Arnett ERAS Protocol

Arnett ERAS Anesthesia Summary/Checklist

 

Preop

1     Check NPO status and inquire about carbohydrate intake and any liquids taken > 2 hours ago

2     Adequate IV access

3     Check preop temperature and make sure prewarming blanket is on

4     Low (T8-11) thoracic level epidural catheter placement

5     Oral Preop medications (Celebrex, gabapentin, etc)

6     Check blood sugar regardless of DM

Intraop

1     PONV prophylaxis with 2 or more agents

a.       8 mg Dexamethasone with induction

b.      4mg Ondansetron prior to extubation

2     If NO EPIDURAL: 20-50mg Ketamine with induction

3     If NO EPIDURAL: Lidocaine infusion at 2 mg/min and continue in recovery room

4     5000 unit heparin SQ after induction and before incision

5     Pre-incision antibiotics and check renal status before re-dosing

6     Use a BIS monitor in elderly patients and titrate volatile as indicated

7     If NO EPIDURAL  give  30 mg toradol (consider renal status). Do not use toradol if epidural is in, It increases the risk of epidural hematoma

8     Desflurane is the preferred volatile anesthetic

9     80% or lower FIO2 during the case

10  Strict fluid therapy as above, preferably use vasopressors if required

11  Minimize opioids

12  Maintain normothermia ie >36 C

13  2-3mL 0.125% Bupivacaine Q5-10min towards the end of the case, monitoring for hypotension

PostOp

1     Confirm adequate analgesia via Epidural in PACU

2     Confirm stable patient vital signs and normothermia

 

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Background

 

Anesthesia provider is responsible for three important aspects of elective colorectal surgery; decreasing surgical stress response, optimizing fluid management and managing perioperative analgesia.

 

(A) Pre-admission Information and counseling

 

Detailed Information should be given to patient before the procedure about surgical and anesthesia procedures which should diminish fear and anxiety and enhance postoperative recovery and speed hospital discharge.

 

(B) Preoperative fasting and carbohydrate treatment

 

Clear liquid should be encouraged up to 2 hours prior to anesthesia induction. Preoperative carbohydrate treatment should be used routinely. In diabetic patients carbohydrate treatment can be given along with diabetic medication. It has been shown in studies to reduce preoperative thirst, hunger and anxiety as well as postoperative insulin resistance. By creating an anabolic rather than catabolic state it also results in less postoperative loss of nitrogen and proteins as well as better maintained lean body mass and muscle strength.

(C) Preanesthetic medications

 

Avoid long or short acting sedatives or anxiolytics because it delays postoperative recovery. If necessary, short acting narcotics such as fentanyl can be administered carefully to facilitate placement of regional anesthesia.

 

In preoperative holding eligible patients should generally receive PO:

 

 

 

(D) Pain management planning

 

  1. Discuss with surgeon: Thoracic epidural vs TAP catheter
  2. For patients receiving Thoracic Epidurals:
    1. Towards the end of the case consider dosing 2-3mL of 0.125% Bupivacaine every 5-10min until an adequate level of analgesia is achieved
    2. Confirm in PACU an adequate level of analgesia and redose epidural or notify supervising Anesthesiologist if it is not rapidly achieved
    3. Hold Ketamine, Lidocaine infusions
    4. Minimize sedatives & PACU narcotics
    5.  
  3. For patients receiving TAP blocks:
    1. Intraop Lidocaine infusion at 2mg/min (note lidocaine infusion works synergistically with volatiles and lesser doses of volatile may be needed)
    2. 20-50mg Ketamine IV bolus between induction and incision
    3. Minimize opioids, sedatives & PACU narcotics

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(E) Thoracic epidural placement

 

  1. Time out
  2. Gentle sedation, minimizing opioids/anxiolytics
  3. Position patient
    • Level the bed and level patient’s buttocks perpendicular to the bedside line
    • Keep the patient upright
    • Give patient firm elbow support on table
    • Ask patient to bow back toward performer & keep head midline down to chest
  4. Palpate scapular tips and draw a line crossing the midline
    • This is T7-8 or T8-9 in 70% of patients in sitting position (it will be T6 in prone)
  5. Find spinous process tips at midline.
    • Symmetric shoulder retraction helps identifying midline esp. for obese patients.
  6. Locate T9 or 10 spinous process and move 1cm paramedian
  7. Prep skin & make a skin wheel w/ lidocaine syringe
    • Consider using the 25g as an explorer to draw an imaginary local 3D map (spinal bodies/processes, ligament & their depth/margin/angle to reach them, see images below) and decide what angle to advance Touhy.
  8. Advance Touhy needle as determined above (generally, 10-20 degree upward and slightly toward midline depending on soft tissue thickness determined above) until it engages ligament.
    • Longer Touhy is seldom needed
  9. Remove the stylet
  10. Use loss of resistance technique with small (1-3mm at a time which is the thickness of thoracic epidural space) advances.
    • Each alternating color of the needle corresponds each centimeter (3 or more advances for each)
    • If advance is blocked by bone, see the depth of needle & withdraw fully out of the ligament
    • Bending needle seldom helps redirection in thick ligament
    • Remember the needle angle & depth for the next trial.
    • DO NOT push the needle hard against bone. The needle can slide & pierce to the spinal cord!
    • The feeling of opening snap doesn’t happen as frequently as lumbar epidural.
    • If the loss of resistance is not complete, either advance 1 more mm or back completely out and try again
    • Keep the depth when turning.
  11. Confirm no CSF or blood out of needle
    • If CSF returns, completely remove the needle from the skin & stop the procedure
    • If blood returns before loss of resistance, the needle can be advanced based upon your judgement
    • If blood returns after loss of resistance, withdraw the needle out of ligament & redirect
  12. Thread in catheter approximately 4cm
    • Easy threading is another positive sign of proper placement
    • Read Tuohy needle depth and threading depth
  13. Remove needle over catheter
  14. Confirm the depth of catheter
    • Example: needle depth=5cm & 4cm catheter threading
  15. Give 3ml of test dose (1.5% lidocaine with epinephrine) to rule out intravascular injection
    • No blood on aspiration is not a reliable method of determining intravascular catheters

 

 

 

(E) DVT Prophylaxis

 

Patient should wear well-fitting SCD and receive pharmacological prophylaxis with LMWH post operatively. Extended prophylaxis for 28 days should be given to patients with colorectal cancer.

5000 Units SQ Heparin should be administered before incision

 

(F) Antimicrobial prophylaxis with skin prep

 

Routine prophylaxis with intravenous antibiotics 30-60 minutes before surgical incision. Redosing should be given during prolonged surgery according to half life of drug and renal status.

Skin prep is recommended with chlorhexidine alcohol group. Hairs clippers should be used instead of razor.

 

(G) Standard anesthesia protocols

 

No general anesthesia technique has shown to be superior. It makes sense to use short acting induction agents such as propofol combined with short acting narcotics such as fentanyl where necessary. Short acting muscle relaxant should be titrated using neuromuscular monitoring. If PONV is concern, TIVA is always an option but may require more aggressive neuromuscular blockade.

 

Deep anesthesia in elderly population shown to be harmful and leads to postoperative confusion. Therefore, BIS monitoring is recommended in elderly population.

 

(H) Nasogastric tube insertion

 

There is no rationale for routine insertion of a nasogastric tube during elective colorectal surgery except to evacuate air which might have entered the stomach during ventilation by a facial mask and it should be removed before extubation.

 

(I) PONV

 

A multimodal approach should be adopted if more than 2 risk factor are present. Decadron has been shown to be effective but it might take a little longer to work so time it with induction

 

(J) Intraoperative temperature control

 

  1. Normothermia is important to maintain homeostasis
  2. Temp < 36: Increase wound infection and morbid cardiac events
  3. Preop: Prewarm patient (Bair Hugger)
  4. Intraop: Warm solutions and blankets

 

(K) Intraoperative fluids

 

  1. Fluid therapy plays a vital part in surgical outcomes
    • No single parameter (CVP, base excess, LVEDP, LVEDV or variability) can definitively assess volume status
    • Intravascular volume determines cardiac output (CO) & O2 delivery
    • Hypovolemia: hypoperfusion of vital organs and the bowel
    • Hypervolemia: bowel edema, pulmonary edema
    • Normovolemia: Vasopressors to control BP to avoid fluid overload

 

  1. Considerations
    • Laparotomy surgery (particularly emergencies): increased fluid shift, bowel handling and SIRS may require more fluid compared to laparoscopy
    • Laparoscopic surgery: Head-down position & pneumoperitoneum reduces CO
    • Thoracic epidural changes vascular tone & capacitance:
    • Restrictive fluid strategy is shown to improve outcome compared to liberal strategy

 

  1. Intraoperative fluid management
    • LR or plasmalyte is preferred to NS
    • Flow measurements to optimize CO, compensate blood loss and to stratify prolonged surgery
    • Euvolemic epidural-induced hypotension: Control with Vasopressors
    • Postop enteral fluid should be used as early as possible w/ discontinuing IVF
  2. Fluid management for our department
    • Start IVF in preop: Overnight fasting compensation, anticipating fluid shift by epidural and general anesthesia
    • Calculate fluid deficit & replace: (Wt in Kg + 40) x (fasting time in hrs) for adults
    • Maintenance fluid + Replace intraop fluid & blood loss
    • Cut down calculated fluid need if surgery > 3hrs to restrict fluid

 

(L) Control of hyperglycemia

 

  1. Increased blood glucose (BG): This is an independent risk factor (regardless of DM diagnosis) for poor wound healing, morbidity and mortality
  2. Check BG regardless of DM status (optionally HbA1C)
  3. Insulin infusion may have to be used