What is the role of Perioperative Medicine and Enhanced Recovery After Surgery (ERAS) in thoracic surgeries?

From the Guidelines

Perioperative medicine and Enhanced Recovery After Surgery (ERAS) protocols are crucial in thoracic surgeries to minimize morbidity, mortality, and improve quality of life by implementing evidence-based interventions across all phases of care. For thoracic procedures, ERAS implementation begins preoperatively with patient education, nutritional optimization, smoking cessation at least 4 weeks before surgery, and carbohydrate loading (clear liquids up to 2 hours before anesthesia) 1.

Key Components of ERAS in Thoracic Surgeries

• Preoperative multimodal analgesia should include acetaminophen 1000mg, gabapentin 300-600mg, and celecoxib 200-400mg.
• Intraoperatively, lung-protective ventilation strategies with tidal volumes of 4-6 mL/kg, PEEP of 5-8 cmH2O, and recruitment maneuvers are essential 1.
• Regional anesthesia techniques like thoracic epidural (for thoracotomy) or paravertebral blocks with 0.25% bupivacaine should be employed, along with minimally invasive surgical approaches when possible.
• Fluid management should be restrictive, targeting euvolemia with crystalloids at 1-3 mL/kg/hr.

Postoperative Care

• Postoperatively, early mobilization within 24 hours, chest tube management with digital drainage systems, multimodal analgesia (scheduled acetaminophen 1000mg q6h, NSAIDs like ketorolac 15-30mg IV q6h transitioning to oral options, and opioids as rescue only), and early oral feeding are crucial 1.
• Early chest tube removal criteria include drainage <300-400 mL/day without air leak.

Benefits of ERAS Protocols

• These protocols reduce complications like pneumonia and atelectasis by minimizing physiologic stress, optimizing pain control, and promoting rapid functional recovery, ultimately shortening hospital stays by 1-3 days compared to conventional care 1.
• The adoption of ERAS guidelines is associated with decreased hospital length of stay and complications, as evidenced by a meta-analysis of 74 randomized clinical trials with 9076 participants 1.

Implementation and Compliance

• Future research should focus on improving implementation and compliance with ERAS guidelines to improve patient outcomes 1.
• The type of surgery and number of ERAS elements are associated with estimates of length of stay, highlighting the importance of tailored ERAS protocols for thoracic surgeries 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 patient outcomes after thoracic surgeries, including lung resections 2, 3, 4, 5, 6.
• ERAS protocols aim to reduce complications, hospital length of stay, and hospitalization costs by applying multimodal, perioperative, and evidence-based practices 3, 6.
• The implementation of ERAS programs in thoracic surgery has been shown to reduce morbidity rates, especially pulmonary and surgical complications, and shorten length of hospital and intensive care unit stay 5, 6.
• ERAS programs also aim to improve postoperative recovery, reduce opioid use, and decrease direct costs of surgery and hospitalization 4, 5.

Key Components of ERAS Protocols in Thoracic Surgeries

• Early removal of chest tubes and urinary catheters 5.
• Early mobilization and ambulation 4, 5.
• Limited use of opioids and opioid-sparing analgesia 4, 5.
• Multidisciplinary, evidence-based care pathways 2, 5.

Benefits of ERAS Protocols in Thoracic Surgeries

• Reduced length of stay and hospitalization costs 3, 5, 6.
• Improved patient outcomes, including reduced morbidity and mortality rates 5, 6.
• Reduced opioid use and decreased direct costs of surgery and hospitalization 4, 5.
• Accelerated postoperative recovery and improved patient safety 3, 6.