You are on page 1of 24

Eko Setijanto

Departement of Anaesthesiology and Intensive Theraphy


dr Moewardi Hospital
Surakarta
Preoperative Counselling The Key Principles of
the ERAS
Preoperative Nutrition

Avoidance of Preoperative
Fasting

Carbohydrate Loading up to 2
hours preoperatively

Standardized Anesthesia &


Analgesia Regimen

Early Mobilization
NUTRIENT

RECOVERY AFTER
IMMUNE SYSTEM
SURGERY



VITAMIN Risk factor of infection ↑
DEFICIENCIES

Depress Cellular
Immunity
PROTEIN &
CALORIES
DEFICIENCIES
Inhibit Function of
Phagocyte
Weight Loss > 10% to 15% in 6
Months
European
Society of
Parenteral and
Enteral Nutrition
(ESPEN) defines Body Mass Index < 18.5 kg/m2
“severe”
Nutritional risk
as one or more
of the following:
Serum Albumin < 3 g/dL
Surgical patients at
risk of nutritional Disease Impact
depletion related to
inadequate intake
both pre and post
Surgical stress
operatively
Inflammation/Metabolic Derangements

Altered Nutrient Utilization


Disease
Impact
GI tract dysfunction: Diarrhea, Nausea,
Vomiting, Abdominal Pain

Decrased Intake or Restricted Diets prior


to Surgery
PERIOPERATIVE STRESS RESPONSE

CHANGES IN HYPOTHALAMIC
PITUITARY ADRENAL AXIS

CATABOLISM

IMMUNE BONE IMPAIRED FLAP WOUND


SYSTEM REMODELLING HEALING SURVIVAL REVASCULARIZATION
NUTRITION IMPLICATION OF
ERAS

Optimize Calorie &


Protein Intake
Preoperative
Nutrition Optimize Micronutrient
Assesment Intake
Reduced
PREOPERATIVE Immunonutrition
Preoperative
Fasting Time

Carbohydrate
Loading
NUTRITION IMPLICATION OF
ERAS

Early Feeding and Rapid Diet Advancement

POST
Increased Calorie and Protein Intake Post Operatively
OPERATIVE

Gum Chewing
Who should receive preoperative nutrition support?






PREOPERATIVE
OPTIMIZATION

CARBOHYDRATE LOADING
(carbohydrate-rich clear liquid consumed
the morning of surgery)

Reduced the Risk for Dehydration

Improve Subject Satisfaction

Reduce Fasting/Catabolism-Induced Insulin Resistance

Avoid Hyperglicemia

Allow Safe General Anesthesia


Carbohydrate 100g at HS, 50g morning of surgery (2-3
Loading hours before) of isoosmolar clear fluid drink

SPECIALIZED ORAL SUPPLEMENT


Preload (Vitaflo UK), Clearfast (BevMD), preOp
(Nutricia)

ALTERNATIVE TO SPECIALIZED ORAL SUPPLEMENT

• PHC
 CURRENT PRACTICE – 500ML + 250ML JUICE
 COMING SOON – 500ML + 250ML MALTODEXTRIN POWDER/SUGAR
(COMPOUNDING PHARMACY TO DISPENSE) WITH H2O
• OTHERS
 JUICE, GATORADE
 SOS 25 (VITAFLO, CANADA) – DRIED GLUCOSE SYRUP
 GLYCOSADE (VITAFLO, CANADA) – HIGH AMYLOPECTIN MAIZE STARCH
Carbohydrate Loading
with Diabetes?

• Concerns with:
Delayed Gastric emptying
Impaired Glycemic Control

• Limited Research

• ERAS Recommendation: “In Diabetic patients carbohydrate treatment can be


given along with the diabetic medication”
Evidence level: Very Low
Recommendation grade: Weak

• PHC: Same protocol for diabetics with juice


Role of Immunonutrient Compared These 3 Standard Formulas

ARGININE
Improves Tcell Function & enhance NO & collagen formation
Improve wound oxygenation & healing

NUCLEOTIDE
As Building blocks for RNA & DNA
Necessary for immune cell activation & cell growth

OMEGA 3 FATTY ACID


Enhance Lymphocyte Function
Modulate Inflammation
PHC RESEARCH



PHC RESEARCH
CONCLUSION



Thank You…