What is the Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing major surgery?

Enhanced Recovery After Surgery (ERAS) Protocol for Major Surgery

The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal pathway designed to reduce perioperative stress, maintain physiological function, and accelerate recovery, resulting in significantly decreased postoperative complications, faster recovery, and shorter hospital stays across multiple surgical specialties. 1

Preoperative Phase

Patient Education and Counseling

• Provide detailed information about the surgical procedure, expected recovery timeline, and ERAS pathway
• Set realistic expectations regarding pain management, early mobilization, and dietary progression
• Explain the patient's active role in recovery process 1

Medical Optimization

• Strong recommendation to optimize medical conditions prior to surgery 1
• Smoking cessation at least 4 weeks before surgery (strong recommendation) 1
• Reduction of alcohol consumption in patients who consume excessive amounts 1

Nutritional Preparation

• Avoid prolonged fasting
• Clear fluids allowed up to 2 hours before anesthesia
• Solid food allowed up to 6 hours before anesthesia 1
• Preoperative carbohydrate loading (oral carbohydrate drinks) for non-diabetic patients 2-3 hours before surgery 1

Bowel Preparation

• Mechanical bowel preparation (MBP) should generally not be used routinely 1
• Exception: May be necessary when a diverting stoma is planned in pelvic surgery 1

Thromboprophylaxis

• Well-fitting compression stockings
• Pharmacological prophylaxis with low molecular weight heparin (LMWH)
• Extended prophylaxis (28 days) for cancer patients or those with increased VTE risk 1

Intraoperative Phase

Anesthetic Protocol

• Standard anesthetic protocol to attenuate surgical stress response
• Maintain adequate hemodynamic control, oxygenation, muscle relaxation, and appropriate analgesia 1
• Consider epidural anesthesia for open procedures (moderate evidence) 1
• Consider IV lidocaine infusion as alternative to epidural (low evidence) 1

Minimally Invasive Surgical Approach

• Laparoscopic approach when feasible to reduce surgical stress and postoperative ileus 1

Temperature Management

• Active prevention of intraoperative hypothermia using warming devices
• Continuous body temperature monitoring 1

Fluid Management

• Goal-directed fluid therapy using cardiac output monitoring
• Avoid fluid overload and maintain euvolemia
• Judicious use of vasopressors for hypotension
• Targeted fluid therapy using esophageal Doppler system recommended 1, 2

Antimicrobial Prophylaxis

• Single dose before skin incision
• Repeated doses may be necessary depending on drug half-life and surgery duration 1

Drainage and Tubes

• Avoid routine use of nasogastric tubes - should be removed before reversal of anesthesia if placed during surgery 1
• Avoid routine use of abdominal/pelvic drains 1

Postoperative Phase

Pain Management

• Multimodal analgesia approach to minimize opioid use:
  • Local anesthetic infiltration
  • Scheduled acetaminophen and NSAIDs
  • Dexamethasone for anti-inflammatory effect
  • Opioids only as rescue medication 1, 2
• Epidural analgesia for open procedures 1

Nausea and Vomiting Prevention

• Multimodal approach to PONV prophylaxis for all patients with ≥2 risk factors
• Treatment via multimodal approach if PONV occurs 1

Early Mobilization

• Begin mobilization within 24 hours after surgery
• Structured mobilization plan with daily targets 1

Early Oral Intake

• Early removal of urinary catheter (day 1 post-op) when appropriate 1
• Early oral feeding starting day of surgery or postoperative day 1
• No need to wait for flatus or bowel movement 1

Laxative Use

• Postoperative oral laxatives to promote bowel recovery 1

ERAS Protocols by Surgical Specialty

Colorectal Surgery

• First and most established ERAS protocol
• Emphasis on avoiding mechanical bowel preparation, early feeding, and mobilization 1, 3

Liver Surgery

• Avoid prophylactic nasogastric intubation and abdominal drainage
• Goal-directed fluid therapy with low central venous pressure
• Early oral intake and mobilization 1

Bariatric Surgery

• Focus on nutritional optimization
• Thromboprophylaxis particularly important due to obesity-related risks 1

Urological Surgery (Radical Cystectomy)

• Early nasogastric tube removal
• Doppler-guided fluid administration
• Multimodal prevention of ileus, including gum chewing 1

Common Pitfalls and How to Avoid Them

1. Poor compliance with protocol elements

   • Use standardized order sets and checklists
   • Regular audit and feedback to improve adherence

2. Inadequate patient education

   • Provide written materials and preoperative counseling
   • Involve family members in education sessions

3. Overuse of opioids

   • Implement structured multimodal analgesia protocols
   • Set expectations about pain management with patients

4. Delayed mobilization

   • Set clear daily mobility goals
   • Ensure adequate pain control to facilitate mobilization

5. Inappropriate fluid management

   • Use goal-directed therapy rather than fixed regimens
   • Monitor for signs of fluid overload or dehydration

6. Failure to adapt protocols to individual patient needs

   • Consider comorbidities and specific surgical requirements
   • Modify protocol elements when medically necessary while maintaining core principles

The evidence consistently demonstrates that implementing ERAS protocols reduces complications, shortens hospital stays, and improves patient satisfaction across multiple surgical specialties 1, 3.