Enhanced Recovery after Surgery (ERAS)

H Sahajananda

Department of Anesthesiology and Critical Care; Department of Central Research Laboratory, RajaRajeswari Medical College and Hospital, Kambipura, Bengaluru, Karnataka, India

Corresponding Author: H Sahajananda, Department of Anesthesiology and Critical Care; Department of Central Research Laboratory, RajaRajeswari Medical College and Hospital, Kambipura, Bengaluru, Karnataka, India, Phone: +91 9448085401, e-mail: h.sahajanand@gmail.com

How to cite this article: Sahajananda H. Enhanced Recovery after Surgery (ERAS). J Med Sci 2021;7(2):21-23.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

It is worthwhile to cut the prolonged hospital stay to reduce morbidity. Outcome after major surgery is said to be good when the hospital stay of the patient is reduced with faster recovery. But it is still a difficult task. Researchers have come out with a new concept of faster recovery after major surgical procedures using protocols that are evidence-based in nature. It is followed in all phases of surgery and anesthesia including rehabilitation. These protocols are to be implemented by the dedicated staff to achieve the goals.

Prof. Kehlet and Wilmore described enhanced recovery after surgery (ERAS) in the last decade of the 20th century.¹ He followed ERAS in colorectal surgeries. A great amount of research was carried out in colorectal, vascular, thoracic, urosurgery, spine, neurosurgery, orthopedic, liver, pancreatic, and cardiac surgery¹ to develop ERAS protocols. ERAS society was registered in 2010, with a mission to develop perioperative care and to improve recovery through research, education, audit, and implementation of evidence-based practice.

Enhanced recovery after surgery (ERAS) reduces the patient’s stress response to injury caused by the surgery¹^,² (Flowchart 1). It optimizes their physiologic function and facilitates faster recovery.

Flowchart 1: Ill effects of surgery and possible multimodal interventions to control stress response

The evidence-based guiding principles of ERAS include patient education, optimization of the patient before admission, and minimizing fasting that includes a carbohydrate drink 2 hours before anesthesia. Multimodal analgesia reduces the need for opioids when indicated. The patients are made to return to a normal diet early. They are encouraged to ambulate early after surgery so that they return home faster.

Evidence-based Guiding Principles of ERAS

Preoperative optimization
It is vital to educate patient and relative
Cessation of smoking for 1-month
Alcohol abstinence for 1-month
Preoperative fasting:
- Liquids for 2 hours
- Solids for 6 hours
Institute carbohydrate loading
Appropriate premedication
Must avoid long-acting sedative agents
Use prophylaxis for thromboembolism
Mechanical bowel preparation (abdominal surgery)
Intra- and postoperative elements
Antibiotic prophylaxis and skin preparation.

Evidence-based Anesthetic Protocol

Multimodal analgesia
Regional blocks like epidurals, TAP block, etc.
PONV prophylaxis
Minimally invasive approach
Prevention of intraoperative hypothermia
Tight perioperative fluid management
Adhere to zero fluid balance
Employ goal-directed therapy
Use of balanced crystalloids
Minimal use of drainage all types of catheters or avoid
Adopt perioperative nutritional care
Screening of patients depending on their comorbidities
Active nutritional support in high-risk patients
Try and curtailed fasting duration
Institute early feeding in the postoperative period (for feeding)
Perioperative glycemic control
Early mobilization
Early bowel movement
Use of chewing gum
Use of postoperative laxatives and prokinetics.

Surgeons and anesthesiologists have started using enhanced recovery protocols in their practice that are summarized in Figure 1 and Table 1.

**Table 1:** Examples of ERAS in different surgical specialties (basic elements)
Type of surgery	Important ERAS elements
Neurosurgical procedures	Goal-directed fluid therapy
Cardiothoracic procedures	Postoperative multimodal analgesia
Abdominal surgery (open and minimally invasive)	Selective bowel preparation, early feeding use of chewing gum, postoperative multimoda analgesia, minimal or avoiding usage of drains
Pediatric surgery	Carbohydrate drink, goal-directed fluid therapy, prevention of hypothermia
Orthopedic procedures	Early mobilization, multimodal analgesia
Gynecological procedures	Early feeding, early mobilization, screen for malnutrition
Obstetrics	Early mobilization, early feeding

Fig. 1: Sample enhanced recovery elements (ERAS) protocol. Adopted from: American Association of Nurse Anesthesiology | 222 South Prospect Ave | Park Ridge, Illinois 60068-4001 | AANA.com Professional Practice Division l 847-655-8870 l

ADVANTAGES OF IMPLEMENTATION OF ERAS

As per the current literature,³ enhanced recovery after surgery (ERAS) leads to:

Good outcomes
Better patient satisfaction
Reduction in cost of healthcare
Faster recovery
Shortened hospital stay and
Fewer complications.

Integration of ERAS into practice by multimodal approach along with patient education and awareness may be valuable.⁴

We must recognize the challenges of ERAS program and act accordingly which will lead to the significant success of an ERAS program.

CHALLENGES IN IMPLEMENTATION OF ERAS

ERAS program has faced implementation challenges that are multidimensional in nature.

They are patient-related:

Patient needs and expectations
Health literacy
Attitudes and behavior
Health history

Staff-related:

Staff attitudes and behavior
Engagement, communication, and collaboration
Skills and competencies.

Specialty and practice-related factors:

Leadership and necessary support
Continuing education and training
Availability of resources, medications, and equipment
Use of policy and procedures
Monitoring, data collection, and transforming into practice.

This ERAS program is being created in various hospitals with the help and involvement of various departments of surgical specialties and anesthesiology. This will help in improving the care of patients from the preoperative stage to recovery after undergoing major surgical procedures and also reduce the cost. However, it is critical that the ERAS protocols are updated regularly when there is new evidence and implemented efficiently.

The basic components of a successful ERAS program include the use of a minimally invasive surgical approach and avoidance of drains, nasogastric tube, and urinary catheter, patient/family education, avoidance of fluid overload/underload, procedure- andpatient-specific nonopioid multimodal pain management to reduce interference with functional outcomes, early oral intake, and early mobilization.⁴^,⁵

The areas that remain for further research include:⁶

Implementation of good anemia management
Intra- and postoperative blood transfusion management
Prevention and management of postoperative fatigue
Prevention and management of delirium, and cognitive dysfunction
Perioperative use of high dose steroids in preventing the surgical inflammatory responses need further research.

Finally, the role of the anesthesiologist in facilitating the development and implementation of ERAS program using a multidisciplinary approach is critical. We should embark on randomized well-designed, procedure-specific, and adequately powered studies. These should be outside the current standard of care and can influence postoperative outcome⁶ in a big way.

REFERENCES

1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78(05):606–617. DOI: 10.1093/bja/78.5.606

2. Bartels K, Karhausen J, Clambey ET, et al. Perioperative organ injury. Anesthesiology 2013;119(06):1474–1489. DOI: 10.1097/ALN.0000000000000022

3. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248(02):189–198. DOI: 10.1097/SLA.0b013e31817f2c1a

4. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg 2005;242(03):326–341. DOI: 10.1097/01.sla.0000179621.33268.83

5. Melnyk M, Casey RG, Black P, et al. Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J 2011;5(05):342–348. DOI: 10.5489/cuaj.11002

6. Joshi GP, Kehlet H. Enhanced recovery pathways: looking into the future. Anesth Analg 2019;128(01):5. DOI: 10.1213/ANE.0000000000003746

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