What is the Enhanced Recovery After Surgery (ERAS) protocol?

From the Guidelines

Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, evidence-based approach to perioperative care designed to improve surgical outcomes and speed recovery, as recommended by the most recent guidelines 1. The protocol begins in the preoperative phase with patient education, nutritional optimization, and carbohydrate loading up to 2 hours before surgery. Patients are encouraged to avoid prolonged fasting, with clear liquids allowed until 2 hours before anesthesia. During surgery, ERAS emphasizes minimally invasive techniques when possible, goal-directed fluid therapy to maintain euvolemia, prevention of hypothermia, and multimodal pain management including regional anesthesia techniques like epidurals or nerve blocks. Postoperatively, the protocol focuses on early mobilization (often within 24 hours), early oral feeding, prompt removal of drains and catheters, and continued multimodal analgesia with opioid-sparing strategies such as scheduled acetaminophen (1000mg every 6 hours), NSAIDs like ketorolac (15-30mg IV every 6 hours), and gabapentinoids. ERAS has been shown to reduce complications, shorten hospital stays, and improve patient satisfaction across multiple surgical specialties by reducing the physiological stress response to surgery and maintaining normal organ function throughout the perioperative period, as supported by high-quality evidence from recent studies 1. Key aspects of perioperative care in ERAS include integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, start of nutritional therapy early, metabolic control, reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function, minimize time on paralytic agents for ventilator management in the postoperative period, and early mobilisation to facilitate protein synthesis and muscle function, as outlined in the guidelines 1. The ERAS protocol has been successfully applied to various surgical specialties, including colorectal surgery 1, and has been shown to be safe and beneficial in the elderly 1. High adherence to ERAS protocols may be associated with improved 5-year cancer-specific survival after major colorectal surgery 1. Overall, the ERAS protocol is a valuable tool for improving surgical outcomes and should be implemented in clinical practice to enhance patient recovery and reduce morbidity and mortality.

From the Research

ERAS Protocol Surgery Overview

• The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal approach to perioperative care that aims to reduce morbidity, mortality, and length of stay after surgery 2.
• ERAS protocols have been shown to be effective in a variety of surgical fields, including colorectal surgery, total knee arthroplasty, and total hip arthroplasty 3, 4, 5.

Key Components of ERAS Protocols

• Preoperative care:
  • Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and gabapentinoids 3, 4.
  • Optimization of patient's physical and physiological condition before surgery 6.
• Intraoperative care:
  • Use of spinal anesthesia with light sedation for total knee and total hip arthroplasty 3.
  • Use of ketamine, lidocaine, and magnesium for analgesia and to reduce opioid consumption 4.
• Postoperative care:
  • Multimodal pain management, including peripheral nerve blocks, acetaminophen, and NSAIDs 3, 4.
  • Early mobilization and ambulation to reduce length of stay and improve outcomes 5.

Benefits of ERAS Protocols

• Reduced length of stay and hospital readmission 3, 4, 5.
• Decreased postoperative pain and opioid consumption 3, 4.
• Improved patient outcomes, including reduced morbidity and mortality 2, 6.
• Cost savings due to reduced length of stay and complications 2.