Enhanced Recovery After Surgery for Cesarean Delivery Visual

Enhanced Recovery After Surgery for Cesarean Delivery: Visual Abstract Deck Alex Friedman Peahl, MD Roger Smith, MD +The ERAS Team @AFriedman. Peahl alexfrie@med. umich. edu

EDUCATION PREPARES AT ALL PARTS OF THE PATIENTS FOR SURGERY SURGICAL EPISODE Pre-Cesarean Hospitalization Recovery Set expectations Decrease anxiety Set expectations Assist with coping Set expectations Discharge skills Decrease Pain Improve emotional experience Return to work/duties A new ERAS handout will help patients prepare for and navigate their cesarean Kalogera 2016, Nelson 2016, ERAS Soceity

SHARED DECISION MAKING ↓ OPIOID USE PRE-OP through POST-OP- Shared Decision Making (SDM) has led to decreased opioid prescription size after cesarean delivery 0 MIN 20 5 10 15 MAX A new ERAS SDM tool will help patients choose the right # of opioid tabs Prabhu 2018, Smith 2018

PO INTAKE PRIOR TO SURGERY PREOP PREP NO NPO after midnight Clear fluids up to 2 hours pre-op No adverse Effects Prevents dehydration + catabolism Improved hydration *Uncertain benefit of carb drinks for pregnancy* No change in gastric p. H or complications Patients can drink up to 2 hours before surgery, and have a meal 8 hours prior Smith 2014, Wilson 2018

NORMOVOLEMIA PROMOTES RECOVERY INTRA-OP / POST-OP Fluid Overload Poor hydration Slow recovery Complications Decreased tissue O 2 Slow recovery Renal/gastric injury Goal UOP: 20 m. L/hour Intra-op: goal of normovolemia (<2 L) Post-op: 40 cc/hr crystalloid, d/c with PO intake or POD 1 @ 8: 00 am Wilson 2018, Caughey 2018, Lobo 2002

MULTIMODAL PAIN CONTROL STARTS BEFORE THE OR INTRA-OP / POST-OP Pre-op: Prevent pain Acetaminophen 1 g in PACU Post-Op: Multimodal pain control Acetaminophen 1 g q 8 hr Toradol 15 mg 8 hr (x 3) Ibuprofen 800 mg q 8 hr Intra-op: Maximize pain control Duramorph if feasible Toradol 30 mg in OR Post-Op: Opioid-sparing protocol Oxycodone 5 mg q 6 hr PRN Limited IV morphine No PCA if possible Intra-op: regional anesthesia, Toradol Post-op: scheduled non-narcotics, opioid sparing medications Wilson 2018, Caughey 2018, Prabhu 2017

ERAS ELEMENTS ARE TAILORED FOR OB PATIENTS INTRA-OP / POST-OP Delayed Cord Clamping Skin to skin in OR Breastfeeding support Hemorrhage prophylaxis with Pitocin Postpartum contraception OB ERAS elements optimize the infant and maternal course Wilson 2018, Caughey 2018

ERAS HELPS PATIENTS RETURN TO “NORMAL” Advance Diet As Tolerated (regular diet as ready) Bowel regimen w/ Polyethylene glycol POST-OP Chewing gum to improve motility Patients eat faster and have quicker return of bowel function Charoenkwan 2014, Xu 2018

ERAS HELPS PATIENTS BACK ON THEIR FEET POST-OP Decreases Infection Promotes ambulation Decreased risk of VTE EARLY CATHETER REMOVAL Decreases Pain Remove Foley catheter 12 hrs post-op, if no void in 4 hrs, follow UMHS protocol Encourage ambulation POD 0, and >3 times/day POD 1 -discharge Ituk 2018, Deniau 2016

WHAT IS ERAS FOR CESAREAN DELIVERY A compilation of evidence based protocols Helps patients return to physiologic function SUMMARY And can achieve the TRIPLE AIM Improved patient experience Better quality By touching all parts of the patient journey Decreased costs

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