ERAS

PRACTICE AND APPLICATION IN

NEUROANESTHESIA

I Putu Pramana Suarjaya

Department of Anesthesiology and Intensive Care

Sanglah Hospital – Faculty of Medicine Udayana University
Bali - Indonesia
ERAS
 is a standardized perioperative care program
involve multiple components that are combined
to minimize stress and facilitate the return of
function

 reduce complications
 shorter LOS
 better long-term survival
Enhanced Recovery After Surgery (ERAS)
• 1990’s Henrik Kehlet
• 2000s’ Colorectal Surgery
• 2010 ERAS Society:
The cornerstones of ERAS®
 Evidence-based perioperative care
 Multidisciplinary and multi-professional
approach
 Teamwork
 Continuous interactive audit and reporting
 Data-driven change
 Readiness to make the next change
ERAS considerations
 Clinical Effectiveness
 Patient Safety
 Patients Satisfactions
Surgery is a stressor
 Stress Response Modification:
Modern Approach

What can the anesthesiologist do to

reduce surgical stress?

 No single answer
 A number of multimodal approaches that the
anesthesiologist can employ to minimize surgical stress and
the physiological disruption that prevents early recovery
 Stress Response Modification:
 Decrease the stress of
Surgery
 Decrease the Insulin
resistance related to
surgical stress
 Avoid prolonged fasting
 Carbohidrat loading
 Optimal Pain
management
 Goal Directed Fluid
Theraphy
ERAS

 Preoperative preparation and medication

 Fluid balance
 Anesthesia
 Postoperative analgesia regimens
 Perioperative nutrition
 Mobilization
 ERAS protocol vs. conventional care
Pre-hospital Phase
Patient/family education Pain management plan Patient optimization Prehabilitation of select
patients
Preoperative Phase
Limit fasting light meal up to 6 Carbohydrate beverage up to 2 Initial multimodal medications Discharge planning. education,
hrs preop hrs preop and/or regional block placement and home medication plan

Intraoperative Phase
Opioid sparing, Normovolemia Nausealvomiting Normothermia Normoglycmia Avoid tubes and
multimodal analgesia prophylaxis drains

Postoperative Phase
Early nutrition Early mobilization Multimodal Nausea/vomiting V No or judicious IV Patient & family
analgesia management fiuid management education

Post-Discharge Phase
Monitor for symptoms or changes in health Follow-up with surgeon, proceduralist, Continue therapy and other
to seek assistance primary care and/or specialty care interprofessional activites as planned

Continued Quality Improvement Team Activities

Analyze and share quality measures, patient suveys, and staff input to celebrate successes and
identify opportunities for improvement
ENHANCED RECOVERY

Full recovery following major surgery is

complete when the inevitable postoperative
functional decline has returned to the
preoperative baseline values.

 Early Mobilization
 Early resumption of Nutrition
 ERAS pathways have become the established
standard of care in many areas of surgery.

Anesthesiologist play a unique and

vital role in the success of ERAS
ERAS Development in
Neurosurgery & Neuroanesthesia
ERAS in Spinal Surgery
Clinical Neurology and Neurosurgery 164 (2018) 142–153

Results: This study will guide further efforts to limit post-operative

morbidity in patients undergoing elective spinal surgery and to highlight
the impact of ERAS care pathways in improving patient reported
outcomes and satisfaction.
ERAS in Spinal Surgery
ERAS in Craniotomy Surgery

When comparing inhalational anesthetics to intravenous anesthetics, either regimen

produces similar recovery results. Newer shorter acting agents accelerate the process
of emergence and extubation. A balanced inhalational/ intravenous anesthetic could
be desirable for patients with normal intracranial pressure, while TIVA could be
beneficial for patients with elevated intracranial pressure. Comparison of
inhalational anesthetics shows all appropriate for rapid emergence, decreasing time
to extubation, and cognitive recovery.
ERAS in Craniotomy Surgery
ERAS in Craniotomy Surgery
BMC Neurology (2021) 21:127
https://doi.org/10.1186/s12883-021-02150-7

Methods: Pragmatic prospective non-randomized controlled trial, consenting adult

patients scheduled for elective supratentorial intracranial tumor excision

Conclusion: There is a significant reduction in the proportion of patients requiring

ICU/ HDU stay > 48 h. Better pain and glycemic control in the postoperative period
may have contributed to a decreased stay. More extensive randomized studies may
be designed to confirm these results.
 ERAS protocol vs. conventional care
Strategy
Preoperative counseling and
education
Preoperative fasting
Preemptive analgesia
Preoperative RBS
ERAS Group Control Group
Preoperative
ERAS protocol and strategy explained in Conventional/routine Patients were
detail. Patients were explained the benefits explained the benefits of counseling and
of abstaining from alcohol and smoking. reoperative counseling
Relatives were explained the benefits of
early ambulation and discharge from the
ICU. Active involvement with the nursing
team to assist in postoperative feeding and
ambulation under nursing supervision was
encouraged.
Preoperative maltodextrin 200ml (380 Kcal) 6-8 hours. For solid food and 2 hrs for water
is given on the night before surgery and
100ml 2 hrs. before surgery
Tab. Fiupiritine maleate (100 mg) given the Nil
night before and 2 hrs. before surgery
Measured for all patients Measured only for diabetics
ERAS protocol vs. conventional care
Strategy ERAS Group Control Group

Intraoperative
Scalp blocks with Inj Given shortly after induction for all Routine infiltration with 10-20 ml 1%
Bupivacaine 0.25% patients lignocaine at incision and pin site.

Normothermia Ensured with warm IV fluids and Similar

forced air warmers and body
temperature monitored via
temperature probe

Intraoperative IV fluid therapy Goal-directed approach with PPV Conventional

measurement

Nasogastric tube Placed shortly after induction Not placed

Surgical Technique Minimally invasive Standard Micro Neurosurgical
technique

Drainage Tube Only in special circumstances Conventional Indications

ERAS protocol vs. conventional care
Strategy ERAS Group Control Group

Postoperative
Pain management 1.Paracetamol 1. Paracetamol
2.Tab. Flupiritine maleate 2.Inj. Fentanyl
3.Rescue with Inj. Fentanyl

Foley’s Catheter Removed in Day 1 or 2 of surgery Removal let to the discretion of

surgical team

Oral sips of via RT Encouraged immediately (within 2 Withheld for 4-6 hr. after
hrs.) of extubation extubation

DVT Prophylaxis DVT pumps immediately

postoperatively. Chemical
prophylaxis considered actively in
patients with hemiparesis/ plegia
etc
RECOVERY:
 Cochrane 2016

 No Difference
Propofol TIVA vs
Sevoflurane
Anesthesia = titration to needs
 Pharmacodynamic approach: titrating drugs to effect
 Clinical signs, hemodynamics
 EEG parameters or other techniques to measure “depth” of
anesthesia
 Pharmaceutical approach: choosing “forgiving drug”
 Pharmacokinetic approach: knowledge of concentration-
effect relationship
 MAC
 Therapeutic window concentrations
 Dosage schemes that pretend to achieve these concentrations
 Target Controlled Infusions
Target Plasma Concentration (µg/ml)

µg/ml Cp50 LOC Cp95 LOC

Propofol 5.4 15.2
(+ moderate dose (3.4) (4.2)
narcotics)
Thiopental 15.6 39.8

Midazolam 0.14 0.25-0.35

Etomidate - 0.31-0.5
 Target concentrations opioids

IC50 IC50 IC50 IC50 Infus.

incisie 50% 50% paza Rate
(ng/ml) EEG MACiso
PO
fenta 4.2 6.9 1.7 0.7 1-5
µg/kg/h

alfenta 240 540 50 10 0.5-3

µg/kg/min

sufent 0.4 0.7 0.15 0.04 0.2-1.2

 
µg/kg/h

remi 4 15 1.4 0.6 0.1-1

µg/kg/min
Awake Craniotomy: "Less is More" -

 Minimal (sedative) drugs which depress

wakefulness,
 Ultra fast-offset drugs
 intraop neurologic testing
 Avoidance of invasive lines/tubes
Opioid-free Anaesthesia for Craniotomy

 Especially appealing for brain surgery

 Local anaesthetics, dexmedetomidine,
paracetamol - crucial OFA anchors.
 Pain adjuvants may enhance recovery
because of specific analgesic and
antihyperalgesic properties
 Opioid analgesics as "rescue"
 Best Practice & Research Clinical Anaesthesiology 31 (2017) 441e443

Combination of several adjunct medications, defined as multimodal

general anesthesia, to reduce intraoperative opioid use to zero.
This also allows further postoperative opioid reduction
Pain Management

Multimodal Analgesia
Options
1. Scalp block
2. NSAIDS (Cox2)
3. Dexmedetomidine
4. Lidocaine
5. Gabapentinoids
6. Paracetamol i.v
International Journal of Medical Sciences

2020; 17(11): 1541-1549. doi: 10.7150/ijms.46403

 Objective: To prospectively evaluate the efficacy of a

neurosurgical enhanced recovery after surgery (ERAS)
protocol on the management of postoperative pain after
elective craniotomies.
International Journal of Medical Sciences 2020; 17(11): 1541-1549

 Method : 129 patients undergoing craniotomies were enrolled in a RCT

comparing an ERAS protocol to a conventional postoperative care .The
primary outcome was the postoperative pain score numerical rating scale
(NRS).
 Conclusion: The implementation of a neurosurgical ERAS protocol
for elective craniotomy patients has significant benefits in alleviating
postoperative pain and enhancing recovery
 J Neurosurg 130:1680–1691, 2019

CONCLUSIONS This multidisciplinary, evidence-based, neurosurgical ERAS protocol for

elective craniotomy appears to have significant benefits over conventional perioperative
management. Implementation of ERAS is associated with a significant reduction in the
postoperative hospital stay and an acceleration in recovery, without increasing
complication rates related to elective craniotomy
ERAS : Patients Satisfactions

BMJ Open 2019;9:e028706.

doi:10.1136/bmjopen-2018-028706
ERAS Safety & Efficacy
 Acceleration of functional recovery
without increasing the complication or
readmission/reoperation rates
 Reduction in postoperative LOS
Summary

 ERAS concepts applicable to neurosurgery

 There are unique techniques for craniotomy
already enhance recovery (scalp block, awake
craniotomy)
 Protocol for neurosurgery under development
TERIMA KASIH
Overview

 Current Landscape and Trials

 Minimally Invasive Surgery - Innovation in
Surgical Techniques
 Awake Craniotomy - "Less is More"
 Opioid-free Anaesthesia (OFA) - Why
especially in Neurosurgery?
MULTIDISCIPLINARY
(TRANSDISCIPLINARY) APPROACH
ERAS team approach

 Surgeon Team work :

 Anesthestist  Training
 HDU Specialist  Implementing
 Ward nurses  Planning
 Anesthesia nurses  Auditing
 Physiotherapist
 Updating
 Dietitian
 Reporting
 Management
 Research
OUTLINES

 Introduction
 ERAS Component
 Pre Operative
 Intra Operative
 Post Operative
 ERAS in Neurosurgery
TCI Introduction

 TCI : the goal is to achieve clinical and

therapeutic level effect rapid and accurate as
fast as possible and a maintained
concentration

 This situation is related with drug dose-

respons relationship