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THE ROLE OF THE ANESTHESIOLOGIST IN FAST TRACK

SURGERY: FROM MULTOMODAL ANALGESIA TO


PERIOPERATIVE MEDICAL CARE
BY DR LEE JUNE LYNG
SUPERVISOR: PROF JAAFAR
Introduction
Fast track surgery is also known as ERAS ( Enhanced Recovery After
Surgery)
This concept was described in 1990s by Prof Dr Henrik Kehlet (
surgical gastroenterologist)
is a healthcare program that combines a range of simple evidence-
based interventions aimed at improving post-operative recovery for
patients undergoing major surgery.
ERAS consists of Enhanced Recovery Programs(ERP) which is a
multimodal perioperative care pathway that aims at reducing stress
response to surgery and acceleration of recovery.
GOALS :
Optimise pre-operative preparation for surgery
Avoid iatrogenic problems such as postoperative ileus
Minimise the stress response to surgery
Speed recovery and return to normal function
Early recognition of abnormal recovery and intervention if necessary
Team Members for Successful ERP (1990s)
Nurses
Dietitians
Physiotherapists
Occupational therapists
Pain team
Theatre staff
Anesthetists
Surgeons
Hospital management
Audit team
Team Members for Successful ERP (21st
century)
Nurses
Dietitians
Physiotherapists
Occupational therapists
Pain team
Theatre staffs
Anesthetists
Surgeons
Hospital management
Audit team
THE STRESS RESPONSE TO SURGERY AND
TRAUMA
Induce complex metabolic, hormonal, hematological and
immunological responses in the body
Summary of the Stress Response to Surgery

Hormones whose levels are:

Increased: ACTH, cortisol,


GH, IGF-1
ADH, glucagon

Reduced/ inappropriately low: Insulin

Mobilisation of substrates Glycogenolysis


Skeletal muscle breakdown
Formation of acute phase proteins
Lipolysis

Overall:

Reduced ability to respond to and control hyperglycaemia


Utilisation of alternative compounds, e.g. ketone bodies, as energy substrates
Detrimental effects of the stress response
Increased myocardial oxygen demand, increasing risk of ischaemia
Hypoxaemia
Splanchnic vasoconstriction which may impact on healing of anastamoses
Exhaustion of energy supplies and loss of lean muscle mass, leading to
weakness of both
peripheral and respiratory muscles if severe
Impaired wound healing and increased risk of infections
Hypercoagulability
Sodium and water retention
ERP Components
Pre-Admission Pre-Operative
Optimization Admission on the day of surgery
Counseling Preoperative fasting and Carbohydrate Loading
Oral Supplements No Mechanical Bowel Preparation
Prophylaxis: DVT, Antibiotic
Perioperative opioid sparing analgesia
Anesthesia
Normothermia
Mid Thoracic Epidural Analgesia Surgical
Avoidance of fluid overload
Approach: Laparoscopy/ Short Incision/ Transverse Incision
Avoid Surgical Drains or Nasogastric tubes

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

Premedication Pain management


Hydration status Anaesthetic techniques PONV
Glycemic control Temperature control Ileus and costipation
Preop assessment Nutritional supplements
Preoperative assessment
to assess the risks before the operation and institute treatment to
optimise the patients condition. Thus, reducing postoperative
complications.
psychological preparation of patients undergoing surgery
about the surgical procedure, anticipated sensory experiences, analgesic
treatment, and the recovery period.
Premedication
To provide sedation, reduce anxiety, optimization intraop
hemodynamic stability, and decreased postop side effects
Eg: benzodiapines ( most commonest)
Beta blocker and alpha-2- agonist( gaining popularity)- d/t their
anaesthetic and analgesic-sparing effects
Beta blocker (eg: atenolol) suppresses surgery induced-
catecholamines, thus, preventing periop CVS event.
Decrease cardiac events esp pt with pre-existing coronary artery disease.
Improved hemodynamic stability during emergence
Anticatabolic properties- facilitate resumption of normal activities.
Premedication
Alpha- 2 agonist: (clonidine and dexmedetomidine)- a/w with
reduction of opiod analgesics, PONV, and intraopertaive blood loss
Hydration status
Avoid mechanical bowel preparation
6 hour fast for solid food and liquids containing fat or particulate
material
Clear fluids can be taken until 2 hour before induction of anesthesia.
Can be practice on obese patient
Carbohydrate loading :
800 ml given before midnight and 400 ml given 2 -3 hours before surgery
This reduces preoperative thirst, hunger and anxiety, and significantly reduce
postoperative insulin resistance
Glycemic control
Recent evidence suggests that moderate increases in bl glucose are
a/w adverse outcomes. (CVS, infections, and neurological diseases)
Intraop hyperglycemia is an independent risk factor for postoperative
complications ( includes death after cardiac surgery)
Preop : aim bl glucose btw 6-10mmol/l
If hyperglycemia is detected perioperative, to start on insulin infusion.
Temperature control
Periop hypothermia :
Increased rates of wound infection
Morbid cardiac events
Blood loss
Prolong hospital stay
Can be reduced by:
Forced-air-warming blankets
Warming irrigation and IV fluids
Warm and humidified insufflation gas ( laparoscopic)
Fast track anaesthetic techniques
LA
Regional anaesthesia
Monitored anaesthesia care (MAC)
General anaesthesia
Local anaesthesia
Infiltration around LA arounds surgical incision esp superficial
procedures ( eg: inguinal herniorhaphy, breast, shoulder and knee
arthroscopy) lessen both intra and postop opiod requirement.
? Role of continuous infusion of LA over the wound site and
intraperitoneal LA some studies shows that is superior to placebo
across a range of acute clinical surgical settings, however, it remains
inferior to gold standard analgesic techniques such as epidural
analgesia and major peripheral plexus blocks. This may be acceptable
in certain clinical scenarios, for example, where epidural analgesia is
contraindicated, or poorly tolerated.
Regional anesthesia
Peripheral nerve blocks Central neuraxial block

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

Multidrug antiemetic prophylaxis strategy


Nausea and vomiting
Multimodal anti emesis drugs prophylaxis + multimodal strategies to
reduce risk of PONV, ( propofol, LA tech, adequate hydration,
minimum usage of opiods and nitrous oxide)
Non-pharmacological tech:
Acupuncture, acupressure, transcutaneous electrical nerve stimulation
Ileus and constipation
Multimodal fast track surgery:
Minimal invasive surgery techniques
Avoid NG tubes
Early oral feeding
Ambulation
Opiod sparing analgesic regimes
Epidural analgesia ( continuous infusion)
Peripheral acting miu opiod receptor antagonist ( methylnatrexone,
alvimopan)- to avoid post op ileus
Intraoperative reduced in sodium administration and avoidance of excess
fluid
Nutritional supplementation
Objective:
To accerelate wound healing and increase resistance to infection while
preventing loss of functional and structural proteins.
Choice of perioperative analgesia ( epidural or IV PCA opiods) affect
the perioperative feeding strategy
Epidural analgesia facilitates glucose use and improves insulin sensitivity ,
thus diminishing the amount of energy required to attenuate the catabolic
losses after major abdominal surgery
Hasten recovery of ileus and allows early oral nutrition
Key elements of perioperative anaesthetic management for
facilitating Fast Track Recovery in elective surgery

Preop period Intraop period Postop period

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