Greetings from India

Hinduja Hospital &

Medical Research
Centre
Mumbai , India
 ERAS in INDIA

• Dr. Manju Butani

• Head of Department of Anaesthesiology
Pain Management and operating rooms
The Journey From Ether to ERAS
Ether Dome,
16th Oct 1946
 The Journey From Ether to ERAS

• Ether era, Muscle relaxants, Balanced anaesthesia

• Long acting agents, Long duration of Surgeries
• New agents, shorter acting, safer
• Better drugs and inhalational agents
• Technological advances in Anaesthesia and surgery
(Laparoscopy, Robotic surgeries)
• Superior Monitoring leading to safety and accuracy
• Better understanding of Physiology, fluid
management, and Pain control
• Arrival of Ambulatory care, Next fast tracking and
then to development of ERAS
 ERAS Goals

• Reduce surgical stress / inflammatory processes

• Maintain postoperative physiological function
• Early mobilization after surgery
• Faster recovery
• Reduced complications (morbidity, mortality)

• Reduced length of stay

• Reduced expenses
• Better resource utilization and use of Hospital beds
17 Elements to ERAS
8 ERAS Elements Pertain Specifically to Anesthesia
 ERAS & Anesthesia
• Prevention of PONV
• Optimal Fluid Therapy
• No Opiates / Multimodal Pain Therapy
• Keeping the Patient Warm
• No Premedication
• Short-acting Anesthetics
• Carbohydrate Loading
• Mid-thoracic Epidurals
Indian Scenario
• Do we practice
ERAS?
• Where?
• What are our
barriers to
Implementation?
• Intention to expedite recovery and return to health after surgery
• ‘Fast track’ or ‘enhanced recovery after surgery’ (ERAS) or
‘multimodal rehabilitation’
• The benefit is maximized when the practices are implemented
together, there is reduction in the impact of surgical stress on the
patient
• Contribution of each measure to the overall improvement in outcome
remains unclear
 Barriers to implementation
• Lack of awareness or training at medical school teaching
• Conflicts with personal beliefs of surgeons
• Use of newer technology and operative techniques and
need for training for surgeons
• Need to not just depend on final outcome but on the entire
course of the patient and satisfaction
• Setting up of a multidisciplinary enthusiastic team and
setting protocols
• Complications and its response and review of protocols
 Major hindrance
Indian patients
• Have different expectations and acceptance
• Socio-economic reasons
• Lack of home care and home follow-up
• Distance from home to hospital
• Under privileged patients prefer staying in
hospital for better care and nutrition
• Patient feels we are pushing him out and care
will reduce when they go home, unlike the west
where they move across the hospitals in limited
care and lower cost facilities
 Barriers in Healthcare Providers
• Majority of healthcare services are provided by public
sector hospitals, mismatch between the patient load and
the available facilities leading to long wait-lists for
elective procedures
• The hierarchy in policy-making does not allow for
adoption of new practices until deemed fit by the top
officials
• There is no regulation or impartial audit of surgical
practices
• No emphasis on or demand for a smooth postoperative
recovery either from the doctor or the patient.
• Resulting in compromised care in the perioperative
period and adoption of several substandard practices
• BUT a definite NEED in developing world and we are
moving towards that
• “Same old thinking leads to same old results,”
• The surgeon should satisfy “hitherto unquestioned dogmas”
which deviate from the fast track protocol
• Few observational studies utilizing only a few ERAS care
elements
• The promising trend in the studies reported from India will
lead to a successful and wider implementation of ERAS
pathways in India
• Should translate into real‑life cost savings and improvement
in quality, both for the patient and the health‑care system
VOL. 72, NO. 2, April 2019
 Controversies and concerns
• ERAS guidelines for liver surgery published in 2016
• Role of thoracic epidural catheterization, associated hypotension and
postoperative organ dysfunction, thromboprophylaxis, need for low CVP,
and type of fluids to be administered.
• Alternative analgesia by abdominal wound catheters, IV or intrathecal
morphine
• Thromboprophylaxis in presence of coagulopathy questioned
• The ERAS society recommends the maintenance of low CVP with close
monitoring during hepatic resection and the use of balanced crystalloids
over normal saline to maintain intravascular volume, avoid hyperchloremic
acidosis, and renal dysfunction.
• Recent evidence suggests dynamic indices of fluid responsiveness could
replace CVP.
 J Gastrointest 10):1732-1742. Surg. 2018 Oct;22(
• 394 patients
• Feb 2014 - Dec 2016, Elective pancreatic cancer
surgery
• 13 elements (6 Preop, 4 intraop and 3 postop)
• Compared Compliance > 80% vs < 80%
J Gastrointest Surg. 2018 Oct;22(10):1732-1742.
• ERAS protocol in pancreatic (n = 33) and hepatobiliary (n = 28) surgeries
• Results: Mean Hospital stay 8.7 days pancreatic surgery
9.0 days hepatobiliary
Reduced major complications
• Both groups- decrease in flatus time, early removal of surgical drains, nasogastric
tube and urinary catheter, early mobilisation and introduction of oral/ feeding
jejunostomy feeds
• Conclusion: The ERAS program implemented in our study
was found to be safe and feasible in HPB surgeries in
reducing POPH.
• Manipal Hospital, India
• Total 90 patients
• Length of stay:
Primary debulking (6 vs 4 days; p<0.001), and complex
cytoreductive surgery (5 vs 4 days; p=0.019)
• Overall compliance for the ERAS protocol was 90.6%
• Occurrence of moderate or severe (17.8% vs 0%; p=0.003)
and ≥grade 2 extended Clavein-Dindo complications (22.2%
vs 0%; p=0.001)
• Hospital stay due to occurrence of complications (31.1% vs
2.2%; p<0.001)
• No difference in the 30-day readmission rates.
 Indian Journal of Anaesthesia | Volume 63 | Issue 1 | January 2019

• Colorectal surgeries, 215 patients

• The median LOS after surgery was 9 days (interquartile range
[IQR] 6‑12.75).
• Approximately, 15% patients had postoperative complications.
• Good adherence (more than 80%) to certain elements of ERAS
such as preoperative counseling and nutritional assessments,
selective bowel preparation, antibiotic and antithrombotic
prophylaxis, etc.
• Conclusion: The audit revealed that compliance to
individual ERAS elements were variable, which needed
urgent modification for better adherence to ERAS
guidelines.
 ERAS for Neurosurgery
• The application of ERAS to craniotomy population has significant
potential for better outcome with smoother ride for patients
perioperatively
• In patients undergoing craniotomy considerations such as Immuno
nutrition, techniques for scalp blocks, non‑opioid alternatives for pain
control and improved outcomes with minimally invasive surgery are little
different from the traditional ERAS concept.
• Adherence to ERAS for craniotomies may improve patient outcomes,
accelerate functional recovery and decrease length of stay.
• However, prior testing an ERAS model for craniotomies is
needed
• The value and safety of such a strategy is to be tested
• More researches are needed in future to formulate a proper
strategy for craniotomy patients to have a better
perioperative outcome.
zinc
775 patients (392 unilateral TKA {UTKA} and 383 bilateral {BTKA})
 UTKA BTKA

Walked on day 85.49% 77.22%

of surgery
LOS 3.17 days 4.78 days

Major 1.55% 6.05%

Complications
Hb decrease 1.25 ± 0.41 g% 1.85 ± 0.62g%

Transfusion 0.5% 3.9%

Conclusion
• Pain following TKA is a major deterrent in early
mobilization
• We recommend our multimodal interdisciplinary
protocol to achieve early mobilization, better
pain scores and minimize complications,
resulting in overall reduced LOS
 Individual issues relevant to ERAS
India Today

• Quick look to where we stand on various steps in

the pathways in India and in my hospital in the
next few slides time permitting!
 Pre-admission information, education and counseling

• Diminishes fear and anxiety

– Improve post-op recovery
– Quicken hospital discharge
– Improves wound healing and recovery after
surgery
 Pre-operative Medical Optimisation

• It is necessary
• Respiratory and Cardiac
• Alcohol abuse
– ↑ wound and cardio pulmonary complications
• One month of abstinence improve results
 Pre-op Bowel Preparation

• Mechanical bowel preparation

– Causes dehydration
– Spillage of bowel contents
– Prolonged ileus
– Bowel preparation should be avoided
 Pre-op Fasting & Carbohydrate
Treatment

• Clear and high carb liquid should be

allowed up to 2 hrs prior to surgery
• Solid food up to 6 hrs prior to surgery

•Change of timing happens very often

•Patient compliance
•Cancellations
American Society of
Anesthesiologists® Sues
BevMD®, Maker of
Clearfast®, for False Claims
of Product Endorsement

Society seeks relief from

damages to its reputation as
an unbiased scientific
organization

Released: 27-Jan-2015
 Pre-anesthetic Medication
• Long acting sedative premedication
avoided within 12 hrs of surgery because
it affects immediate post-op recovery by
impairing mobility and oral intake
• Short acting anaesthetic drugs combined
with regional anaesthetic procedures like
spinal anesthesia & field blocks
 Prophylaxis against Thrombo-Embolism

• The incidence of asymptomatic DVT in

colorectal surgery is 30% and fatal
pulmonary embolism in 1%
• All colorectal patients and joint replacement
surgery should receive mechanical thrombo
prophylaxis to reduce DVT
• Use of LMWH reduces DVT and VTE
 Antimicrobial Prophylaxis

• IV antibiotics - 30-60 min before the

incision
• Repeat doses during prolonged
procedures may be beneficial.
 Standard Anesthesia Protocol
• Tri-modal approach
– Regional anesthesia block ± GA
• Reduced post-op use of opioids
• Rapid awakening from anaesthesia
• Early enteral intake and mobilisation
• Use of epidural analgesia is superior to
opioids
 Nonopioid Pain Management
• Local and regional anaesthesia
• Systemic lidocaine
• Acetaminophen
• NSAIDS (e.g., ketorolac)
• Corticosteroids
• Ketamine
• Magnesium
• α2 Adrenoceptor Agonists (clonidine and dexmedetomidine )
• Gabapentinoids (gabapentin and pregabalin)
• Corticosteroids
http://www.medscape.com/viewarticle/811736_7
 Goal Directed Fluid Therapy
• Intravenous fluid therapy in the
perioperative period is undergoing a
“reassessment crisis” with a trend towards
giving less fluid volumes and a smaller
salt load.
• Third spacing has been debunked!
• This means more use of pressors like
phenylephrine.
• Monitoring
 Perils of Aggressive Fluid
Resuscitation
New evidence suggests that aggressive fluid
resuscitation leads to severe tissue edema
that compromises organ function and leads
to increased morbidity and mortality

Marik PE: Iatrogenic salt water drowning and the hazards of a high central
venous pressure. Ann Intensive Care 2014; 4:21

Kelm DJ, Perrin JT, Cartin-Ceba R, et al: Fluid overload in patients with severe
sepsis and septic shock treated with early goal-directed therapy is associated
with increased acute need for fluid-related medical interventions and hospital
death. Shock 2015; 43:68–73
 Peri-operative Fluid Management

• Fluid overload can cause bowel and lung

edema
• Fluid shift should be minimized by
– Avoid bowel preparation
– Maintain hydration upto 2 hrs before
surgery
– Avoid blood loss
 Preventing Intra-op Hypothermia

• Hypothermia (<36 degree C) can cause

cardiac events, bleeding and wound infection
• Normothermia maintained with
warming device and warm IV fluid
 Drainage of Peritoneal Cavity after
Colonic Resection

• Routine drainage is discouraged

Post-op Nausea and Vomiting (PONV)

• Regional anesthesia techniques like

epidural and TAP block has reduced the
opioids use and thus PONV
• Use of Paracetamol and NSAIDS as an
alternative to opioids is well established
Laparoscopy and Modifications of Surgical Access

• Laparoscopic surgery for colonic resection

is recommended if expertise is available
• Robotic surgery
• Minimally invasive joint replacement and
spine surgery
 Naso-gastric Intubation

• Post operative NG should not be used

routinely
• NG tube should be removed before
reversal of anesthesia
 Urinary Drainage

• Routine transurethral bladder drainage for

1-2 days is recommended
• Catheter should be removed early
 Post-operative Analgesia

• Optimal analgesia should give

- Good pain relief
- Allow early mobilization
- Early return of gut function and feeding
 Wound Infiltration
• 9 RCTs, 505 patients, evaluating wound infiltration versus epidural
analgesia in abdominal surgery
• The primary outcome was pain score at rest after 24 h on a NRS
Secondary outcomes were pain scores at rest at 48 h, and on
movement at 24 and 48 h, opiate requirements, nausea and
vomiting, urinary retention, catheter-related complications and
treatment failure
• Conclusions: No differences in pain scores at rest 24 h after surgery
were detected between epidural and wound infiltration. There were
no significant differences in pain score at rest after 48 h, or on
movement at 24 or 48 h after surgery
• Both epidural and wound infiltration effective
• Less urinary retention with wound infiltration
N. T. Ventham, M. Hughes, S. O'Neill, Systematic review and meta‐analysis of continuous local
anaesthetic wound infiltration versus epidural analgesia for postoperative pain following abdominal
surgery. BJS 2013; 100: 1280-1289.
 Peri-operative Nutritional Care

• Under ERAS protocol early enteral feeding

– Reduce risk of infection
– Reduce hospital stay
– No anastomotic dehiscence
 Peri-operative Nutritional Care

• Immuno-nutrition containing arginine,

glutamine, Omega-3 fatty acids are used
 Post-operative Control of Glucose

• Hyperglycemia is a risk factor for complication

• Patients with higher pre-op HBA1C level has
more complications
• Control of hyperglycemia showed improved
results
• ERAS protocol improves insulin action.
 Early Mobilization

• Reduce chest complication

• Counteract insulin resistance
• Improves muscle strength
 Audit

• Periodic auditing is a key element in

ERAS
programme and improves quality of
healthcare.
 Outcomes of ERAS

• ERAS versus traditional peri-operative

care
– Early recovery & discharge from hospital
– Morbidity
– Re-admission
– Cost
Performance Monitoring

https://www.youtube.com/watch?v=vjm45CyEQGQ
 Special Considerations for
Ambulatory Surgery Cases
• Spinals and epidurals are sometimes not
practical in ambulatory surgery but other forms
of regional anesthesia sometimes are.
• Special emphasis on
– Pain control
– PONV prevention
– Discharge readiness (several dimensions)
 Conclusions
• Barriers are still there, even though awareness
is more
• Many dedicated centres coming out with data as
shown
• Most centres or individual surgeons partly
adopting the pathways which they can and are
moving towards more laid down protocols in
their departments
• Early discharge is now more acceptable by
educated patients
 Conclusions
• ERAS programs are a particularly effective
way of providing improved surgical care.
• Clinical trials evaluating various ERAS
protocols have been published.
• All ERAS programs have important
anesthetic components, especially with
respect to pain management.
• The ERAS Society has many valuable
resources to help interested clinicians.
“Patient safety is not a fad. It is not a preoccupation of the
past.
It is not an objective that has been fulfilled or a reflection of
a problem that has been solved. Patient safety is an
ongoing necessity.
It must be sustained by research, training, and daily
application in the workplace.”

Dr. J. Pierce
Founder member APSF
• Thank You
• Organisers of the
Summit
• My Department
members
• My Hospital
• My Patients
• My friends who
made this
possible