From the Guidelines
Perioperative medicine and Enhanced Recovery After Surgery (ERAS) protocols are crucial in thoracic surgeries to optimize patient outcomes by reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, published in 2024 1, demonstrates that ERAS guidelines are associated with decreased hospital length of stay and complications, highlighting the importance of implementing these protocols in thoracic surgery.
Key Elements of ERAS Protocols
The ERAS protocols for thoracic surgery include:
- Preoperative optimization with smoking cessation at least 4 weeks before surgery, nutritional assessment, carbohydrate loading, and patient education
- Intraoperative minimally invasive approaches when possible, lung-protective ventilation strategies, goal-directed fluid therapy, multimodal analgesia, and prevention of hypothermia
- Postoperative early mobilization, early removal of chest tubes, early oral intake, multimodal pain management, and early removal of urinary catheters
Implementation and Benefits
Implementation of ERAS protocols requires a multidisciplinary approach involving surgeons, anesthesiologists, nurses, respiratory therapists, and physical therapists to ensure protocol adherence and optimal outcomes. The benefits of ERAS protocols include reducing the surgical stress response, minimizing complications, decreasing opioid requirements, and accelerating functional recovery. As noted in a recent study published in 2021 1, the morbidity of pulmonary lobectomy ranges between 10 and 45%, and mortality rates range from 1 to 2%, emphasizing the need for effective perioperative management strategies like ERAS.
Recent Guidelines and Recommendations
Recent guidelines, such as those published in 2022 1, provide procedure-specific postoperative pain management recommendations for video-assisted thoracoscopic surgery, further supporting the importance of tailored ERAS protocols in thoracic surgery. The adoption of ERAS guidelines is associated with improved patient outcomes, including decreased hospital length of stay and complications, as demonstrated by the 2024 meta-analysis of randomized clinical trials 1.
From the Research
Role of Perioperative Medicine and Enhanced Recovery After Surgery (ERAS) in Thoracic Surgeries
- The implementation of ERAS protocols in thoracic surgeries has been shown to improve patient outcomes, reduce complications, and decrease hospital length of stay (LOS) 2, 3, 4, 5.
- ERAS protocols apply multimodal, perioperative, and evidence-based practices to decrease postoperative morbi-mortality, the length of hospital stay, and hospitalization costs 3.
- The focus of the ERAS concept is on uniform patient care from admission to discharge, with the aim of improving perioperative processes by implementing evidence-based protocols involving a multidisciplinary treatment team 6.
- The implementation of ERAS concepts in thoracic surgery (ERATS) is intended to establish standardized perioperative procedures based on study results and/or expert recommendations 6.
Benefits of ERAS in Thoracic Surgeries
- ERAS has been associated with decreased length of stay, fewer intensive care unit readmissions, and decreased frequency of pneumonia, atrial arrhythmias, and need for home oxygen 4.
- ERAS was independently associated with decreased pulmonary and cardiac complications on logistic regression after thoracotomy but not minimally invasive operations 4.
- The implementation of a multidisciplinary, evidence-based Thoracic ERAS Program reduced length of stay, morbidity, opioid use, and direct costs without change in readmission 5.
Challenges and Limitations of ERAS in Thoracic Surgeries
- The implementation of ERAS protocols in low- and middle-income countries (LMIC) is problematic due to various challenges, including limited resources and infrastructure 3.
- Buy-in and adherence to a new protocol are necessary for implementation to be effective, and prolonged air leaks commonly lead to prolonged LOS 2.
- The effectiveness of ERAS protocols may vary depending on the type of surgical approach, with ERAS being more effective for thoracotomy than for minimally invasive operations 4.