WILLIAM MAYER: Again, a lot of what we're going to be talking about today is not rocket science, It's not new insight. All this stuff you know about. These are all protocols and things we've done throughout the years. What we're going to really do today, more than anything else, is question a lot of the reason why we do these things. And really ask ourselves if maybe some of the stuff we're doing, we're doing just because that's what we always do. This stuff is not new by any means, enhanced surgical recovery protocols, ESR or ERAS, everything in medicine has about three different names which is enhanced recovery after surgery, I've even seen in it called enhanced surgical protocols, ESP.

These things have been around in academic studies over the last several years. It always impressed me that the folks would say, well, we gathered this data we did this study, of course we utilized ESR protocol, of course we utilized ESR protocol. And I was taught-- I got into conversations with administration and such. And the problem with the ESR, it's not something that one person can do. It really has to be a systematic, sort of company wide protocol because it incorporates, as you'll see here in a second, it incorporates not just surgical surgeons and physicians. It incorporates nursing care, it incorporates ancillary help. It incorporates administration as well.

So it's kind of good as I'm looking over the crowd that I see representatives from the entire spectrum of the hospital here today and I think that's appropriate. Why are we talking about this now? Well, for a couple of reasons. One, we have actually done a protocol at St. David's here for the last year or so where we've identified a few patients, instituted ESR, and followed them along. And that's really a big part of the talk today is hearing about some of our results.

At the same time, I think what the key is, one of the keys, is that this ESR protocol has gone from the academic realm to now, mainstream. And I know that to some extent because I have a couple of examples. When I was taking our CME, our self study course, a lot of the different specialties had-- we in surgery had that as well. One of the most recent cell studies that we had had a lot of questions relating to ESR protocol.

And the purpose of self-study courses are not just simply to find out how much knowledge you have, but they're really to educate and inform you about where the field is going. So when you see a lot of questions about a certain entity, you know that that's-- there's a big push on. And in the most recent self-study, ERAS protocols were identified, they were noted to be originally developed for colorectal surgery. But it was explained that there are now be expanded to patients undergoing a variety of operations, and you'll see that's true in our discussions today.

The essentials that they want to emphasize, and we'll go out piece by piece through this, but the essentials involve easily understood patient education. A pre-op education that includes post-operative expectations and discharge criteria. We're going to change the regimen of strict NPO before surgery, we're actually going to encourage them to drink up until two hours before. We're actually going to provide a carbohydrate solution for them so that they don't start surgery dehydrated, so they don't start surgery hypoglycemic. Laparoscopic approaches where possible, aggressive pain control, not aggressive pain, but control with one modality where we amp it up and render people intoxicated, aggressive pain control from a multi modality standpoint. We're going to avoid drains and tubes as much as possible, encourage early ambulation.

A meta analysis showed that when you institute these sort of protocols across the board, the end result is predictable shorter hospital stays, and fewer complications. This results in decreased morbidity, and as you probably can imagine, since this is HCA, decrease hospital stay, decreased complication, decrease costs. All right? I mean, these are two the main drivers for costs is prolonged hospitalization and complications.

Has this data show that we've decreased mortality? No. I mean, obviously these are big operations. Big operations have big complications, and involve sick patients. But we're not about that, we're just simply trying to take the situation and utilize it that's not groundbreaking stuff, we're just trying to take the situation, the dogma that we have now, and reimagine and reconsider other alternatives.

Naturally. Oh, before I get started, I may be committing a crime here, I'm going to fully admit it, I don't want to use a conspiracy to develop. I'm not in the process of colluding with the Russians, I don't even know who Harvey Weinstein was until about three weeks ago. But if I don't acknowledge the fact that I barred a lot of these slides, I probably would be plagiarizing. So this is a gentleman, Brian Harkins, is a surgeon from Tomball, Texas who gave a talk set couple months ago. I liked it, I liked the slides. He was kind enough to share the slides. And the fact is, rather than just take his slides, and steal his ideas and come up on my own, I just thought it was reasonable just to use this slide.

A lot of my talk is going to be just basically an overview. Just so you know what's going to happen, I probably should have introduced myself. I'm William Mayer. I'm one of the general surgeons here. I know a lot of you in the audience, I didn't feel obligated. Dr. Eric Allen is an anesthesiologist who specializes in showing up for lectures approximately 1 minute before he's supposed to talk. We coordinated, as you can tell, our dress code. I said I was perfectly comfortable wearing scrubs and a white coat he said, no no no this is one we need to dress up for.

So you can see. He was patient. Melissa Lamberth is a nurse in the ICU. Abram Bustamante is a nurse on the floor. I think Eric and I, it's kind of appropriate we got our table separate here, Eric and I are going to try and focus mostly on protocols and give you kind a broad view of what the state of the art is, as regards to ESR's. And then Abram and Melissa are going to spend a lot of time talking about what we've accomplished so far here at St. David's and where we're going with this, and what we hope to implement.

So without any further ado, here's just kind of a broad overview, you can see there's a lot of moving parts when it comes to these ESR protocols. You might find it interesting that when the American College of Surgeons had its conference, its annual conference last month, they gave us daily updates on an app. And one of the first things they talked about on the first day was ESR protocols. They were eager to reveal that there is an increasing body of evidence that demonstrates the ability to optimize clinical outcomes, and again, reduce costs.

The College of Surgeons was really interested in what they call rehabilitation. The idea that you kind of school somebody about what the expectations are, and when somebody has expectations, and those expectations are at least reasonably met, then the outcomes tend to be better. I've often thought that the key to pain control is when expectations and reality are fairly close. I think when people come in with unreasonable expectations you can't control pain, and other things in that situation.

They cited studies from MD Anderson that suggested that these kind of ESR protocols are facilitating big surgical cases and getting people back towards their oncological protocols as fast as possible. They're averaging within three weeks. UVA reveal data about how they use multi-disciplinary teams design and implement these ESR protocols. And again the emphasis was on shorter hospital stays, and in particular 60% to 70% reduction in morphine equivalents.

What I'm going to do now is just kind of drill down, just so we can kind of start the discussion on the same plane. I'm going to try and drill down a little bit on each one of these various points. Again an ESR protocol is a lot of moving parts, and we can argue at the end of all this, which are the critical parts and probably not all of them are. But it's kind of a way of thinking. It's sort of a culture, it's an idea. It's not just one thing. So the reason I used Harkins' slides you can see they're very well organized he's got the bullet point here, he talks a little bit about summary. He looks at evidence levels. I'm not sure I agree with all the things he reports, and sort of his recommendation level. I will kind of I'll kind of go through each slide fairly quick and just kind of give my own two for what it's worth.

Sir?

AUDIENCE: [INAUDIBLE]

WILLIAM MAYER: Yeah he's trying to suggest that there's some data on some of these, and that some of these are just based on anecdotal evidence. So I would say data, anecdotal. But we're not going to spend a lot of time on data today, you can just get caught in the weeds going on all these various different studies. I mean, a lot of this stuff, like you said, none of it's going to be new insight. It's going to be a lot of stuff that we all do. It's just going to be taking a different spin on it.

AUDIENCE: So when you speak of evidence level, is that you are making these recommendations that are listed below. So when the recommendations are strong, there must be [INAUDIBLE] that recommendation even though [INAUDIBLE]

WILLIAM MAYER: Probably so, probably so. It may not even be that much, I mean maybe just the fact that there's some data on this other than just anecdotal stuff. You'll see. A lot of it that doesn't lend itself to data. We talked about NG tubes, there are no randomized, prospective trials on whether we let an NG tube [INAUDIBLE] or not. A lot of this is just dogma, and a lot of what we're doing today is just questioning dogma.

So that's where some of the limitations are. I mean here, look this first slide, we're talking about pre-op admission education rehabilitation that people are talking about now, and I think what we're trying to say you're going to have any randomized, prospective trials on how you spoke to these patients. You're not going to get 50 or 100 doctors to all give you the same spiel. But recommendation wise it can't hurt. I think what we're trying to look at is why we do the things we do, and just make sure that the only reason we're doing them is not because we've always done it that way.

I do believe though, and I think that the reason that at least the four of us and others are here talking today, is that I do believe, regardless of whether the data is there to prove it, I do believe this as something worthwhile. You know we've all spent enough time in medicine and in life that we've seen technological advances, we've seen things come and go. And in medicine, there's no end to the number of new insights. But this one seems true, this one seems right. I've seen things with these kind of protocols that is not just an accident.

And I mean, obviously I feel strongly about this, Eric feels strongly about this, Melissa and Abram, we felt strongly enough to come here and talk today. And I put this right up there with major insight compared to the internet, smartphones, minimally invasive, now robotics surgery, something like that. This is going to change. And if we're not doing it we're going to be behind. Pre-operative optimization-- these things have been looked at. I mean there are plenty of other studies.

So pre-operative optimization, it simply means that we're going to try and get the patient in the best possible shape for surgery. We're going to counsel them, we're going to try and diminish their alcohol use, diminish their cigarette use. We're asking to try and lose weight and exercise more. These are all ambitious, and all make sense on a superficial level. You can't argue that these are good ideas, but I can tell you with my patient population, these are very hard to implement.

If I'm telling my patient to stop cigarette smoking and stop drinking and lose weight before I do a surgery, It's just a matter of time before they find somebody else. And then the next patient comes in and tells me, why should I talk to Dr. so-and-so, the other day and he said I had to lose weight and all the rest but he went to my surgery and I'm still having pain.

And what are you going to do? So these all make sense, there's some good data. The data for this sort of stuff actually comes out of a lot of the hernia surgery data where we've clearly shown that there is a benefit. And in terms of reduced recurrence in patients who control their cigarette use part of surgery, optimize their glucose control, with hemoglobin A1C and the like. So the evidence level is low and inconsistent, but one can't argue that this is a good idea.

This is a somewhat controversial slide. It talks about mechanical bowel preparation. And says, in his slide, that they should not be used. I can tell you I disagree with this. And then there was a lot of disagreement when Harkins presented this at his meeting. I think a lot of the colorectal surgeons would argue that, for distal colorectal surgery, bowel preps are, if not essential, very important. I do agree. I think you can be selective. I don't do a whole lot of bowel prepping for lesions prior or proximal to the transverse colon. Again, there are a lot of moving parts in ESR, and this is just one part of a big picture.

And just so you know, too, this is not a standard protocol. I mean, obviously we're taking bits and pieces after taking the bulk of these. But each institution will be taking bits and pieces of this, putting it together, coming up with their own protocols. But what I wanted to show you before we got started, just kind of a sense of what people are talking about across the board.

So here's one that people largely associate with ESR and that is the idea that we don't need to preoperatively fast patients 12 hours before a case. It makes intuitive sense, I mean why should I bring my patient to surgery for a major operation, and create dehydration and hypoglycemia and all the rest before surgery? I think this is a big challenge for anesthesia, but Eric is going to spend a little bit more time and detail talking about this.

A lot of ESR protocols center around volume control and blood sugar control. And this is one way of kind of doing this. We're already starting to Institute here, the protocol. You can see that you don't have to use the marketed clear fast preoperative glucose solution. You could just use something as simple as Gatorade two hours before the case and get pretty much the same benefits.

The next slide talks about pre-anesthetic medications and such. And this is not a big part of most ESR protocols, not a big part of our ESR protocol. Again, Eric's going to spend a lot more time drilling down on this I'm going to kind of pass through this one really quick. Thromboembolism prophylaxis, so this is just old data. I mean there's nothing new here, and there's really truthfully, nothing that we're not doing here at St. David's.

We are instituting thromboembolism prophylaxis on all the patients. That includes pneumatic compression. That does include pharmacological prophylaxis. The slide emphasizes that, on patients with colorectal cancers, that we should probably Institute prolonged, two weeks, four weeks post-operative use of a low molecular weight heparin, Lovenox. And while that's not always done because of patient plans largely we can't overemphasize the need for thromboembolism prophylaxis.

This has been brought up in other studies, skip protocols and that sort of thing. So this is already being tracked and targeted so you can see not all of this is really new insights some of it is just reemphasizing you know, here's the dogma that maybe actually makes sense. Anti-microbial prophylaxis, again this is another part of other criteria that are being utilized the skip protocols in particular.

Routine prophylaxis with IV antibiotics should be given 30 to 60 minutes before colorectal surgeries. Colorectal surgery is being emphasized here again because ESR protocols developed largely, the data to support them at least, developed largely from colorectal surgery experience. And we've gone on to now utilize this. But while the evidence is not as strong for non-colorectal cases, this is a protocol that we do in here at St. David's.

OK so this Eric's talk basically. Standard anesthetic protocol is utilizing rapid awakening. Careful hemodynamic monitoring and fluid monitoring to avoid metabolic stress syndrome, consideration for post-operative spinal anesthesia or alternative and he mentioned morphine PCA, but even alternative multi modality pain management protocols. I think this is a big part of the emphasis, and I think that's something that it's worthwhile, but Eric is going to spend a lot more time on this. I'll even spend a little bit more time on this when we get to it towards the end of the discussion here.

Suffice to say this is a bit of a moving target. I don't think epidurals will used all that extensively here at St. David's but it's something we certainly can consider. I can't emphasize enough my interest in multi modality pain management. I think that we as a profession need to look at how we're managing patients' analgesia. And to date it seems like I kind of joke, but it seems like that pain management protocol at St. David's oftentimes can be summarized in one sentence, which is-- how much more Dilaudid do you want me to give this patient, or your patient?

And we need to start to understand pain management a little better than that. It's all changing. But it can't be done alone. I can't just sit here and ramble on and on. I start to look like an idiot Dr. Marietta starts to caution me, they stop inviting me to meetings and that sort of thing. But if we do it as a team, if we do it as a group , we can actually make some progress.

OK again, post-operative noise involving, I'm not going to steal Eric's speech so I'm not going to much time on that. Use of laparoscopic surgery, no question about it. Laparoscopic surgery in other ways big idea is that if you thought it didn't have staying power it clearly does. If you need any proof, 10 years ago this used to be a special procedure. Dave Faulkers and others like me and Ken Fotenberry would have to petition for special privileges and all the rest right now it's considered core privileges it implies basically if you're not doing laparoscopic surgery, you are not practicing surgery in 2017.

We're now seeing advancements beyond laparoscopic surgery with introduction of robotic surgical technology. Basically now computer assisted, I don't like the term robotic because implies it's automated, and it really isn't. But, computer assisted surgical technology, there's clearly benefits associated with that. Don't get me wrong, ESR is not limited to laparoscopic or robotic surgical patients. Not at all. They just want to emphasize that where possible, limit the incision size.

This will help to kind of minimize complications, and to enhance recovery. But at the same time, we have cases and I think you'll probably present them, Melissa, where we've done big major open surgical cases, appendectomies and pancreatectomies and utilized protocols and found the same benefits. So ESR is not about incision size necessarily, obviously where possible, nice to limit the incision size for the patient.

I must've practiced this a little bit too much because I'm kind of running through my notes real quick so I have to read them every now and again and see if I talked about everything. I think one point I want to emphasize as I was talking about that other thing, that surgery is not about doing things laparoscopically, it's not about doing things robotically. It's not about how you do it, it's about doing it well and being consistent. I tell other medical students that surgery is more of a discipline than it is creative writing. It's important to try and incorporate laparoscopic, robotic, et cetera in your practice but it's more important that you honor and are consistent with good surgical principles.

So this is not an excuse to take unnecessary risk. Good surgical principles mean just basically good exposure good lighting, minimizing trauma to tissues particularly hemostasis, the right surgery done at the right time for the right reasons performed correctly. All those is what will get us where we want to be. OK now here's another one. We've talked about this briefly. Nasogastric intubation.

This is an area that clearly falls under the realm of dogma. A lot of us put NG tubes in and don't really even understand why we do it. We do it because, well, we always did it. And ESR calls into question the routine use of NG tubes. Now let me caution, I'm not saying that it calls into question the use of NG tubes. There plenty of times when it's perfectly appropriate if you're dealing with an obstructed patient. Then I see clear benefits using an NG tube. The question is, on a routine case with a routine patient, does it make sense to always leave an NG tube in?

And the data, the evidence, and ESR protocols will suggest maybe not. If you think about what you're trying to do on a routine basis, you're putting this tube in the stomach, there's about 20 feet of bowel distal to that. Your hope is that by putting a little bit of inefficient suction on that tube, that before it actually cleans itself up against them, because of the gastric wall, that's going to actually decompress that bowel 20 feet down the road we did that colorectal anastomosis, unlikely. Nevertheless, a lot of us were taught to leave NG tubes in. I've stopped doing it and it's worked really well.

I say uh-oh because my subtle signal that I've been talking too long has been given to me. So I'm going to move through the rest of these as quick as I can. So preventing inter-operative hypothermia, perhaps preoperative fluid management. This is important. There have been some studies that actually show that the similar patients with similar conditions in similar circumstances having anesthesia performed by the same anesthesiologist may have vastly different fluid administration during surgery. We're not looking for giving too little fluid, we're not looking for giving too much fluid. ESR emphasizes that we want to give optimal fluid during the course of a surgery. And again, Eric I think I'll spend a little bit more time on this. But this is one of the goals of ESR protocols.

He threw in this interesting slide which showed that 1 liter of normal saline is actually the equivalent of that many bags of Lay's potato chips worth of salt. I think he was trying to prove a point. The only thing I took away from that is, what's wrong with having a bag of Lay's potato chips every now and then, right? You can't you can't stop at one, right? Peritoneal drains again, a lot of us do because we've done it all the time. ESR protocols call into question all this sort of routine dogma that you're doing just because you always did it. These don't prevent bleeds, they don't prevent post-operative and anastamotic leaks. They help surgeons sleep at night, but they irritate the heck out of patients, so they probably aren't needed all the time. Foley catheters, we've all been down that road numerous times, and we have protocols in place already at St. David's to manage that.

A lot of the reason to put in NG tubes is to prevent post-operative ileus. Post-operative ileus is much more complicated, as this slide implies, than simply failing to put an NG tube in your patient post-operatively. There's a lot that goes towards creating post-operative ileus, and some of the stuff we do. Hey look, the idea that you do a big operation, and then you put persons on pain pump and put tubes and drains in every orifice, and leave them in bed. And while you encourage ambulation, you don't actually monitor it. May be what's causing ileus more than the actual procedure itself. This is what ESR is all about.

I'll let Eric talk about post-operative analgesia, I could spend all day on that. Per-operative nutritional care, it goes without saying. Post-operative control of glucose, again the data for this is most strong with regards to septic research and ICU critical care patients. But all surgery is trauma. Hyperglycemic control, I mean I have a whole lot of data behind it, is a smart idea and well worth pursuing.

Early mobilization. This is something that we're trying to institute on the floor. Not just interested in getting patients up early. I bet if I had a show of hands, everybody would acknowledge that early ambulation after surgery is important in improving patients' outcomes. We're not looking for just early ambulation. We want six walks on the first post-operative day. And we want the patient walking themselves from the stretcher to the bed. You don't think it can happen, it can happen. And when you keep track of how many times you're walking the patient, then they finally start walking. When they're not so drugged up with an excess amount of narcotic, they can walk.

So I jumped right to right to the end of it and it's time for Eric to speak. Let me kind of put my two cents in if you don't mind. The reason I'm here today, more than anything else, is because we started instituting this as a group about a year or a year and a half ago or so. And most of my patients, if you know me, they have a certain flavor. Let me put it that way. They tend to be a little bit older, a little bit sicker, they have a lot of habits, they're a bit overweight. And so I was a bit skeptical.

But I'll be honest with you, I can't tell you what it felt like and it's happened numerous times now, when I come on the floor the first post-operative day and invariably, I'll walk onto the floor looking for my patient and I'll bump into them walking. And not just walking, walking vigorously, not being dragged on the floor. And I'll have a conversation with them. And the conversations are real conversations. They're clear eyed. Not that, what's your pain level, it's an 11. 11 is prime number. Man that must be bad. I mean they're clear eyed, they're coherent, they're ambulating, they're already eating.

You know, it used to be we waited until they had flatus and witnessed still production, sorry you're eating, and then only then will we then Institute clear liquid diet. And then the next day, we'd Institute full liquid diet. And then the next day would Institute the light diet. And then the next day with the medium to heavy diet. Then the next day the concentrated sweets diet. Then the next day-- it was ridiculous. You were like buying an extra week of hospitalization just because it's a slow protocol.

And guess what? When you don't feed them, they don't get returning bowel function. So I mean, it goes without saying. You start feeding them, you get bowel-- bottom line is, it works. I'm going to quit talking. Thank you very much.

ERIC ALLEN: What I was hoping is that Bill would talk about the first patient that we did with the ESR protocol. There was an older lady who had colon resection. Her whole hospitalization, she used 1 milligram and Dilaudid. That's actually amazing. And I think since then, we've found that that's been the experience. Melissa's probably going to show some slides about that. But it's impressive how scant narcotics we can give for these people. I'm going to focus a little bit more on some of the specifics. We've implemented ESR initially in colorectal and general surgery patients, but it's spread to orthopedics, GYN-ONC, hyperthermic intraperitoneal chemotherapy, bariatrics. And we've been doing this in bariatrics for a long time. We've sort of added a few more things.

We're in the process of developing our protocol for the big spine surgery patients. This is a typical patient before we started enhanced surgical recovery. He was NPO for eight hours. Surgery was scheduled it at 2:00 PM, so it's almost 24 hours without anything to eat or drink. He's had a bowel prep. He's nervous. He went on a run at Town Lake the day before because he's getting his colon out and wouldn't be able to exercise. We have changed completely how we approach this. There's so much literature to say that we can give people clear liquids or water up to two hours before the case.

What happens with this guy, he comes in, he gets hypotensive after we put him to sleep. His blood pressure drops, and we give him about a liter of LR or saline. 42 bags of potato chips, and all that fluid goes straight to their bowel wall. Which means that their edematous in their next bowel movement, or their first bowel movement is going to be Saturday. So we've really changed how we hydrate these people and prepare them for surgery.

In all of our protocols, we give them a carbohydrate drink the night before. And then two hours beforehand Gatorade, Clear Fast, which is kind of the sexy drink for this, but really I don't think it matters that much. But what we're going to do is get them in the process of getting some nutrition onboard so that they can begin healing. Definitely will decrease anxiety, it will quench their thirst, decrease their hunger, and there's some evidence, particularly in orthopedics patients that there's improved immune function if you give them a little food ahead of time.

Here's narcotics, this is our hammer, or has been our hammer. And it's pretty cool because narcotics work at this site of the tissue, where the tissue injury occurs. It works at the spinal cord from where this impulse goes. So you kind of prevent it from heading up there. It also works at the brain to decrease the way that your pain is perceived.

What's not cool is it gives you all these things, respiratory depression, nausea, vomiting, constipation, urinary retention, anybody that takes care of patients knows that these are the things that happen to people when they get narcotics. None of them are good. I mean if Bill developing a website to talk about what he's going to do to patients, this is not what he's going to put on it. One of the things that some people get, particularly orthopedic patients, is hyperalgesia. And that is a paradoxical, increased response to noxious stimuli.

Some of the drugs I'm talking about in a little bit address and prevent this hyperalgesia. Does anybody ever see that? I mean RSD is one of the things, CRP complex regional pain syndrome, that's another. But this is something that we're going to address a little bit with these techniques. Also, hospitalization, surgery, medical procedures is the gateway to people becoming narcotic dependent, and everybody's aware of the opioid crisis. I think we are partly to blame for that. I don't know where to point this.

So part of our pre-op protocol is we give we give four categories of drugs. We give Tylenol, we give an anti-inflammatory either Toradol or Celebrex, we give Decadron, this is a steroid, we give 8 to 10 milligrams in patients without diabetes, we cut it in half end up with diabetics. Steroids are great. I don't if anybody's had them, but they make you feel good, they're good for pain control, good for feeling good. There's no evidence that a single dose, at a relatively small amount causes any delay in wound healing or any increased infection. The fourth category of drugs that we give preoperatively are the gapapentinoids.

So this is how they work. I wouldn't like to spend a ton of time on this, but this is kind of cool. This is that nerve that just got cut when Dr. Mayer was doing colectomy. There is a subunit right here where the gabapentinoids work that prevent the release of neurotransmitters that didn't take it up to the brain. So it works here and it also makes this inhibitory nerve fire so that the conduction doesn't go to the brain. It's a different way to treat pain.

So we give Neurontin or Lyrica I don't think it matters a huge amount. Ideally, you want to give it the night before, and then a couple hours pre-op so it's onboard. It will decrease your opioid requirements, lower your pain scores, decrease that neuropathic pain that we were talking about, and it's especially helpful in people who are on narcotics already. Those are oftentimes your total joint patients and your neuro-spine surgery patients.

Downside is, in some people, particularly the elderly, you get some sedation. The good thing is, it's not linked to respiratory depression and anybody who has impaired renal function we decrease the dose. Used to be that we would give everybody a little Versed before they head back to the operating room because they were anxious. Nothing in our protocol says that we need to make people sleepy. The idea is to get them awake, they need to be doing crossword puzzles in the recovery room.

Melissa may mention that they're going to be wanting them to get up at the end of their PACU stay, right when they get up on the floor. We don't want this drug, or this category of drug, benzodiazepines to make them sleepy, drunk, or have poor balance. So intraop techniques, Dr. Mayer was talking a little bit about fluid status. So if you got the guy that's dry as a chip, none of the things that go along with that are good. If you go overhydrate him, none of these things are good. So the complications, if you're hypovolemic, you get complications, if you're hypervolemic, and you've got 600 bags of potato chips, that's not good either. We sort of shoot for this sweet spot of fluid management.

Oftentimes, I think we have been heavy handed in hydrating people during surgery because we kind of don't have a choice. But there's some technology that's really made us better at managing fluids. This is called clear sight. There's many different things, but the one we use is clear sight technology, where it's a little clip kind of like a pulse oximeter that fits on the finger. It gives us information of blood pressure, cardiac output, stroke volume, systemic vascular resistance, and stroke volume variation. This is the important thing.

I don't know if you can see this slide, isn't that great, but this is somebody's arterial bright trace from this technology. And you can see that with a mechanically ventilated breath, you see a fluctuation or variation in their arterial pulse height. That is expressed as a percentage, and that helps us decide how much fluid to give. The greater the variation, the lower their fluid, they're more behind in their fluids.

There's all kinds of different algorithms. This is a little bit complicated. But if somebody's cardiac index is high or normal, their stroke volume variation goes up when you give them volume. If their stroke volume variation is normal, then we give no therapy. If their cardiac index is low, it kind of helps us guide. If they're SVV is high we give volume, if it's low, then they need some inotropic support.

This has really helped us be much better at managing patients because low blood pressure doesn't always mean give them more fluid and more potato chips. So there's been some studies recently that say that if you use this technology for a while, and you kind of get a feel for it, you're just as good not using it as you are, because it trains us how we manage these patients to some degree.

So we talked about the four drugs that we give preoperatively to help minimize narcotics. I want to spend a little bit of time talking about four drugs that are outside the box in terms of pain control. Most of us think pain control, you give narcotics, and maybe some nonsteroids. Ketamine is a great drug. This is a drug that I've been using in heart, spine surgery, and bariatrics for 10 or 15 years.

It has kind of a bad name because if you give large doses, people wake up, they see Vladimir Putin on a Tyrannosaurus. They have hallucinations and that sort of thing. But at small doses it's very effective in decreasing pain control. There's another slide, I like neuron slides. So here's the pain nerve and it's come into the spinal cord. And these are the neurotransmitters that fit in these holes, it's kind of a schematic. But this is the NMDA receptor. And NMDA is N-methyl D-aspartame.

And so what happens with ketamine, and magnesium, and maybe beta-blockers, is they bind here or somewhere inside that channel to close this so that neurotransmitter doesn't work. Infusions of ketamine give you lower post op pain and pain scores. It is an anesthetic, in that it makes them sleep. It's an analgesic, meaning it treats pain. That hyperalgesic business that we talked about blunts that to a very profound degree. It's a great drug, and people who are already on opioids, low doses that we give are rarely associated with hallucinations.

I've had one patient in about 15 years that said that they had some hallucinations waking up, and it was a guy a couple months ago who said that, I was on a ski boat and it was going like this, not like this. I'm like, nothing scary? He said, no, it's just a ski boat what does that mean? I'm like, I can't explain your hallucinations, but I'm glad it wasn't scary. Ketamine is great because it doesn't cause respiratory depression like narcotics do, and it's great for hemanamics it's very, very stable from a hemanamic standpoint. It's a great drug to give ahead of time. So we start this infusion fairly early in the case.

Magnesium is another drug that works on those in NMDA receptors. Mechanism action is very similar. It's great, there's lots of studies to support its use. We give about a two gram bolus after the induction of anesthesia. Sometimes people get a little hypotensive, so we give it slowly. As a reference point during pre-eclamptic patients, when they bolus those people, they get 4 grams of magnesium. So we're using a relatively small dose compared to what they give and it's safe when they give it.

So IV lidocaine is another drug that's out of the box. Most people think that this is a cardiac drug, and it is. But it also has profound anti-pain effects. It's a good anti-inflammatory. It provides good post-op analgesia, reduced opioid consumption, quicker recovery, and it's particularly good in improving return of bowel function. In orthopedics and GYN-ONC, it's not as beneficial, but in people who have bowel surgery, it's great at getting them back up and going. I've been to Africa, and in South America on medical trips. This is the anesthetic that we often give, it's just a low grade infusion of lidocaine and maybe a little ketamine. So the benefit of these drugs is they don't decrease bowel function, in fact, they it's either neutral or somewhat helpful.

Beta blockers also are in the category of non-narcotic ways to help with pain relief. It potentiates and prolongs narcotic effects. This mechanism is somewhat unclear. It may be that it works on the NMDA receptors. This is something that we're playing around with. The evidence is not quite as strong for this, but I think that there's a future in it. Dr. Mayer talked a little bit about spinal versus general for patients or epidurals. I know that since we started doing this at St. David's, we have patients that get general anesthetic or spinal anesthetic for their total near or hip surgery.

I think it's remarkable how awake and alert and crisp they are. Maybe Melissa can talk in her experience. But it's night and day different in how they wake up. Bill was talking about nausea and vomiting prevention. So one of the biggest things that we can do is not give our inhaled gases and not give narcotics. That's the best the post-op nausea and vomiting prevention that we can do.

So if we don't give a general anesthetic because we get a spinal, that's great, that's what helps out. So these people don't have the delirium, the outcomes if you look at the literature it probably favors spinal anesthetic plus sedation over general. But I know that patients that have had both say, next time I want the spinal because I was wide awake, I could see my family, I didn't feel bad, I didn't feel hungover or pukey. Another thing that we try to do as often as we can is regional anesthesia.

This is a picture of an ultrasound for an adductor canal block for knee surgery. This is the superficial femoral artery. This is the saphenous nerve, this is the sartorius muscle. We come in with the needle, we deposit local anesthetic around there, and then lay a tube in that gives them an infusion for about four days. This really helps decrease the pain afterwards. It doesn't cut it to zero, but it has a pretty good effect because that's the nerve that provides most of the sensory input for the top of the knee and everything above the kneecap.

So we try to do this as often as we can. Adductor canal block for total knee, interscalene for shoulder surgery, popliteal block for foot and ankle. And then we started doing transverse abdominis plane blocks for abdominal surgery, hernias, and that sort of thing. A lot of times the surgeons, when they do colorectal surgery, will do a modified transverse abdominal plane block. So it's not formally done under ultrasound. But they can see where they are, and put that local anesthetic right to the nerves where they need it.

So local infiltration into the surgical site. There's a whole laundry list of studies that say it shortens hospital stay, decreases pain, and that sort of thing. I see lots of surgeons doing this. I see very few of them doing it exactly how it should be done. What we want to do is, any time the needle, the scalpel, the labroscope hits the skin, we want to put local anesthetic in before the insult happens. It's the tree that falls in the woods that nobody hears. If you prevent that pain from ever happening, it makes it much easier to do. The other thing is you put it in at the end help with post-op pain control, but the preemptive effect of putting that local in before you make the incision is absolutely critical in the success of this concept.

So, for the surgeons in the room, you can give one CC per kilo of quarter percent. That's a lot of anesthetic. For me, that's about 80 cc's a quarter percent. Or if you us 1/2%, cut that in half. So it's about 40 cc's of 1/2% marking that you can put into me and not get into trouble with a local anesthetic overdose. So we talked about a lot of different things that we did that weren't narcotics. Tylenol, Toradol, Gabapentin, ketamine, magnesium, lidocaine, local anesthetic, regional blocks. And I was very conservative. Some of these things, there's studies to demonstrate how many morphine equivalents each of those are worth. I kind of erred on the side of low, just in case, but these things added up 30 to 40 milligrams of morphine equivalence. We didn't give a narcotic.

If we do all of this stuff, 8 to 10 drugs that aren't narcotics, they're getting up, they're peeing, they're talking, they're not falling, they're pooping, all the good stuff in life, right? So TEA, this is a tranexamic acid. This is a blood conservation technique. It's an antifibrinolytic, so it prevents the clots from being broken down. We started doing this for orthopedics, a gram pre-op, gram post-op, you know when they're headed to recovery room. There's a lot of good data that suggests that it decreases bleeding and need for blood transfusion. We're also developing that for large spine surgeries.