Enhanced Recovery after surgery (ERAS) programs focus on improving surgical outcomes such as patient experience, complications, mortality, and time to discharge from the hospital. ERAS teams typically consist of surgeons, anesthesiologists, nurses, and other healthcare providers who work together to implement evidence-based interventions with the intention of quickly and efficiently getting patients back to their baseline functional status. Programs implementing ERAS protocols have a 40% reduction in major complications and up to a 30% reduction in length of hospital stay [1]. Hospitals in Alberta, Canada’s state healthcare service have seen an 11% reduction in major complications, an 8% reduction in hospital readmissions, and a savings of $2800-5900 per patient in the program [2]. Here, we will review the preadmission, preoperative, intraoperative, and postoperative strategies currently being employed by ERAS protocols and what effect they are having on patient outcomes.
ERAS begins prior to admission with clinicians advising patents to stop consuming alcohol/tobacco, optimization of medical regimens, and screening for malnutrition. According to the 2019 consensus statement from the ERAS society, there is strong evidence to recommend screening all patients for tobacco use and counseling them on cessation, a practice which shortens hospital stays and improves wound healing [3]. While in preoperative clinic for medical optimization, it is beneficial to screen patients for malnutrition. Two validated screening tools are the Malnutrition Universal Screening Tool, or the Nutritional Risk Score. When patients with malnutrition are identified, they should be followed by a dietician and have documentation of oral intake alongside regular weight measurements to ensure success of any dietary interventions [4].
In the Preoperative setting, reduced fasting time, fluid and carbohydrate loading, and antibiotic prophylaxis reduce readmissions and decrease hospital length of stay. The practice of fasting patients after midnight does not reduce the risk of aspiration during intubation as previously thought. For that reason, the American Society of Anesthesiologists now allows patients to take solid food 6 hours prior to an operation and clear liquids 2 hours prior [5]. Allowing clear liquids two hours prior also opens the door to carbohydrate loading patients preoperatively, which attenuates postoperative insulin resistance, reduces nitrogen production and protein loss, as well as preserves skeletal muscle mass [6]. Finally, although antibiotic prophylaxis is commonly used in all preoperative settings, ERAS protocols enforce the utility of preoperative antibiotic prophylaxis in preventing post-operative infections [6].
Intraoperative interventions include minimally invasive techniques, limiting drain placement, and maintaining adequate fluid balance and optimal body temperature throughout the case. While maintaining adequate fluid balance and using minimally invasive procedures are already common practice at most institutions, limiting drain placement and removing NG tubes prior to emergence are practices that improve time to discharge and patient mobility without any real consequences [2]. For maintenance of body temperature specifically, the ERAS society recommends keeping patients warm using forced air warmers or warmed fluids; this is because low body temperature increases the risk of wound infections, bleeding, and increased length of PACU stay [7].
Postoperatively, a trove of evidence-based interventions is available like early mobilization, removal of foley catheters, and intake of nutrition. Early ambulation and early removal of urinary catheters and IV fluids support patient ambulation and a return to normal movement, which is thought to decrease a number of post-operative complications like DVT formation and deconditioning[7]. Avoiding opioids and using chewing gum, laxatives, and opioid blocking agents can support the return of gut function [8]. Surprisingly, multiple papers including a metanalysis of several randomized-controlled trials show that chewing gum post-operatively reduces both the time to pass flatus and the time until first bowel movement. However, a more a more recent randomized controlled trial showed no difference in time to first bowel movement, which makes the current data less convincing [8][9]. Inadequate protein intake postoperatively is associated with loss of lean body mass even when calorie intake is adequate, so, while the exact composition of early postoperative diet is still debated, a high-protein diet should be given to patients to improve functional recovery and physical quality of life [10].
Throughout all stages of perioperative medicine and anesthesia, ERAS protocols are saving time, money, and lives. Steps like optimizing nutrition, delivering prophylactic antibiotics, maintaining adequate body temperature, and mobilizing patients early help patients leave the hospital earlier and in better health. In the next several years, more health systems will incorporate ERAS protocols into their hospital practice, and anesthesia providers will need to become familiar with coordinating and implementing ERAS protocols.
References
1. Greco, M., et al., Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World journal of surgery, 2014. 38(6): p. 1531-1541.
2. Ljungqvist, O., M. Scott, and K.C. Fearon, Enhanced Recovery After Surgery: A Review. JAMA Surgery, 2017. 152(3): p. 292-298.
3. Feldman, L.S., The Sages / Eras Society manual of enhanced recovery programs for gastrointestinal surgery. 2015, New York, NY: Springer Science+Business Media. pages cm.
4. Weimann, A., et al., ESPEN guideline: Clinical nutrition in surgery. Clinical nutrition (Edinburgh, Scotland), 2017. 36(3): p. 623-650.
5. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology, 2017. 126(3): p. 376-393.
6. Melnyk, M., et al., Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Urological Association journal = Journal de l’Association des urologues du Canada, 2011. 5(5): p. 342-348.
7. Wainwright, T.W., et al., Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 2019: p. 1-17.
8. Purkayastha, S., et al., Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy. Arch Surg, 2008. 143(8): p. 788-93.
9. Atkinson, C., et al., Randomized clinical trial of postoperative chewing gum versus standard care after colorectal resection. The British journal of surgery, 2016. 103(8): p. 962-970.
10. Wischmeyer, P.E., et al., American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesthesia and analgesia, 2018. 126(6): p. 1883-1895.