Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

THE UNIVERSITY OF TEXAS

Conflict Of Interests
SOUTHWESTERN MEDICAL CENTER
Research Grants and/or Honoraria
AT DALLAS

•  Baxter Pharmaceuticals

Enhanced Recovery After Surgery: •  Mallinckrodt Pharmaceuticals

Role of Anesthesiologist •  Pacira Pharmaceuticals

Girish P. Joshi, MB, BS, MD, FFARCSI

Professor of Anesthesiology and Pain Management

Procedure Specific Best Practices

Changes in Healthcare Delivery
Enhance Recovery After Surgery
•  Emphasis on cost containment •  Decrease the incidence and severity
•  Emphasis on evidence-based practice of perioperative complications

–  Need to know what works and at what costs •  Shorten hospital length of stay

•  Rising patient expectations •  Reduce postop readmission rates

–  Importance of patient satisfaction •  Allow early return to daily living

•  Reduce healthcare costs without

compromising patient care

Perioperative Management

Preoperative Considerations
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Preoperative Optimization
Preanesthesia Assessment
Improves Perioperative Outcome
•  Suboptimal preoperative care (i.e., inadequate •  Preoperative screening and optimization of
patient evaluation or incorrect preoperative comorbidities

management) is a major contributing factor to •  Assessment of chronic medication use

perioperative morbidity/mortality –  β-blockade, ACE inhibitors, anti-platelet drugs,
anti-coagulants, anti-diabetic drugs, statins
–  Lienhart A, et al. Anesthesiology 2006; 105: 1087–97
•  Education and psychological preparation of
–  Hove LD, et al. Anesthesiology 2007;106: 675–80
the patient (and their caregivers)
–  Gibbs N, Rodoreda P. Anaesth Intensive Care 2005;33:616–22
–  Reduces anxiety and fear
–  Improves overall patient satisfaction

Preoperative Risk Reduction European Society of

Through “Pre-habilitation” Anesthesiologists Recommendations
•  Preoperative training: muscle strengthening
–  Reduces frailty and disability
•  Preoperative cardiovascular conditioning
•  Snowden CP, Minto G: Br J Anaesth 2015; 114: 186-9
•  West MA, et al: Br J Anaesth 2015; 114: 244-51
It is safe for patients (including diabetics) to drink
•  Avoidance of preoperative dehydration
–  Encourage water intake throughout the fasting period carbohydrate-rich drinks up to 2 h before elective surgery
•  Nutritional support to boost periop immune
Patients with obesity, gastrointestinal reflux, and
function and accelerate convalescence
diabetes… can safely follow all of the above guidelines
–  Preoperative carbohydrate loading
•  Gillis C, Carli F: Anesthesiology 2015; 123: 1455-72
•  Preoperative psychological preparation
–  Avoid anxiety and fear Smith I, et al: Eur J Anaesthesiol 2011;28:556–69

Preoperative Carbohydrate Load:

Well-Controlled Diabetics Vs. Healthy Preoperative Testing

•  Routine screening tests are of no clinical benefit

–  Preop period is not for screening asymptomatic disease
•  Unnecessary tests may cause anxiety, increase
delays and cancellations, cause potential harm
stemming from false-negative or false-positive
results, and increase costs
•  Tests guided by patient’s, clinical status,
comorbidity (cardiovascular, pulmonary, and
White triangles = insulin treated; white squares = oral antidiabetic treated; black squares = healthy
renal) and invasiveness of surgical procedure
ASA Practice Advisory: Anesthesiology 2002; 96: 485-96
Gustafsson UO et al: Acta Anaesthesiol Scand 2008; 52: 946-51
http://www.nice.org.uk/pdf/CG3NICEguideline.pdf
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Preoperative Testing Grid

Premedication Controversies

Avoid Benzodiazepine Premedication

•  Avoid routine preop sedative-

hypnotics even in patients with
significant anxiety
–  Increases cognitive dysfunction
•  Maurice-Szamburski, et al: JAMA 2015; 313: 916-25
Intraoperative Considerations
–  Increases pharyngeal/laryngeal
dysfunction - micro aspiration
•  Haardemark Cedborg AI, et al: Anesthesiology 2015;
122: 1253-67

•  No evidence that pre-induction

midazolam reduces awareness
•  Anesthesiology 2006; 104: 847

Residual Effects of
Sedative-hypnotics/Opioids/NMBs
•  Delays emergence from anesthesia
•  Increases OT stay, PACU stay, ICU admission
Problems that plagues the practice
•  Compromises airway patency
of anesthesia is that the residual •  Increases pharyngeal dysfunction, aspiration
effects of hypnotic-sedative/ •  Decreases ventilatory response to hypoxia
opioids/muscle relaxants influence and hypercarbia

long-term outcomes •  Increases hemodynamic instability

•  Increases cognitive dysfunction
Joshi, Girish, MB, BS, MD, FFARCSI
Balanced General Anesthesia
Unconsciousness/Lack of Recall
(MAC/EEG-based Monitoring)
Hemodynamic Stability
(BP/HR)
Nitrous Oxide
Advantages
•  Amnesia and analgesia
–  anesthetic and opioid dose
•  circulatory stability
•  Facilitates emergence
–  Peyton PJ et al: Anesthesiology 2011;114 596
•  persistent postop pain
–  Chan MT et al: Pain 2011; 152: 2514-20
–  Echevarria G et al: Br J Anaesth 2011;107:959
De Vasconcellos K, Sneyd JR: Br J Anaesth 2014
Enhanced Recovery After Surgery
Desflurane Versus Sevoflurane
•  Meta-analysis of RCTs
(n=29) comparing extubation
times with des and sevo
•  Anesthesia information
management system data
(n=32,792 cases) used model
the time from end of surgery
to extubation
•  Des reduced average
extubation time and
variability of extubation
Muscle Relaxation
(Peripheral Nerve Stimulator) time by 20%–25%
Dexter et al: Anesth Analg 2010; 110: 570–80
Nitrous Oxide and PONV
Disadvantages
•  Systematic review and meta-analysis of RCTs
•  Increase PONV
•  30 studies (2297 patients with N2O vs. 2301
•  Fernandez-Guisasola et al: Anaesthesia
2010; 65: 379-87 patients without N2O)
•  Expand closed spaces (bowel)
•  Avoiding N2O reduced risk of PONV, but overall
• Influence surgical conditions
impact was modest (absolute 33% vs 27%)
•  cardiovascular, pulmonary,
•  Propofol induction negate emetic effects of N2O
thromobotic morbidity
•  Leslie K, et al: Anesth Analg 2011;112:387
•  Turan A et al: Anesth Analg 2013;116:1026
•  Prophylactic antiemetic therapy further negate
•  Myles P et al: Lancet 2014
emetic effects of N2O
Fernandez-Guisasola et al: Anaesthesia 2010; 65: 379-87
Avoid Deep Anesthesia
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Inhaled Anesthetic Concentrations For

Prevention of Recall

•  Doses of inhaled required to

prevent awareness (recall) are
smaller (0.45 MAC) than those
required for unconsciousness
Neuromuscular Blockade
•  0.6 to 0.8 MAC of inhaled
anesthetics with or without
N2O, respectively
Law CJ, et al: Br J Anaesth
–  Dwyer et al: Anesthesiology 1992; 77: 888-96 2014; 112: 675-80

Neuromuscular Blockade Inappropriate Monitoring and

Postoperative Respiratory Outcome
•  Residual paralysis in postop period is frequent
and difficult to recognize clinically
•  Even minimal paralysis (TOF < 0.9) increases
postoperative complications and ICU admission
•  Avoid /minimize muscle relaxants, if possible
•  Reverse blockade unless there is unequivocal
evidence of adequate function
•  Neostigmine dose based on the degree of
blockade at the time of reversal Sasaki N, et al: Anesthesiology 2014; 121: 959-68

Neuromuscular Monitoring Site and High Dose Neostigmine and

Residual Paralysis PACU Stay and Hospital LOS

Thilen SR et al: Anesthesiology 2012; 117:934-6 2 Sasaki N, et al: Anesthesiology 2014; 121: 959-68
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Neostigmine Dose:
TOF Response at Ulnar Nerve

TOF Response Dose

Fade (µg/kg)

4 - 20-30
3 ++ 40 Opioids
2 +++ 50
1 ++++ 60
None – Wait
Modified from Bevan et al: Anesthesiology 1992; 77: 785-805

Reverse unless there is unequivocal evidence of adequate function

Opioids Reduce Propofol Requirements Opioid Reduces MAC

2.00

•  Opioids reduce •  Moderate opioid 1.75

Move

Isoflurane Concentration (%)

No move

propofol dose doses reduce MAC 1.50 MAC of combination

synergistically synergistically (up

1.25

1.00

(approx 40-80%) to 75%) 0.75

•  MAC reduction is 0.50

•  Ceiling effect 0.25

not complete 0.00

0 1 20 30 40 50 6

•  Ceiling effect 0
Computer-assisted continuous infusion
0

Target Remifentanil Concentration (ng/mL)

McEwan AI et al: Anesthesiology 1993; 78:864-9

Smith C et al: Anesthesiology 1994; 81: 820-8

”Front Loading” Opioids During

Induction of Anesthesia
•  Increases post-
induction hypotension Anesthesiology 2016; 124: Epub

•  Increases potential
for acute tolerance”

Chia Y et al. Can J Anaesth 1999; 46: 872-7

Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Opioid Dosing at Induction:

Patient Controlled Analgesia Concept
Fentanyl/sufentanil dosing based IV-PCA concept
Consider other causes of

Sedation
Respiratory
Depression
hemodynamic changes
Opioid Concentrations

Opioid Bolus

Analgesia
Do not attempt to normalize or
Minimal Analgesic
achieve “tight” control of

Pain
Concentration

1 2 3 4 5
hemodynamic variables (HR/BP)
Time (hours)
Front loading of opioids for achieving longer duration of action is NOT acceptable

Intraoperative Long-acting Opioids:

For Postoperative Analgesia
•  Longer-acting opioid
~20 min prior to
expected time to
Procedure Specific
extubation
– Morphine (0.1-0.15 mg/kg) Multimodal Pain Management
– Hydromorphone (10-20
mcg/kg)

Joshi et al: Anesth Analg 2000; 91: 1049-55; Aubrun F et al: Br J Anaesth 2007; 98: 124-30;
Aubrun F et al. Br. J. Anaesth 2012;108:193-201

Multimodal Analgesic Techniques

(www.postoppain.org)
•  Regional analgesic techniques
–  Wound infiltration
–  Peripheral nerve blocks
• NSAIDs/COX-2 inhibitors PONV Prophylaxis
•  Acetaminophen
•  Adjuvants
–  Dexamethasone
–  Ketamine
•  Opioids (as rescue)
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Multimodal Prevention To Facilitate Impact of Risk Assessments on

Implementation Of PONV Policies Prophylactic Antiemetic
Risk-Adapted PONV-Prevention Algorithm

•  “Implementation of PONV prophylaxis

based on prediction models did not
reduce the incidence of PONV despite
PONV-Prevention Algorithm in All Patients increased antiemetic prescription in
high-risk population.”

Gan TJ, et al Anesth Analg 2014;118:85–113 Kappen TH, et al: Anesthesiology 2014; 120: 343-345

Optimal Multimodal Antiemetic Therapy

•  Intraoperative
–  Dexamethasone 4-8 mg
–  Ondansetron 4 mg (end of surgery)
•  High risk population (add)
–  Droperidol 0.625–1.25 mg (intraop) Mechanical Ventilation
–  Transderm scopolamine (preop)
–  TIVA
•  Postoperatively
–  Promethazine (Phenergan) 6.25 mg
–  Dimenhydrinate 1 mg/kg
–  Do not repeat ondansetron, use
another 5HT3 antagonist

Intraoperative Ventilation: Intraoperative Ventilation:

Avoid Hyperventilation Allow Mild Hypercapnia
•  Optimal lung protective •  Increase CO, vasodilatation, O2 off-loading
ventilatory strategy from right shift of oxyhb dissociation curve
–  Low TV (6-8 ml/kg, IBW) •  Improves tissue oxygenation
–  PEEP (5-10 cm H2O) –  Hager et al: Anesth Analg 2006; 103: 677-81,

–  Initial respiratory rate 8/min –  Fleischmann et al: Anesthesiology 2006; 104: 944-9

•  Maintain ETCO2 ~ 40 mm Hg •  Protective effect against organ injury

–  Mild hypercapnia (PaCO2 = 50 •  Laffey JG, Kavanagh BP. Lancet 1999;354:1283-86

mmHg) improves tissue O2 •  Improves postop cognitive function

•  Hovorka J. Acta Anaesth Scand 1982; 26: 498-504
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

Hypercapnia Reduces Systemic Inflammation

and Improves Respiratory Function
•  Patients randomized to PaCO2
35 to 45 mmHg or 60 to 70
mmHg with CO2 inhalation
•  Patients with hypercapnia had Fluid Management
improved respiratory function
and reduced lung and
systemic inflammation
•  No severe adverse events
related to hypercapnia
Gao W, et al Anesthesiology 2015; 122: 1235-52

Perioperative Fluid Therapy

•  Patients commonly receive large amounts of fluids

•  Excessive fluids increase morbidity and mortality
•  Eliminate algorithm use (i.e., preloading and
replacement of “third space”) Postoperative Considerations
•  Avoid fluid administration based upon static
indicators (HR, MAP, CVP), use dynamic indicators
•  Role of CO monitors in ERAS remain questionable
•  Need to follow postop, avoid weight gain > 1kg

Postoperative Care:
Emergence Considerations Fast Track Rehabilitation
•  Primary aim should be to •  Avoid tubes, catheters, drains, restrictions
washout inhaled anesthetic, •  Early mobilization and physical therapy
not build-up CO2 •  Optimize pain relief
•  Pressure support ventilation •  Respiratory therapy
–  Extended lung expansion exercises
to maintain FRC
–  Early use of CPAP, non-invasive ventilation,
•  Nasal ventilation, superior to early tracheal extubation
oral ventilation •  Improve sleep
–  Liang Y et al: Anesthesiology 2008; 108: 998
•  Early oral feeding
•  Semi-upright (30-40º) position
•  Early detection of complications
Joshi, Girish, MB, BS, MD, FFARCSI Enhanced Recovery After Surgery

S u m m a r y Thank You. Questions?

•  ERAS clinical pathways improve periop outcome

and enhances recovery
•  Involves the entire periop period (pre-, intra-,
and post)
•  Anesthesiologists should take leadership in
development and implementation of clinical
pathways
•  Improve communication and teamwork amongst
Insanity is doing the same things the same
caregivers way and expecting different results.
•  Data-driven analytical process of continuous
Albert Einstein
improvement