Implementing change of care

E N HA N C E D R E C O V E RY
A F TE R C A E SA R E A N
SE C TIO N (E R A C S)

dr. ENDRI WIJANARKO, Sp.An

RSUD IBNU SINA GRESIK
INTRODUCTION

Enhanced recovery after surgery (ERAS) adalah konsep

yang menggabungkan berbagai aspek berbasis bukti
ERAS (Evidenced Based) dari perawatan perioperatif untuk
mempercepat pemulihan pasien.

Ituk U, 2018. Liu Zhi-Qiang, 2020

 Enhanced recovery after surgery (ERAS) pertama kali
diperkenalkan oleh Kehlet pada tahun 1997 untuk
ERAS mengurangi lama rawat inap di rumah sakit pada pasien post
operatif reseksi sigmoid terbuka.

Sekarang ini, Enhanced recovery after surgery (ERAS )

banyak diterapkan di berbagai spesialisasi bedah. Beberapa
pedoman telah diterbitkan dan diperbarui oleh para ahli dari
ERAS seluruh dunia.

Ituk U, 2018. Liu Zhi-Qiang, 2020

WHY ENHANCED
R E C O V E RY F O R
C E S A R I A N D E L I V E RY ?

Sebagian besar wanita yang menjalani persalinan cesar

masih muda dan sehat oleh karena itu memiliki potensi
untuk pemulihan yang cepat setelah melahirkan.

Selanjutnya, ibu yang mampu merawat bayi memberikan

motivasi tambahan untuk kembali ke fungsi fisiologis
normal.

Sebuah studi tentang pemulangan dini setelah persalinan

cesar tanpa komplikasi yang mendahului konsep ERAS
melaporkan kepuasan ibu yang lebih tinggi pada kelompok
pemulangan dini dibandingkan dengan wanita dalam
kelompok perawatan rutin Ituk U, 2018
PROPOSED
COMPONENTS FOR
E N H A N C E D R E C O V E RY
AFTER CESARIAN
D E L I V E RY PREOPERATIVE

INTRAOPERATIVE
SELURUH JALUR PERAWATAN
PERIOPERATIF DAN
INTERVENSI KOMPONEN
POSTOPERATIVE

Ituk U, 2018
 • Protokol ERAC bertujuan untuk mengoptimalkan outcome pasien dengan
WHAT IS AN ERAC memodifikasi inflamasi dan perubahan metabolisme yang terkait dengan
operasi dengan mengatur intervensi berbasis bukti multimodal ke jalur
PATHWAY ? perawatan spesifik.
• Konsensus dan rekomendasi ini menyajikan 25 rekomendasi spesifik yang
menurut komite menentukan jalur ERAC.
P E R I O P E R AT I V E E R A C PAT H WAY S E L E M E N T S

ERAC RECOMMENDATION

PREOPERATIVE INTRAOPERATIVE POSTOPERATIVE

5 elements 9 elements 11 elements

 1. Limit fasting interval

2. Nonparticulate liquid carbohydrate loading

3. Patient education
PREOPERATIVE
4. Lactation / breastfeeding preparation and
education

5. Hemoglobin optimization
 1. Prevent spinal anesthesia–induced
hypotension

2. Maintain normothermia

3. Optimal uterotonic administration

INTRAOPERATIVE

4. Antibiotic prophylaxis

5. IONV/PONV prophylaxis
 6. Initiate multimodal analgesia

7. Promote breastfeeding and maternal-

infant bonding

INTRAOPERATIVE
8. Intravenous fluid optimization

9. Delayed umbilical cord clamping

 1. Early oral intake

2. Early mobilization

3. Promotion of resting periods

POST OPERATIVE

4. Early urinary catheter removal

5. Venous thromboembolism prophylaxis

 6. Facilitate early discharge

7. Anemia remediation
POST OPERATIVE

8. Breastfeeding support
 9. Multimodal analgesia

10. Glycemic control

POST OPERATIVE

11. Promotion of return of bowel function

1 Limit fasting interval
2 Nonparticulate liquid carbohydrate
loading

• Nonparticulate carbohydrate drink up to 2 h before

cesarean delivery (nondiabetic women only)
• 45 g carbohydrate is recommended
• Examples: Gatorade 32 oz (54 g carbohydrate) clear apple
juice 16 oz (56 g carbohydrate)
3 Patient education

• Ideal: Direct contact with patients with phone

call/reminder or meeting before cesarean, to remind
patient of ERAC goals
• Minimum: Handout or other standardized educational tool
or interaction
• Example: SOAP videos available on www. SOAP.org
4 Lactation / breastfeeding preparation
and 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
5 Hemoglobin optimization

• All pregnant women should be screened for anemia per

ACOG guidelines
• Women with iron-deficiency anemia should be treated
with supplemental orally, per os (or if refractory anemia
with IV) iron in addition to prenatal vitamins
• Anemia other than iron-deficiency should be further
evaluated
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

1 Prevent spinal anesthesia–induced

hypotension
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

2 Maintain normothermia

• Active warming
• In-line IV fluid warmer
• Forced air warming
• Keep the OR temperature ideally
>72°F or 23.0°C (Joint Commission
guidance)
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

3 Optimal uterotonic administration

• Use lowest effective dose of uterotonic

necessary to achieve adequate uterine tone
and minimize side effects
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

4 Antibiotic prophylaxis
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

5 IONV/PONV prophylaxis

• IONV/PONV is a major stressor for the mother

and should be avoided, bearing in mind the
different etiologies
• Limiting/avoid uterine exteriorization which is
associated with IONV and delayed bowel
function recovery
• Abdominal saline irrigation may worsen IONV
and PONV
• Dexamethasone is effective for PONV and not
IONV due to delayed onset of action
• Metoclopramide is effective for IONV but not
PONV
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

6 Initiate multimodal analgesia

• Neuraxial long-acting opioid : IT morphine 50–

150 µg or Epidural morphine 1–3 mg
• Nonopioid analgesia started in OR unless
contraindicated
• Consider local anesthetic wound infiltration or
regional blocks such as TAP or QLB if neuraxial
morphine is not administered
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

7 Promote breastfeeding and

maternal- infant bonding

• Skin-to-skin contact should occur as soon as

possible in the operating room as appropriate
based on maternal/neonatal condition
 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

8 Intravenous fluid optimization

 INTRAOPERATIVE ERAC PATHWAY ELEMENTS

9 Delayed umbilical cord clamping

• ACOG recommends delay in umbilical cord

clamping in vigorous term and preterm infants
for at least 30–60 s after birth
 POST OPERATIVE ERAC PATHWAY ELEMENTS

1. Early oral intake

• Ice chips and/or water within 60 min

postcesarean admission to PACU
• Heparin/saline lock the IV early once oxytocin
infusion complete, tolerating fluids, and urine
output adequate
• Advance to regular diet ideally within 4 h
postcesarean, as tolerated
 POST OPERATIVE ERAC PATHWAY ELEMENTS

2. Early mobilization
 POST OPERATIVE ERAC PATHWAY ELEMENTS

3. Promotion of resting periods

 POST OPERATIVE ERAC PATHWAY ELEMENTS

4. Early urinary catheter removal

 POST OPERATIVE ERAC PATHWAY ELEMENTS

5. Venous thromboembolism
prophylaxis
 POST OPERATIVE ERAC PATHWAY ELEMENTS

6. Facilitate early discharge

 POST OPERATIVE ERAC PATHWAY ELEMENTS

7. Anemia remediation
 POST OPERATIVE ERAC PATHWAY ELEMENTS

8. Breastfeeding support
 POST OPERATIVE ERAC PATHWAY ELEMENTS

9. Multimodal analgesia
 POST OPERATIVE ERAC PATHWAY ELEMENTS

10. Glycemic control

 POST OPERATIVE ERAC PATHWAY ELEMENTS

11. Promotion of return of bowel

function
TAKE H O M E M ES SAG E ?
Team w ork : Stronger team s for better patient care