This document summarizes traditional perioperative care practices and proposes evidence-based alternatives as part of an enhanced recovery after surgery (ERAS) protocol. It discusses replacing traditional practices like preoperative starvation, high stress levels during surgery, and excessive intravenous fluid administration with a multi-modal intervention approach including carbohydrate loading before surgery, limiting or avoiding premedication, effective pain relief through regional anesthesia, early mobilization, and goal-directed fluid therapy to improve outcomes.

1. ERAS!
THE ROLE OF ANAESTHESIOLOGIST
DR.P.C.VIJAYAKUMAR
PRESIDENT-IAPEN- TAMILNADU CHAPTER
SOORIYA HOSPITAL
CHENNAI,TAMILNADU,INDIA.

2. TRADITIONAL
PERIOPERATIVE CARE

3. •1.STARVE!!
IATROGENIC STARVATION

4. 2.STRESS!!
INCISION,PAIN,IMMOBILIZATION

5. 3.DROWN!
DROWNING IN THE I.V.FLUIDS!

6. CHANGE THE TRADITION !

7. Enhanced recovery after surgery
Surgery Multi-modal intervention
Traditional care
Days Weeks

8. EVIDENCE TO SAY NO TO
STARVATION!

9. Mendelson's syndrome
2006 saw the 60th anniversary of the publication of New York obstetrician Curtis
Lester Mendelson's classic paper, ‘The aspiration of stomach contents into the lungs
during obstetric anesthesia’.
Mendelson went on to show that acid was responsible for this asthma-like
syndrome. He instilled into the respiratory tracts of rabbits a variety of substances
including 0.1N hydrochloric acid and vomitus (both untreated and neutralized) from
pregnant women.
He concluded that gastric retention of solid and liquid material is prolonged during
labour, and that aspiration of vomitus into the lungs can occur while laryngeal
reflexes are abolished.
‘Respiratory failure secondary to aspiration pneumonitis during anaesthesia’ became
synonymous with Mendelson's syndrome, and its prevention a cornerstone of
anaesthetic practice.

11. Key points
Residual gastric volume (RGV) and pH (two surrogate end-points of aspiration risk)
are determined by oral intake, gastric secretion and gastric emptying. A 2 h fasting
interval (vs. midnight) for fluids neither increases RGV nor decreases pH.
Gastric emptying of liquids is an exponential process. The half-time for water is
about 10 min. It is wrong to regard the stomach as either ‘empty’ or ‘full’, and
induction of anaesthesia ‘safe’ or ‘unsafe’.
Current accepted fasting intervals for elective cases are 2 h for water and clear fluids,
4 h for breast milk, and 6 h for food (including milky drinks). ‘Nil by mouth from
midnight’ has no place in modern perioperative practice.
Gastric emptying is impaired by trauma, labour and opioid analgesia. Fasting
intervals assume limited importance compared with other aspects of the
anaesthesia regimen (e.g. choice of airway management) in the prevention of
aspiration.
The ‘top 3’ risk factors for aspiration are emergency surgery, light
anaesthesia/unexpected response to stimulation and upper/lower gastrointestinal
pathology.

12. CHO LOADING
What is it?
• 100G ;12.5% ;CHO
PREVIOUS DAY NIGHT
• 50G ;12.5% ;CHO 2 HOURS
BEFORE SURGERY
• CHO MUST BE COMPLEX
MALTODEXTRINS AND NOT
THE PLAIN GLUCOSE!!!
• NEED A COMMERSIAL FEED
FOR THIS PURPOSE!
Advantages
• Gives satisfaction
• Decreases stress
• Decrease insulin resistance
• No increase in GRV
• No increase in aspiration

13. • CAN HAVE NORMAL ORAL DIET 2 HOURS
AFTER REGIONAL AND 4 HOURS AFTER
GENERAL ANAESTHESIA
• DON’T EVER RESIST THE NATURAL APPETITE!

14. SAY NO TO PREMEDICATION
• ADMISSION ON THE DAY OF
SURGERY
• NO NEED TO PREMEDICATE
• SEDATIVES DELAYS RECOVERY
• NO ROLE FOR PROPHYLACTIC
ANTIEMETICS
• GASTRIC ACID SUPPRESSION
DELAYS APPETITE
• GLYCO TAKES OUT THE TASTE
/DYSPHAGIA
PREMED
• SEDATIVE
DIAZEPAM
• H2 BLOCKER/PROTON
INHIBITORS
RANITIDINE/OMEPERAZOLE
• ANTISIALOGOUGE
ATROPINE/GLYCOPYRROLATE

15. PONV-PREVENTION
• PREOP RISK FACTORS
MILD/MODERATE/SEVERE
YOUNGER/FEMALE/OBESE/ANXIETY/MOTION
SICKNESS/PREVIOUS PONV
• TIVA INSTEAD OF GA IN HIGH RISK
• AVOID NARCOTICS/VOLATILES/N2O/REVERSAL
• LIBERAL ANTIEMETICS
MULTIMODAL
STEROIDS/5HT
ANTAGONIST/METACLOPROMIDE/DOMPERIDONE

17. PAIN RELIEF!
• REGIONAL ANALGESIA
MIDTHORASIC-T8/T9; EPIDURAL
LUMBAR EPIDURAL
TAB-TRANSVERSUS ABDOMINIS BLOCK
• ONLY LA ; HIGH VOLUME/LOW CONCENTRATION
• NO NARCOTICS ;PREFERABLY SHORT ACTING FENTANYL;
NAUSEA/ILEUS/IMMOBILITY
• BUT CLONIDINE/DEXMED IN RA
• GENEROUS USE OF NSAIDS
PARENTERAL PARACETAMOL
NSAID SUPPOSITORIES

18. Why epidural analgesia ?

19. EPIDURAL MANAGEMENT
• IT ATTENEUATES THE STRESS RESPONSE (TETRAD OF
ANAESTHESIA) OF SURGERY/DECREASES CATACHOLAMINES
• EPIDURAL ANALGESIA IN LAPAROSCOPIC SURGERIES????
• MANAGE HYPOTENTION WITH VASOPRESSORS
• DON’T INFUSE MORE VASOPRESSORS
• USE LESS FLUID CHALLENGES
• AVOID LIMB PARESIS
• BALANCE ANALGESIA AND HYPOTENTION

20. INTRA-OP HYPOTHERMIA
HYPOTHERMIA PREVENTION
• TEMPERATURE
MONITORING
• HYPOTHERMIA MORE
COMMON WITH REGIONAL
ANAESTHESIA
• O.T ROOM TEMPERATURE
• EXTERNAL WARMER
• FLUID WARMER
ILL EFFECTS OF HYPOTHERMIA
• INFECTION
• POST OP SHIVERING/STRESS
• BLEEDING
• MI
• ARRYTHMIA

22. EARLY MOBILIZATION
• WALKING EPIDURAL
• SEGMENTAL EPIDURAL WITH PRESERVED
BLADDER SENSATION
• NO SEDATIVES
• NO NARCOTICS

23. HIGH INSPIRED OXYGEN
80%-BAG&MASK
• OXYGEN IS REQUIRED BY IMMUNE CELLS TO
PRODUCE FREE RADICALS-A DEFENCE AGAIST
PATHOGENS
• NEED FOR COLLAGEN SYNTHESIS /
ANGIOGENESIS
• IMPROVES ANASTAMOTIC HEALING
• DECREASE SURGICAL SITE INFECTIONS
• REDUCE PONV

24. NO DROWNING IN SURGERY!!

25. GOAL DIRECTED INTRAOP FLUID
THERAPY
• EXCESS FLUIDS DELAYS GUT FUNCTION/CARDIAC
MORBIDITY
• LiDCO/PICCO DEVICES/OESOPHAGEAL ECHO
• CO/SV/TLW ARE THE GOAL PARAMETERS
• MINIMAL GOALS-UO/MAP/CVP
• POST OP FLUIDS NOT MORE THAN 2.5 L/DAY

26. RESUSCITATION ELECTIVE SURGERY
WET IS BEST BALANCED IS
BETTER

27. MAINTAIN I/O CHART
AVOID POSITIVE BALANCE

28. =
POISON

29. The ability of the patient to get rid of the accumulated sodium is
greatly curtailed in the postop period!
9g Sodium Chloride =
36 Bags of Chips,
or 1L Bag of Saline

30. THE VERDICT ON SALINE
Compared with balanced crystalloids, saline use is
associated with:
• Increased mortality1
• Hyperchloremic acidosis1,2,3,4
• Adverse effects on the kidney1,2
• Increased morbidity1
• Increased resource consumption1
• DELAYED GUT FUNCTION-PARALYTIC ILEUS
The future of IV Fluid Management: Balanced Crystalloids
1. Shaw AD, et al., Ann Surg. 2012 May; 255(5):821-9 2. Chowdhury AH et al. Ann Surgery 2012 ;256(1):18-24 3: McFarlane C. & Lee A . Anaesthesia 1994;49:779-
81.4: Hadimioglu N. et al. Anesth Analg. 2008;107:264-9

31. HOW DO I LIMIT IV
FLUIDS/SODIUM?
TAKE THE DRIP
DOWN ON THE
FIRST POST-OP DAY

32. LET US SEE WHEATHER THIS FIRE
WORKS!
T
THANK YOU!!