From the Guidelines
Perioperative medicine and Enhanced Recovery After Surgery (ERAS) protocols play a crucial role in optimizing patient outcomes in thoracic surgeries by reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, a meta-analysis of randomized clinical trials published in 2024 1, demonstrates that ERAS guidelines are associated with decreased hospital length of stay and complications.
Key Components of ERAS Protocols
- Preoperative optimization with smoking cessation at least 4 weeks before surgery, nutritional assessment, carbohydrate loading, and patient education
- Preoperative medications including anxiolytics like midazolam, multimodal analgesia with acetaminophen and gabapentinoids, and prophylactic antibiotics
- Intraoperative lung-protective ventilation strategies, restrictive fluid management, and minimally invasive surgical approaches when feasible
- Postoperative early mobilization, chest tube management with digital drainage systems, multimodal analgesia, early oral intake, and early chest tube removal
Benefits of ERAS Protocols
- Reduction in complications like pneumonia and atelectasis by minimizing opioid use, promoting early mobility, and optimizing respiratory function
- Decrease in length of stay by 1-3 days and reduction in readmission rates through standardized care pathways
- Improvement in patient outcomes and quality of life, as demonstrated by the 2024 meta-analysis 1 and supported by guidelines from the French Society of Thoracic and Cardiovascular Surgery and the French Society of Anaesthesia and Intensive Care Medicine 1
Recommendations
- Implement ERAS protocols in thoracic surgeries to reduce morbidity, mortality, and improve quality of life, as supported by the highest quality evidence available 1
- Use minimally invasive surgical approaches, such as VATS or robotic surgery, when feasible, as recommended by guidelines and systematic reviews 1
- Follow procedure-specific postoperative pain management recommendations, such as regional techniques like paravertebral blocks or thoracic epidural for open procedures, and intercostal nerve blocks for VATS 1
From the Research
Role of Perioperative Medicine and Enhanced Recovery After Surgery (ERAS) in Thoracic Surgeries
- Perioperative medicine and ERAS play a crucial role in improving outcomes for patients undergoing thoracic surgeries 2, 3, 4, 5, 6
- ERAS protocols aim to mitigate the harmful surgical stress response and accelerate functional recovery of the thoracic surgical patient 3
- Key elements of ERAS protocols include early removal of chest tubes, early mobilization, and limited use of opioids, which are intertwined and have synergistic effects 3
Benefits of ERAS in Thoracic Surgeries
- ERAS has been shown to decrease postoperative morbi-mortality, length of hospital stay, and hospitalization costs 2
- ERAS can improve postoperative outcomes, including decreased length of stay, fewer complications, reduced opioid requirements, and reduced costs 3, 4, 5
- ERAS can reduce pulmonary and cardiac complications after thoracotomy for lung cancer 4
- ERAS can decrease the length of stay for patients undergoing minimally invasive lung resection 5
Implementation of ERAS Protocols
- ERAS protocols should be implemented in a multidisciplinary approach, involving surgeons, anesthetists, ERAS coordinators, and staff from units that care for the surgical patient 6
- The ERAS Society provides updated guidelines for many operations and conducts structured implementation programs to train local ERAS teams from hospitals 6
- Audit of process compliance and patient outcomes are important features of ERAS implementation 6