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    Slide dr. Susilo, Sp. An

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    143 views26 pages

    Slide Dr. Susilo, Sp. An

    Uploaded by

    Dendy

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 26
    PERIOPERATIVE ERAC PATHWAY ELEMENTS 9 Elements, 5 Elements ERAC ice arco olA) ciety for Obstetric Anestl Consensus Statement and Enhanced Recovery A\ LIMIT FASTING INTERVAL Comments ‘Reduces aspiration risk while limiting hypovoe- mia, metabolic stress, and ketosis. + Data extrapolated from colorectal ERAS Solids up to 8h before cesarean delivery programs ASA guidelines state 6-8 hhased on We type of ood ingested: + Alignt meal or mk may be ingested for up to 6h before elective procedures requiring {eneral anesthesia regional anesthesia, oF ‘procedural sedation and analgesic + Additional fasting ime (8 or more hours) may be needed in cases of patent intake of ed foods, faty foods, oF meat Nonparticulate liq carbo loading ( TY Nonparticulate carbohydrate drink up to 2 h before i _ cesarean delivery (nondiabetic women only) oo™ D 45 g carbohydrate is recommended \ f ») Examples: Gatorade 32 oz (54 g carbohydrate) clear \,__/ apple juice 16 02 (56 & carbohyérate) > + Reduces matemel hypogycemia and ‘metabolic stress + The beneit of complex cabohydate (eg, ‘maltodexri) cinks for cesarean delivery is ‘currently undefined, and fetal effects unknown + Can omit if mother is diabetic; follow Institutional protocols for matemal diabetes/ monitoring STANDAR RESEP MINUMAN TINGGI KARBOHIDRAT PRE OPERASI TEKNIK ERACS 400 ML : 335 KALORI (1 CC: 0,8 ML) .NDUNGAN GIZI NO|| NAMABANAN BERAT _[ ENERGI(KKAL) | PROTEIN) | LEMAK (@) | KANG) 1_|AIR PUTIN. 400 ML o 0 oO 0 2 _|MALTODEKSTRIN _|30 GRAM 144 0 0 45,6 3_|GULA PASIR 130 GRAM. us oO 0 ZUF- 4 |JERUK MANIS 150 GRAM. 75 i) 0 18 S_|GARAM. ISECUKUPNYA_ oO oO 0 0 TOTAL 334 o fe 91,3 Patient Education = >> Ideal: Direct contact with patients with phone | call/reminder or meeting before cesarean, to remind ae _/ patient of ERAC goals zo /oN ( \ Minimum: Handout or other standardized \__/ educational to! or interaction ( ) Example: SOAP videos available on www. SOAP.org +The goal of ERAC patient education isto set ‘expectations, and to engage/empower the patent to participate more completely in thee ‘care plan and recovery + Ideally, patient education takes place before ‘the day of surgery + Preoperative discussion should include ERAC gos in addon tothe routine preeratve Lactation/breastfee ding preparation & education Ideal: Structured prenatal classes with books, videos, and in-person lactation support in the / hospital Minimum: Handout or other standardized tool or interaction that includes information on normal breastfeeding physiology, management of / common lactation complications, and resources for breastfeeding support after discharge + ay brestledig improves nexbom and rraeal utes nd pat emovonal attachment, reduced intent inet colons, deed kr ‘sudden infant death syndrome + Breastfeeding is pubic heath pity because tis ik protect foo” dese heath acne such INTRAOPERATIVE ERAC PATHWAY 11 ELEMEN eM han recast + Spinal anesthesia-associated hypoten- ‘lon is primanily on afteroaddriven Goal Isto prevent intraoperative ae posi Maintain blood ves pressure at ‘anesthesia and maintain baseline uteroplacental perfusion + Vasopressor regimen may need to be modifies in women with preeclampsia Optimally managed with prophylactic ‘28 the degree of hypotension with vasopressor infusion, for example, ‘spinal anesthesia may be less than phenylephrine (or norepinephrine) infusion ‘that in nonpreeciamptics- + Data are well supported in terature INTRAOPERATIVE ERAC PATHWAY ELEMENTS oa aaa + Corie ace warming ating rena SSM cure INTRAOPERATIVE ERAC PATHWAY ELEMENTS ee MU re cl Pere + Inthe case of bemonhage caused by ‘erin ator. transition from ERAC to eae cane eeu acca Insttons| nemormage resuscitation Prete enc une s ue ea Mac) ‘protocol Bolus 1 1U oxytocin; start oxytocin infusion at "2.57.5 IU-h* (0.04-0.125 1U-min!) -and intrapartum cesarean delivery: 31U oxytocin over =30 : start oxytocin infusion at 7.5-15 IU: * (0.125-0.25 twin? INTRAOPERATIVE ERAC PATHWAY ELEMENTS INTRAOPERATIVE ERAC PATHWAY ELEMENTS ene EU I Weasel = Skin-to-skin contact should occur as soon as possible in the operating room as appropriate based on maternal/neonatal condition is j lee area Ye] eyez cola) Limit intravenous fluids to < 3L for routine cases In the case of hemorrhage, transition from ERAC to institutional hemorrhage ote cass) SM ee oa aca UC nS primarily managed with vasopressors, instead of fluids eee ory oe Sere established INTRAOPERATIVE ERAC PATHWAY ELEMENTS Delayed Umbilical Cord clamping Benefts: Ter: improved iron stores, develorental benefits; ‘ete: iproved tanstona relation reduced ree for am nm ‘vrei henoxtage + Does rot nerease matemal risk for bood loss or transfusion ~The pride dye craig may vay aang Inston and settings Dele cud dang stl be oe a cert stuns, tera nally, eeatl ned fo nmediate esusctation)* OF POSTOPERATIVE ERAC PATHWAY ELEMENTS Ice chips and/or water within 60 min | ies Ext or ita est: postcesarean admission to PACU sydney + Reduced hospital gh of tay Heparin/saline lock the IV early once ist spec peepee oxytocin infusion complete, tolerating ————————— cuntig fluids, and urine output adequate + Reduced postoperative catabolism + irved insulin sett + Reduced sical sess response | ance to regular diet ideally within 4 h cesarean, as tolerated aA ea Ue a ela) + Ambulate only after adequate retum of motor function | Early mobilization decreases: Examples: Insulin resistance 0-8 h postoperatively: + Muscle atropty = Siton edge of bed Hypoa + Out of bed to ehait + Venous thromboembolism + Ambulation a8 tolerated + Leng of stay 8-24 h postoperatively: Remove bamiers to early mobilization: + Ambulation as tolerated V poles + Walk: 1-2 times (or more) in hal + Urinary catheters 24-88 h postoperatively: + Poor pain contol + Wail: 3-4 times (or more) in hal + Sedation + Out of bed for & h se + Slow block regression POSTOPERATIVE ERAC PATHWAY ELEMENTS (2) Promotion of = Opin sep and rest + Fatigue potently enact ognitive hss Level CEO resing prods Encounge clustered itenentions (eg, function depression, ain, mterrafant tl sigs assessments incooinaton bonding, andrsk of respatary depression ‘wth anges ainsi: tring of ‘ra arlgesicsconteporaneoush opopite seo postoperaie tonto se SOAP eu opine monitoring consensus statemert®) an POSTOPERATIVE ERAC PATHWAY ELEMENTS Benefits incu: * Improved ambulation + Reduced length of stay * Lower ates of symptomatic UT ari catheter emoval may be asscited ith higher rates of urinary retention and ‘eed for recateterization Dose of neural tcl anesthetic and oid ‘an impact eateter removal tne Urinary catheter removed by 6-12 h postpartum Construct protocols to establish criteria for appropriate removal and to manage postcatheter removal urinary retention POSTOPERATIVE ERAC PATHWAY ELEMENTS Follow instutional practices as per ACOG Cesarean delivery approximately doubles, and ACCP guidelines! the ik of venous thromooembalsm ‘compare to vagal delve but in otherwise heady patients the absolute Fisk ielow ‘ACOG recommends mechanical ‘tromboembolsm proptans foal ‘women not already receiving pharmacoogle ‘tvemboprontyans™ aes POSTOPERATIVE ERAC PATHWAY ELEMEN (Oca exty — Sandricedscage paring ad» Dict plangon POD snd) Classe C0 Cischage sore cam str reopen pda ett, aed + Estland ralseaty crete ping + esol patent cree oid oresibegat dstage + Use mest mano patent press inmeatng ey tae cet POSTOPERATIVE ERAC PATHWAY ELEMENTS POSTOPERATIVE ERAC PATHWAY ELEMENTS Multimodal analgesia protocols include: + Low-dose long-acting neuraxal opioid such as ‘morphine (see above) + Scheduled NSAID + Scheduled APAP + Local anesthetic techniques as indicated Example: + APAP 650-1000 me Bral, per os ah scheduled + Ibuprofen 600 mg orally, per es qh scheduled ‘after IV ketorolac 45-30 mg was gven after

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