Enhanced recovery after surgery

Concept of ERAS is to treat undesirable perioperative pathophysiological processes with the goal to speed patient recovery.

Protocols are utilized for which metabolic injury and physical interventions affect recovery to hasten the recovery process.

Processes such as systemic inflammation and catabolic responses to surgery, deranged fluid homeostasis and vascular responsiveness, anemia, pain are considered specific interventions included in protocols.

ERAS includes patient education, the use of the epidural analgesia, avoidance of nasogastric tubes, early mobilization and early feeding, and fluid therapy targeting euvolemia.

Surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and altered pulmonary and gastrointestinal function.

Enhanced Recovery After Surgery (ERAS) pathways goals are to maintain normal physiology in the perioperative period, thus optimizing patient outcomes without increasing postoperative complications or readmissions.

Basic principles include attention to the following: preoperative counseling, preoperative nutrition, including avoidance of prolonged perioperative fasting,

Perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis.

ERAS pathway benefits include shorter length of stay, decreased postoperative pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction.

The implementation of the ERAS program requires collaboration from all members of the surgical team.

The basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis.

Traditional components of perioperative care include: bowel preparation, cessation of oral intake after midnight, liberal use of narcotics, patient-controlled analgesia use, prolonged bowel and bed rest, the use of nasogastric tubes or drains, and gradual reintroduction of feeding, early mobilization and appropriate thromboprophylaxis.

Many of the commonly implemented interventions are not evidence-based, and their use frequently does not promote healing and recovery.

Surgical stress induces a catabolic state that leads to increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and altered pulmonary and gastrointestinal function.

Surgical response can lead to organ dysfunction with increased morbidity and delayed surgical recovery.

A delay of postoperative recovery may include nosocomial infections, development of venous thromboembolism, long term diminishment of quality of life, and increased health care costs.

Enhanced Recovery After Surgery pathways were developed with the goal of maintaining normal physiology in the perioperative period, thus optimizing patient outcomes without increasing postoperative complications or readmissions.

A meta-analysis of six randomized controlled trials demonstrated that implementation of at least 4 of the 17 possible components of the ERAS pathway in patients undergoing colorectal surgery resulted in reductions in length of hospital stay (by more than 2 days) and complication rates (by nearly 50%).

ERAS benefits include shorter length of stay, decreased postoperative pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and increased patient satisfaction.

Implementation of ERAS protocols has not been shown to increase readmission, mortality, or reoperation rates.

Preoperative risk assessment should include identification of tobacco and alcohol use, overweight status and obesity, anemia, and sleep apnea, to choose the appropriate preoperative and postoperative care.

Smoking-related impairment in wound healing decreases and pulmonary function improves within 4–8 weeks of smoking cessation

Patients who consume 3–4 drinks per day may have up to 50% higher complication rates, including bleeding, cardiac arrhythmias, impaired wound healing, and intensive care unit admissions when compared with patients who consume 0–2 drinks per day.

Surgical complication rates increase to 200–400% for those who have five or more drinks per day.

Preoperative anemia is associated with postoperative morbidity and mortality and should be actively identified and corrected.

Studies have suggested patients undergoing elective colorectal surgery demonstrated no difference in wound infections or anastomotic leakage rates between groups of participants who received or did not receive mechanical bowel preparation.

Some studies showed that the combination of oral antibiotics with a mechanical bowel preparation regimen reduces rates of infection and anastomotic leakage, while others have not demonstrated a significant difference.

Patients undergoing hysterectomy, which is classified as a clean contaminated surgery, should receive broad-spectrum antibiotics to cover skin, vaginal, and enteric bacteria.

For laparoscopic surgeries that do not involve genitourinary or digestive contamination, no antibiotic prophylaxis is necessary.

Intravenous antibiotics should be administered within 60 minutes before a skin incision is made.

Amoxicillin–clavulanic acid and cefazolin provide appropriate antibiotic coverage against bacteria frequently involved in postoperative infections.

For lengthy procedures, additional intraoperative doses of the antibiotic are recommended to maintain adequate levels throughout the operation

Prophylactic antibiotic dosage should be increased in obese patients and, in surgical cases with excessive blood loss.

Preoperative surgical site skin preparation with an alcohol-based agent unless contraindicated is performed.

Vaginal cleansing with either 4% chlorhexidine gluconate or povidone-iodine should be performed before hysterectomy or vaginal surgery.

The judicious use of opioids is appropriate to achieve postoperative pain control.

There is increased attention to alternative, stepwise and multimodal, and nonopiate pain management strategies.

Ketorolac is effective alternative to opioids in controlling postoperative pain and does not increase postoperative bleeding.

Epidural and spinal anesthesia strategies compared with general anesthesia, decreases overall mortality and postoperative complications, including VTE, blood loss, pneumonia and respiratory depression, myocardial infection, and renal failure.

A transversus abdominis plane block involving injection of local anesthetic into the transversus abdominis fascial plane, may be effective in for reduction of postoperative opioid use in patients undergoing laparoscopic surgery, or undergoing total abdominal hysterectomy.

Minimizing opioid use reduces nausea and vomiting, impairment of bowel function, delayed mobilization, and pulmonary problems.

Paracervical nerve blocks or intrathecal morphine may be useful to reduce opioid usage for vaginal hysterectomies.

Spinal analgesia or thoracic epidural analgesia can be used postoperatively for open gynecological surgery to reduce opioid use.

Antiemetics are encouraged to reduce postoperative nausea and vomiting.

Maintaining intraoperative fluid volume is essential, as is preventing hypothermia.

Fluid retention and its excess may lead to electrolyte abnormalities, peripheral edema, impaired physical and bowel mobility, and pulmonary congestion.

The development of hypovolemia may result in decreased cardiac output and oxygen delivery.

Preventing hypothermia, even of mild degree, is important as a decrease of 1°C from core temperature stimulates adrenal steroid and catecholamine production and results in increased incidence of wound infections, cardiac arrhythmias, and blood loss.

Routine use of nasogastric, abdominal, and vaginal drains hinder mobilization, increase morbidity, and prolong hospital stay with limited evidence of benefit.

Therefore, surgical associated drains should be removed as soon as possible.

Early ambulation postoperatively protects against deconditioning, reduces thromboembolic complications, reduces insulin resistance and results in shorter hospital stays.