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

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
 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?

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 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

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PHC RESEARCH
 CONCLUSION

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Thank You…