Enhanced Recovery After Surgery (ERAS) Protocol Components
ERAS protocols are multimodal, evidence-based perioperative care pathways consisting of approximately 20-24 key elements spanning preoperative, intraoperative, and postoperative phases that reduce surgical stress, accelerate recovery, and improve outcomes by reducing length of stay by 30-50% and complications by 29% compared to traditional care. 1, 2, 3
Preoperative Components
Patient Preparation and Education
- Patient counseling about the surgical procedure, expected recovery course, and active participation in their recovery is essential for successful implementation 2, 3
- Nutritional screening should identify patients at risk of malnutrition who require additional support 1, 2
- Prehabilitation incorporating nutritional optimization, physical exercise, and stress-reducing psychological components reduces postoperative complications, particularly in high-risk patients 2
Fasting and Carbohydrate Loading
- Minimize preoperative fasting: clear fluids allowed up to 2 hours and solid food up to 6 hours before anesthesia to reduce insulin resistance and catabolism 1, 2, 4
- Carbohydrate loading with oral carbohydrate-rich drinks 2 hours before surgery reduces insulin resistance and postoperative catabolism 2, 3
Prophylaxis
- Thromboprophylaxis using compression stockings and pharmacological prophylaxis with low molecular weight heparin 2, 4
- Antimicrobial prophylaxis administered within 60 minutes before incision 2
- No routine mechanical bowel preparation as it does not improve outcomes and can lead to dehydration and electrolyte disturbances 2
Intraoperative Components
Surgical Approach
- Minimally invasive surgical approach when feasible to reduce inflammatory response and improve outcomes 2, 3
- Open surgery is associated with increased length of stay compared to minimally invasive approaches 5
Anesthesia Management
- Standardized anesthesia protocol using short-acting anesthetic agents allowing rapid awakening 2, 3
- Multimodal analgesia combining regional techniques, acetaminophen, and NSAIDs to reduce opioid requirements 2, 6, 5
Fluid and Temperature Management
- Goal-directed fluid therapy with cardiac output monitoring to optimize hemodynamics and avoid fluid overload 2, 4, 3
- Maintenance of normothermia using warming devices and warmed intravenous fluids to maintain body temperature >36°C 2
Tube and Drain Management
- No routine use of nasogastric tubes with removal before reversal of anesthesia 2, 3
- No routine drainage of the peritoneal cavity after anastomosis 2
PONV Prevention
- Prevention of postoperative nausea and vomiting with a multimodal approach for at-risk patients 2
Postoperative Components
Pain Management
- Multimodal analgesia is the most protective element against increased length of stay 5
- Scheduled acetaminophen and NSAIDs as first-line agents 2, 6
- Limited opioid use (less than 16 morphine milligram equivalents per day) is associated with decreased length of stay and readmissions 5
- Readmissions increase with the number of morphine milligram equivalents per day 5
Mobilization and Nutrition
- Early mobilization with patients out of bed within 24 hours after surgery and at least 6 hours per day thereafter is one of the most impactful elements for reducing length of stay 2, 6, 5
- Early oral feeding with resumption of oral diet within 24 hours after surgery 1, 2, 4, 3
- Oral fluids can be started as soon as the patient is lucid after surgery 6
Catheter Management
- Early removal of urinary catheter within 1-2 days postoperatively 2
Implementation and Compliance
Protocol Adoption
- The number of ERAS elements included in protocols is more important than the branding (ERAS vs fast-track vs enhanced recovery protocol) 1
- Most studies included less than 70% of traditional ERAS elements, suggesting room for improvement 1
- A phased implementation approach starting with high-impact components facilitates successful protocol adoption 2, 4
Key High-Impact Elements
The subset of elements most influential on outcomes includes: 5
- Minimally invasive procedures
- Multimodal pain control with limited opioid use (less than 16 MME/day)
- Early mobilization
Patients who underwent minimally invasive procedures with multimodal pain control and less than 16 MME per day had only 23% likelihood of length of stay >3 days, while those with open procedures and less than 15 ERAS elements completed had 84% likelihood of length of stay >3 days. 5
Monitoring and Audit
- Regular audit of outcomes and compliance with protocol to identify areas for improvement is crucial 2, 4
- Greater compliance with ERAS improves outcomes, but only about 20% of studies report compliance data 1
- Mean compliance is likely lower than 75%, suggesting current findings underestimate the potential benefits of ERAS 1
Outcomes
Clinical Benefits
- Reduced length of hospital stay by 1.9 days on average, with greater reductions in pancreatic, orthopedic, and gastrointestinal surgical procedures compared to gynecological and breast surgery 1
- 29% reduction in complications (RR 0.71,95% CI 0.58-0.87) 1
- Reduced costs and readmissions 3, 7
- Increasing compliance with ERAS elements has an inverse linear relationship with length of stay 5
Special Populations
- Emergency laparotomy patients benefit from ERAS principles with additional focus on rapid assessment, optimization, and treatment of sepsis 1, 2, 8
- Cancer patients undergoing surgery should be managed within an ERAS program, with every patient screened for malnutrition and given additional nutritional support if at risk 1
- Liver surgery requires specific adaptations including goal-directed fluid therapy with maintenance of low intraoperative central venous pressure 2
Common Pitfalls
- Failing to achieve high compliance across all elements reduces the effectiveness of ERAS protocols 1, 7
- Focusing on protocol branding rather than the number and quality of elements included 1
- Inadequate monitoring of compliance and outcomes prevents identification of areas for improvement 1, 2
- Excessive opioid use undermines the benefits of other ERAS elements 5