What are the key components of Enhanced Recovery After Surgery (ERAS) guidelines for patients undergoing major surgery?

Key Components of Enhanced Recovery After Surgery (ERAS) Guidelines for Major Surgery

ERAS protocols are multimodal pathways that significantly reduce perioperative morbidity, hospital stay, and costs by implementing evidence-based interventions throughout the perioperative period. 1, 2

Preoperative Components

• Patient education and counseling about the surgical procedure, expected recovery course, and active patient participation in recovery is essential for successful ERAS implementation 2
• Avoidance of prolonged fasting with clear fluids allowed up to 2 hours and solid food up to 6 hours before anesthesia to reduce insulin resistance and catabolism 1, 2
• Carbohydrate loading with oral carbohydrate-rich drinks 2 hours before surgery reduces insulin resistance and postoperative catabolism 2, 1
• No routine mechanical bowel preparation as it does not improve outcomes and can lead to dehydration and electrolyte disturbances 2
• Thromboprophylaxis with compression stockings and pharmacological prophylaxis with low molecular weight heparin 2, 1
• Antimicrobial prophylaxis administered within 60 minutes before incision 2
• Prehabilitation including nutritional, physical exercise, and stress-reducing psychological components can reduce postoperative complications, particularly in high-risk patients 1, 3

Intraoperative Components

• Minimally invasive surgical approach when feasible to reduce inflammatory response and improve outcomes 2, 4
• Standardized anesthesia protocol using short-acting anesthetic agents allowing rapid awakening 2
• Goal-directed fluid therapy with cardiac output monitoring to optimize hemodynamics and avoid fluid overload 1, 2
• Maintenance of normothermia using warming devices and warmed intravenous fluids to maintain body temperature >36°C 2, 1
• Prevention of postoperative nausea and vomiting (PONV) with a multimodal approach for at-risk patients 2
• No routine use of nasogastric tubes with removal before reversal of anesthesia 1, 2
• No routine drainage of the peritoneal cavity after anastomosis 1, 2

Postoperative Components

• Multimodal analgesia combining regional techniques (e.g., thoracic epidural for open surgery), acetaminophen, and NSAIDs to reduce opioid requirements 2, 4
• Early mobilization with patients out of bed within 24 hours after surgery and at least 6 hours per day thereafter 2, 5
• Early oral feeding with resumption of oral diet within 24 hours after surgery 1, 2
• Early removal of urinary catheter within 1-2 days postoperatively 2
• Regular audit of outcomes and compliance with protocol to identify areas for improvement 2, 3

Special Considerations for Different Surgical Types

• Liver surgery requires specific adaptations including goal-directed fluid therapy with maintenance of low intraoperative central venous pressure 1
• Emergency laparotomy patients benefit from ERAS principles with additional focus on rapid assessment, optimization, and treatment of sepsis 1, 6
• Gynecologic oncology patients show improved outcomes with ERAS implementation, including lower complication rates and shorter hospital stays 7

Most Impactful ERAS Elements

Research has identified the components that most significantly impact length of stay and readmission rates:

• Early mobilization is one of the most protective elements against increased length of stay 4
• Multimodal pain management significantly reduces length of stay and readmission rates 4
• Limited opioid use (less than 16 morphine milligram equivalents per day) is associated with reduced readmission rates 4
• Minimally invasive surgical approach when feasible is strongly associated with shorter length of stay 4

Implementation Considerations

• ERAS protocols should be implemented by multidisciplinary teams including surgeons, anesthesiologists, nurses, and other healthcare professionals 3
• A phased implementation approach starting with high-impact components may facilitate successful protocol adoption 8
• Regular audit and feedback are crucial for continuous improvement and maintaining compliance 8, 3

The implementation of ERAS protocols has been shown to reduce complications by 30-50%, decrease length of hospital stay, lower readmission rates, and reduce overall healthcare costs across multiple surgical specialties. 3, 1