What are the current ERAS (Enhanced Recovery After Surgery) guidelines for an adult patient undergoing major abdominal surgery?

Current ERAS Guidelines for Major Abdominal Surgery

For adults undergoing major abdominal surgery, implement a comprehensive multimodal ERAS protocol spanning preoperative optimization through postoperative day 1-2, with core elements including preoperative carbohydrate loading, avoidance of bowel preparation (except colorectal surgery with oral antibiotics), mid-thoracic epidural analgesia for open procedures, goal-directed fluid therapy with balanced crystalloids, multimodal opioid-sparing analgesia, early feeding within 4 hours, and early mobilization. 1, 2

Preoperative Phase

Patient Optimization

• Smoking and alcohol cessation are mandatory components with strong consensus across all ERAS guidelines 3, 2
• Nutritional assessment and optimization should occur during the prehabilitation phase, with particular attention to malnourished patients 1, 4
• Check and reinforce physical functional status before surgery 5

Fasting and Carbohydrate Loading

• Avoid prolonged fasting: Clear fluids until 2 hours preoperatively, solid food until 6 hours 1, 2
• Preoperative carbohydrate loading is recommended, though this represents a mixed-strength domain requiring local appraisal 2

Bowel Preparation

• Avoid mechanical bowel preparation alone in most abdominal surgery 1, 3
• Exception for colorectal surgery: Mechanical bowel preparation combined with oral antibiotics is now recommended based on large-scale studies 5

Intraoperative Phase

Anesthesia Management

For open abdominal surgery, use mid-thoracic epidural analgesia (T7-10) started before surgery and continued for 48-72 hours postoperatively 1. This provides superior analgesia compared to systemic opioids and reduces surgical stress response, insulin resistance, and time to bowel function return.

Critical epidural management caveat: When hypotension occurs with epidural, confirm euvolemia first and add vasopressor before giving additional IV fluids. A patient may be fluid-responsive without being fluid-depleted 1.

Anesthesia for Minimally Invasive Surgery

• Do not use epidural analgesia for laparoscopic/MIS procedures 1
• Alternative: Spinal analgesia with long-acting opioid plus local anesthetic (1.5-2 ml total volume to avoid high spinal block) - this has strong evidence for MIS colorectal surgery 1
• Monitor patients receiving spinal morphine closely for 24 hours due to delayed respiratory depression risk, especially in elderly 1

Additional Analgesic Techniques

Abdominal wall blocks (TAP, subcostal, rectus blocks) are strongly recommended 1:

• TAP blocks provide T10-L1 coverage (below umbilicus)
• Subcostal and rectus blocks cover upper abdomen
• Duration concern: typically 8-10 hours; consider infusion catheters or liposomal bupivacaine 1

IV lidocaine infusion decreases anesthetic requirements, pain scores, opioid needs, and improves bowel function return 1:

• Benefits seen in both open and MIS surgery
• Mandatory continuous ECG monitoring during infusion
• Watch for systemic toxicity: blurred vision, dizziness, tinnitus, perioral anesthesia, tongue paresthesia 1

Neuromuscular Blockade

Complete reversal is mandatory before extubation 1:

• Monitor with peripheral nerve stimulator at hand muscles (not facial)
• Use quantitative (objective) monitoring
• Document train-of-four ratio ≥ 0.90 1

Ventilation Strategy

• Low tidal volumes 6-8 ml/kg with PEEP 6-8 cm H₂O reduces pulmonary complications 1

Temperature Management

• Maintain normothermia throughout surgery and postoperatively 1, 2

Fluid Management

Use balanced crystalloids (Ringer's lactate) with goal-directed therapy 1, 2:

• Avoid 0.9% saline due to salt and fluid overload risk 1
• Do not treat oliguria reflexively with fluids - it's a normal physiological response during surgery; investigate the cause first 1
• Target near-zero fluid balance 1

Prophylaxis

• Antibiotic prophylaxis with appropriate skin preparation 3, 2
• Thromboprophylaxis with LMWH for in-hospital and at-home VTE prevention 3, 2

Postoperative Phase

Multimodal Analgesia

Baseline regimen: Paracetamol + NSAIDs unless contraindicated 1:

• Both have strong recommendations with moderate evidence
• NSAIDs: Recent meta-analyses remain inconclusive regarding anastomotic leak risk, but they remain recommended 1
• Avoid opioids; use short-acting opioids only if absolutely needed 1

Fluid Management

• Discontinue IV fluids by postoperative day 1 at latest 1
• Encourage oral intake when fully recovered
• If IV fluids needed: use hypotonic crystalloid with 70-100 mmol/day sodium and up to 1 mmol/kg/day potassium 1
• Replace ongoing losses (vomiting, diarrhea) with balanced solution, not saline 1

Nutrition

• Offer oral diet within 4 hours after surgery 1, 2
• Early feeding is a consistent core element across all ERAS guidelines 2

Ileus Prevention

• Peripherally-acting mu receptor antagonists for ileus prevention 3
• Multimodal opioid-sparing analgesia facilitates bowel function return 1

Mobilization

• Early mobilization starting postoperative day 0-1 2, 4

Glucose Control

• Maintain appropriate perioperative glucose control 3

PONV Prevention

• Multimodal antiemetic regimen 3, 2
• Avoid nitrous oxide (increases PONV and delays bowel function) 1

Special Population Considerations

Elderly Patients (≥65 years)

ERAS protocols are effective and safe in elderly patients undergoing major abdominal surgery 6:

• Reduces hospital stay by approximately 3.3 days
• Lowers complication rates (RR 0.63)
• Borderline reduction in 30-day mortality (RR 0.53)
• No increase in readmission rates 6

Implementation Considerations

Protocol compliance is critical but variably reported - when documented, ranges from 42-89.6% 6. The strength of evidence varies by component 2:

• Consistent domains (>80% agreement): multimodal analgesia, fasting, thromboprophylaxis, antimicrobial prophylaxis, nutrition, temperature management, fluid management 2
• Mixed-strength domains requiring local appraisal: fluid management details, preoperative carbohydrate administration specifics, preanaesthetic medication 2

Team approach with audit system is essential to maintain and develop protocols, maximize adherence, and optimize outcomes 5, 4.