ERAS.ppt

Starting from the guide- ERAS in application and practice of general surgery,Catalogue,1.The origin and meaning of the concept of ERAS 2.How to practice the ERAS,What factors affect the patients postoperative rehabilitation？,BMJ 2001;322:4736,Surgery,Delayed recovery,ERAS A New Concept,ERAS stands for Enhanced Recovery After Surgery,is a multimodal approach to patient care using a combination of several evidence-based peri-operative interventions to expedite recovery after surgery.,ERAS,Professor Henrik Kehlet was one of the first to describe a peri-operative care regime which facilitated early ambulation and discharge after surgery.,Professor Henrik Kehlet,Br J Anaesth 1997;78:606-17.,Less trauma and stress - the core of the ERAS,Br J Anaesth 1997;78:606-17.,Reasonable use of analgesic drugs Minimally invasive surgery Pain alleviation Substrate administration Anabolic/catabolic hormonal manipulation Heat loss prevention Reduction of inflammatory reponse,What can ERAS bring to us?,ERAS can shorten the hospital stay for 2.5 days,Clinical Nutrition 29 (2010) 434440,The meta-analysis participants included 452 patients in six studies.,ERAS can decrease the risk of complications by up to 47%!,Clinical Nutrition 29 (2010) 434440,The meta-analysis participants included 452 patients in six studies.,ERAS can reduce the risk of readmission 20%,Clinical Nutrition 29 (2010) 434440,The meta-analysis participants included 452 patients in six studies.,ERAS reduces the risk of death by 47%!,Clinical Nutrition 29 (2010) 434440,The meta-analysis participants included 452 patients in six studies.,Catalogue,1.The origin and meaning of the concept of ERAS 2.How to practice the ERAS,The implementation of the ERAS need effective multidisciplinary collaboration,Improvement of anesthesia method Combined the local anesthetic Regular oral glucose on surgery day morning Reducing the dosage of opioids Early awakening and early extubation Liquid treatment Targeted therapy with patients needs Avoid excessive liquid causes gastrointestinal edema Supplemented by oral administration,The implementation of the ERAS need effective multidisciplinary collaboration,Peri-operative pain management Preventive analgesia Multimodal analgesia Other measures Temperature monitoring and heat preservation Antithrombotic therapy,General surgery: the earliest and most successful field of ERAS application,As early as in 2005, the European version of the ERAS expert consensus has been published to guide clinical work,General surgery: the earliest and most successful field of ERAS application,In 2009, the ERAS group published Consensus Review of Optimal Perioperative Care in colorectal surgery,Application of ERAS in perioperative period in general surgery,Preoperition,Intraoperation,postoperation,Clinical Nutrition 31 (2012) 783-800,Clinical Nutrition 31 (2012) 801-816,Clinical Nutrition 31 (2012) 817-830,ERAS requires preoperative counselling to patients,ERAS要求对患者进行术前宣教,1.1 Preoperative counselling,1.2 Preoperative fasting,6 hours before operation,Fasting solid food,2 hours before operation,Fasting transparent liquid,1.3 Preoperative nutritional support,术前人工营养支持不是必须的。 但是，若患者严重营养不良，则应该给与口服营养补充剂或术前肠内营养,1.4 Preoperative sedative medication,不推荐术前常规使用长效或短效镇静药物，若有必要，应在椎管内麻醉时使用短效静脉药物，并由麻醉医师仔细滴定以便于安全管理,1.5Preoperative antithrombotic therapy,推荐： 患者应穿好合适的弹力袜，并接受低分子量肝素药物预防。大肠癌或其他静脉血栓风险增加患者的预防应考虑延长28天。,1.6 Preoperative prophylactic antibiotic treatment,预防性抗生素的使用可防止手术部位感染，应该在切皮前30-60分钟单剂量的方式使用。 术间也可能使用重复剂量，这个由药物的半衰期和持续作用时间来决定。,1.7 Preoperative “preventive analgesia“,Surgery 2011;149:830-40.,ERAS建议术前“预防镇痛”来积极控制患者的疼痛,Whats preventive analgesia？,Preoperation,Intraoperation,术后,为防止痛觉过敏的发生，在术前采取镇痛措施以减缓术后痛的发生，即“预防镇痛与抗炎”；早进行术后镇痛,Anesthesiology 2003; 98:1515 Current Opinion in Anaesthesiology 2006, 19:55155,Perioperative,Meta-analyse：NSAIDs to prevent perioperative analgesia benefit clearly,Anesth Analg 2005;100:75773,A meta-analysis was performed on 66 patients (RCTs) of the 3261 patients who underwent analgesia after surgery,Note：+ positive role; 0 means no benefit; ? Indicates no conclusion,NSAIDs：ideal drugs in pre-emptive analgesia,Drugs. 2003;63(24):2709-23.,Application of ERAS in perioperative period in general surgery,Preoperition,Intraoperation,postoperation,2.1 ERAS recommended mid-thoracic anesthesia,2.2 ERAS requires intraoperative temperature should not be less than 36,NICE clinical guideline 65 Inadvertent perioperative hypothermia,使用液体加温装置将静脉输注的液体或血液制品加温到37,麻醉超过半小时的患者或者麻醉小于半小时但容易发生低体温的高危患者在手术期间应当使用空调装置保暖,2.3 ERAS avoid routine nasogastric tube placement,放置鼻胃管并不能改善患者预后,因此不建议做为常规措施,2.4 The suggestion for intraoperative fluid management of ERAS,推荐接近于0的体液平衡，避免水盐超载。平衡晶体液 优于0.9的生理盐水,2.5 ERAS does not encourage placement of peritoneal drainage,不鼓励常规引流，因为可能会影响术后患者的早期活动,Application of ERAS in perioperative period in general surgery,Preoperition,Intraoperation,postoperation,80% of patients undergoing moderate to severe pain after surgery,Anesth Analg 2003; 97:53440.,Moderate,Severe,Extremely severe,Mild,The consequences of Inadequate pain-control is serious,Anesthesiology Clin N Am 23 (2005) 21 36,致死、致残,恢复缓慢,降低镇痛满意度,导致慢性痛,3.1 ERAS Recommend postoperative multimodal analgesia,ERAS推荐术后采取多模式镇痛,NSAIDs in postoperative multimodal analgesia,非甾体类抗炎药是多模式镇痛的重要组成部分。 尽管有临床案例显示双氯芬酸和COX-2抑制剂塞来昔布与吻合口漏的发生率增加，但是，目前还没有证据支持应停止使用非甾体抗炎药这一多模式镇痛的重要组成部分,ERAS recommendations for postoperative analgesia,Guidelines for implementation of enhanced recovery protocols - December 2009,阿片类药物、包括可待因和曲马多，仅作为爆发痛的保留用药。 此外，应用阿片类药物时，应注意预防恶心和呕吐反应，规律给予止吐药处方治疗。,术后，如无治疗禁忌症，应对患者进行规律的对乙酰氨基酚和NSAIDS处方治疗，如布洛芬或双氯灭痛。,NSAIDs for postoperative pain： Sooner i