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Overall:
Post-Operative
Hydration
Active, Multimodal and preventive pain control
Aggressive management of nausea and vomiting
Early oral feeding and mobilization
Nutritional support
Remove urinary catheters and drains
Discharge criteria
Role of an anaesthetist
preoperative intraoperative Postoperative
Most popular
a/w faster discharge, lower costs and hasten recovery process
Improved postop analgesia and reduce opiod based s/e
As supplement to GA
Regional anaesthesia
SAB- combination of intrathecal LA combined with opiod results in
faster recovery of sensory and motor function
Epidural analgesia provides better pain relief than IV opiod PCA
delivery system
Reduced postop pulmonary Cx after thoracic or upper abd surgery
Reduce ileus
Improved perioperative nutritional status
Facilitate the acheivement of postop milestones( eg: early extubation,
discharge from ICU, short time to ambulation)
Monitored anaesthesia care (MAC)
Normally, involving the use of LA via infiltration and peripheral nerve
blocks
Seen in inguinal hernia repair, anorectal, and hand surgery
a/w reduced postop pain, need of opiod drugs, less PONV,
constipation, ileus, urinary retention
Normally, using propofol ( 25-100mcg/kg/min) or
dexmedetomidine(0.5-1mcg/kg) or ketamine ( 75-150mcg/kg)
With opiod fentanyl 0.5 - 1 ug/kg) or remifentanil 0.25 0.5 ug/kg bolus or
0.025 0.05 mcg//kg/min infusion)
Extra vigilance to avoid resp complications
General anaesthesia
Short acting anaesthetic agents
Induction
Propofol 1.5 3 mg/kg
Volatile agents
Desflurane (less soluble)
Analgesic
Remifentanil ( 0.05- 2 mcg/kg/min)
Obtund sympathetic reflex
Beta blocker
esmolol ( 500mcg/kg)
Labetolol (5 to 10mg)
General anaesthesia
Airway
LMA vs ETT
Neuromuscular blocking agents
Short / intermediate acting
Eg: cisatracurium, rocuronium
Reversal
Sugammadex vs neostigmine/anticholinergic
Decreased post op resp complication from residual muscle paralysis
TIVA
General anaesthesia
PONV
Anti emetic prophylaxis
Combination of low dose droperidol (0.625 1.25mg), dexamethasone 4 8
mg
If pt is high risk of PONV, combined with 5-HT3 antagonist (ondansetron/
granisetron)
Pain Mx
Non opiod analgesic as part of multimodal
Eg: NSAIDs, COX-2 inhibitors, acetaminophen, alpha2 agonist, ketamine, LA
Postoperative issues
Pain Mx PONV
Nutritional
Ileus and constipation
supplementation
Pain Management
Multimodal analgesia
Combination of opiods and non opiods( eg : NSAIDS, acetaminophen, COX-2
inhibitors, gabapentin, Mg, ketamine)
Newer fast-tracking criteria recognize the importance of controlling
pain and opiod-related side effects
White Fast Track scoring system
Appendix 1
fast-track criteria ** score
Level of consciousness
1. Awake & orientated 2 1. M
2. Arousable w/minimal stimulation 1 2. M
3. Responsive only to tactile stimulation 0 3. U
Physical activity
Able to move all extremities on command 2 1. B
Some weakness in movement of extremities 1 2. D
Unable to voluntarily move extremities 0 3. A
Hemodynamic stability
(MAP = Mean arterial pressure)
2 1. 2
1. Blood pressure <15% of baseline MAP value
1 2. 2
2. Blood pressure 15-30% of baseline MAP value
0 3. 5
3. Blood pressure >30% below baseline MAP value
Respiratory stability
1. Able to breathe deeply 2 1. F
2. Tachypnea with good cough 1 2. A
3. Dyspneic with weak cough 0 3. N
Oxygen saturation status
1. S
1. Maintains value > 90% on room air 2
2. S
2. Requires supplemental oxygen (nasal prongs) 1
S
3. Saturation < 90% w/ = supplemental oxygen 0
3. S
Postoperative pain assessment
1. None or mild discomfort 2
2. Moderate to severe pain controlled w/IV analgesics 1
3. Persistent severe pain 0
Postoperative emetic symptoms
1. None or mild nausea w/no active vomiting 2
2. Transient vomiting or retching 1
3. Persistent moderate to severe nausea & vomiting 0
*
Nausea and vomiting
Risk factors Points
female 1
Non smoker 1
h/o PONV 1
Intra and postop opiod usage 1
Total 2 or more high risk
Utilize anesthetic
techniques which optimize
Stabilizing co-existing
surgical conditions, while
disease and encourage
insuring rapid recovery Allow pt who meet
prehabilitation exercise
with min s/e discharge criteria to be fast
program and smoking
Admin Local analgesia via tracked ( discharged earlier
cessation
RA or LA from recovery units)
Optimizing pt comfort
Apply mutlimodal analgesia Insure adequate pain
(anxiety & discomfort)
and antiemetic prophylaxis control
Insure adequate hydration
Minimize usage of NG
tubes and avoid excessive
fluid administration
Conclusion
Anaesthesiologist play an important role in implementing the fast
track surgery programs
Future advances in fast track surgery will require interdisciplinary
collaborations involving anesthetic, surgery, and nursing
care.(previous slide)
Thus, implemention of multidisciplinary apporach to minimizing
common postoperative side effects can lead to a reduced recovery
room and hospital stay , as well as pain control and pt satisfaction
after surgery
Reference
Multimodal Approach to control postoperative Pathophysiology and
rehabilitation- Henrik Kehlet. Brit. J A 1997; 78: 606-617
The role of anaesthesiologist in fast track surgery: from multimodal
analgesia to perioperative medical care- Henrik Kehlet, Paul F. White.
International Anesthesia Research Society 2007; Vol 104, No. 6
Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in
postoperative recovery. Lancet. 362: 1921-1928