting reduced further and then closed toward the end of surgery
as Etaa is commonly maintained with minimal flow rates during final suturing.

• The time constant allows for a slow change in the actual Etaa.
• With closed-circuit anesthesia : the time constant for gas elimination at 0.2 L/min is
about 30 min. —> the vaporizer can be turned off for the last 15-20 min

• At the end of surgery : wash- out of the inhaled anesthetic is sought; by increasing
FGF rate to minute ventilation while monitoring the Etaa
Monitoring Depth Anesthesia
Balance Depth of Anesthesia/Analgesia with
Surgical Stress
 Anesthetic drugs

Most general anaesthetics (e.g., propofol, etomidate, pentobarbital

or halothane) produce anaesthesia by increasing the activity of
inhibitory Gamma aminobutyric acid type A receptors (GABA-A
receptors, a type of ligand gated ion channels) in the brain

Reflected in a general reduction of EEG activity, accentuated with

progressive anaesthetic concentrations
 Variability in anaesthetic drug conc.

Variability in Different patients will

Different patient’s age
pharmacodynamics reach at different
or general health
and kinetics anaesthetic conc.

Important to establish whether a DGA monitor detects

relevant clinical changes (i.e., the transition point between
awareness and loss of consciousness) independently of the
amount of drug needed for that effect to occur
 Methods of monitoring depth anesthesia
• Subjective methods
• Autonomic response
• Hemodynamic changes
• Lacrimation
• Sweating
• Pupilary dilatation
• Isolated forearm
technique
Kaul H.L., Bharti N. Monitoring of Depth Aanesthesia, Ind Journal Anesth, 2002
• Objective methods
– Spontaneous surface electromyogram
(SEMG)
– Lower oesophageal contractility (LOC)
– Heart rate variability (HRV)
– Electroencephalogram and derived
• Spectrual edge frequency
• Median frequency
• Bispectral index
• Entrophy module
– Evoked potentials
• Auditory evoked potentials
• Visual evoked potentials
• Somatosensory evoked potentials
• Auditory evoked potential index
 EEG-based depth
of Anesthesia monitoring

EEG-based depth of anaesthesia monitors have

been variously recommended as an option in
patients at greater risk of awareness or those likely
to suffer the adverse effects of excessively deep
anaesthesia, and also in patients receiving TIVA

Recommendations for standards of monitoring during anaesthesia and

recovery 2015 : Association of Anaesthetists of Great Britain and Ireland.
Anaesthesia 2016, 71, 85–9
Intra-operative Consideration
RELAXANT
(NEUROMUSCULAR BLOCKADE)
Minimal Neuromuscular Blockade
• RNMB was present in 186 patients (31%)on admission to the PACU

• AREs were more frequent in patients with RNMB

(21% vs 14%, P = .033)
 Cummulation: Neuromuscular Blockers

All intermediate acting NM blockers, particularly

vecuronium, exhibit cumulation due to
redistribution

Study comparing infusions of cisatracurium and

rocuronium

Infusion rate had to be decreased with time, in

long duration surgery, to maintain same degree
of NM blockade

Miller DR et al.Can J Anaesth 2000;47:943-49

Routine “Full” Dose Reversal With
Neostigmine Not Appropriate

Neostigmine cause muscle weakness when

given after complete neuromuscular recovery
• Eikermann M et al: Anesthesiology 2007; 107: 621-9
• Herbstreit F et al: Anesthesiology 2010; 113: 1280-8
• Grosse-Sundrup M et al: BMJ 2012; 345: e6329
 Optimal dose of Neostigmine

Joshi GP et al. IARS 2013 Review course Lecture

Fuchs-Buder T, et al. Anesthesiology 2010; 112:34-40
 Neuromuscular Block
NMB is associated with accumulation

Residual NMB is associated with adverse

respiratory events in PACU
Routine full dose of reversal with Neostigmine is
not appropriate
Use the smallest possible dose of muscle relaxant
Neostigmine dose needs to be titrated
BoA Dashboard TM

Induction: Maintenance: Recovery:

Focus on the moment and safety Focus on the balance of Focus on the stability of patient’s
during the induction anesthesia vital signs
Analgesia Management
1. This is the most important anaesthetic factors
2. Good pain management is essential for rapid recovery
from surgery.
3. Postoperative analgesia focuses on Multimodal Pain
relief, aiming to minimise side effects of the different
classes of drugs, particularly opioids
PONV Management
APAKAH TEKNIK ANESTESIA ERAS,“COST EFFECTIVE” ?
Tidak ada yang mahal untuk membayar “SAFETY”

Harga Desflurane / ml :RP. 10.000 ,-

Operasi 1 jam dengan

dial 6% FGF 1 lpm

17,14 ~ 18 ml x Rp. 10.000

= Rp. 180.000 / jam

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TERIMA KASIH