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CASE REPORT
Implementation of Enhanced Recovery After Caesarean Section
(ERACS) in Elective Procedure : A Case Report
Sardimon*, Yusmalinda*, Zafrullah Khany Jasa*, Rahmi*, Fauzan Bachtiar Amin*
Copyright @ 2021 Authors. This is an open access article distributed under the terms of the Creative Commons
Attribution- 4.0 International License (https://creativecommons.org/licenses/by/4.0/)
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo.
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 48
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
complications, compared to patients with solution may lie in adjusting the ERACS
0-60% ERAS compliance who had a protocol to better suit the conditions of
24.2% risk of infection of and 41.3% in poor and developing countries. This has
complications. Another study revealed been suggested by Nelson in 2021, who
that 38.5% of women who had a C- proposes focusing on the basic
section went home the next day. These components of ERACS in advance (e.g.,
findings suggest that ERAS protocol pre-operative optimization, multi-modal
compliance had a role in the low pain management, early post-operative
incidence of secondary infections due to mobilization) and assure to provide
surgical procedure, lower post-operative affordable drugs available to patients.
complications rates and shorter Hospitals in developing countries may
hospitalization periods 6.7. not able to adopt all ERACS
In low- and middle-income recommendations at once, but rather start
countries, including Indonesia, small and then establish their own
implementation of the ERACS protocol protocols when improvements in clinical
is still less than optimal. Though outcomes achieved and more resources
cesarean delivery rates continue to are available8,9.
increase significantly from year to year. This case report describes
The results of Basic Health Research implementation of ERACS and its
(RISKESDAS) 2018 showed the birth outcome in patient who underwent
rate with caesarean delivery in Indonesia elective C-section procedure.
was 17.6% with the highest prevalence CASE ILLUSTRATION
in DKI Jakarta at 31.1% and the lowest A 31-year-old woman came to
prevalence in Papua at 6.7%. In Aceh, RSUD Zainoel Abidin Banda Aceh with
the proportion of cesarean delivery is the main complain of fluid discharge
above the national average of 22% 7. since ± 3 hours before admitted to the
The lack of optimal hospital. There is no contraction or
implementation of ERACS in Indonesia mucous discharge. The patient suggested
occurs due to lack of resources and costs that she is 9-months pregnant and had
needed5. Despite the obstacles, the active fetal movement. The First Day of
ERACS protocol must still be the Last Menstruation (Hari Pertama
implemented and prioritized. The Haid Terakhir/HPHT) is on January 4th,
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 49
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
2021. Estimated of due date was October anesthetic regimen administered were
11th, 2021. The estimated gestational age bupivacaine 6.5 mg plus fentanyl 25 mcg
was 37-38 weeks. Routine antenatal care and morphine 100 mcg, with a total
to obstetricians was 12 visits and to volume of 1.9 cc diluted with
midwives was 2 visits. History of cerebrospinal fluid (CSF) up to a total
previous diseases and family history of volume of 2.1 cc. The anesthesia
asthma, heart disease, diabetes mellitus regimen was injected at a speed of
and hypertension were denied. The 0.4cc/second. Post-spinal anesthesia,
history of allergies was denied. The patient was given oxygen via nasal
previous labor was 6 years ago, and this cannula 3 l/m and administered 10 mg of
is the second pregnancy. Physical ephedrine and 8 mg intravenous
examination and laboratory results dexamethasone. The location of spinal
within normal limits. anesthesia was obtained as high as T4.
Based on anamnesis, physical Aseptic and antiseptic precautions were
examination, and laboratory performed, and draping was one to limit
examination, concluded that the patient the area of surgery. Incision began 15
had an early rupture of membrane with minutes after spinal anesthesia
gestational age of 37-38 weeks and performed. The baby was safely born 15
single, alive, head-presentation fetus. minutes after the onset of incision and
Patient was ASA II physical status and cried spontaneously. Umbilical cord
had already scheduled for elective SC clamping was delayed for 1 minute.
procedure with spinal anesthesia. During the procedure, there were
Pre-operative treatment no hypotension and IONV (intra-
consisted of 6-hours fasting prior to operative nausea and vomiting). Patient
procedure (solid food), patient was was administered oxytocin 20 IU drip in
allowed to drink sweet tea up to 2 hours 500 cc Ringer Lactate after the baby was
before the delivery. Intra-operative born. Thirty minutes before the
treatment included ondansetron injection procedure was completed, the patient
of 4 mg before spinal anesthesia was was given analgetic (paracetamol drip
performed. Patient was arranged with 1gr and ketorolac IV 30 mg). The
spinal anesthesia in a sitting position, procedure lasted for 1 hour and 45
performed puncture on the intervertebral minutes, with amount of intra-operative
space L4-L5 using spinocain 27G. The hemorrhage was 400 cc, urine output of
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 50
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 51
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 52
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
100
50
0
09:30 10:00 10:30 11:00 11:30
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 53
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
the surgery procedure, the patient was with fluid, but with vasopressor. This is
observed and no hypotension and IONV because the root cause of hypotension is
(intraoperative nausea and vomiting) vasodilatation, not due to hypovolemic
were found. state. Blood pressure is maintained
Intra-operative nausea and according to the patient's daily baseline.
vomiting (IONV) or post-operative The regimens includes
nausea and vomiting (PONV) is phenylepinephrine, ephedrine or
common in women undergoing regional norepinephrine.16,18 Ephedrine is the
anesthesia during SC procedure and it first drug of choice to maintain maternal
has become an important clinical blood pressure. Its sympathomimetic
problem because this technique is widely stimulant activity on α- and β-adrenergic
used. A study showed the incidence of receptors causes positive inotropic and
IONV and PONV accounted for 80% chronotropic effects. Norepinephrine
and 30% of all patients undergoing may be used as an alternative
regional anesthesia during cesarean vasopressor to stabilize the maternal
section, respectively. The underlying blood pressure during spinal anesthesia
mechanisms of IONV and PONV in at SC procedure without causing side
cesarean delivery mainly include effects to the neonatal outcomes18.
hypotension due to sympathy colysis Furthermore, hypotensive
during neuraxial anesthesia, bradycardia prevention may achieved by use of low-
due to increased vagal tone, and dose local anesthesia, the addition of
intravenous administration of opioids16. intra-thecal opioids, the use of local
Based on current guidelines and solutions of hyperbaric anesthesia for
literature, the first step to reducing IONV adequate control of neuraxial
and PONV incidence is comprehensive distribution such as Bupivacaine 6.5mg,
management of circulation parameters. Fentanyl 25 mcg, and Morphine 100
This management includes the mcg16,17.
administration of perioperative fluids In addition, administration of
and the use of vasopressors in antiemetic agent as a prophylaxis of
accordance with the necessary IONV or PONV. Some of regimens may
circumstances17. Hypotension due to be used are 5HT3 antagonists (e.g.
spinal anesthesia in SC is not treated ondansetron 4 mg before spinal
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 54
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 55
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 56
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 57
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 58
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2, October 2022 59
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo
Sardimon, Yusmalinda, Zafrullah Khany Jasa, Rahmi, Fauzan Bachtiar Amin
Implementation of Enhanced Recovery After Caesarean Section in Elective Procedure: A Case Report
Solo Journal of Anesthesi, Pain and Critical Care | Vol 2, No 2 October 2022 60
Medical Faculty of Universitas Sebelas Maret - PERDATIN Solo