From the Guidelines
The ERAS protocol for surgery should be implemented as a comprehensive perioperative care pathway to achieve early recovery for patients undergoing major surgery, as recommended by the most recent and highest quality study 1. The ERAS protocol typically spans three phases: preoperative, intraoperative, and postoperative.
Preoperative Phase
In the preoperative phase, patients should receive:
- Counseling and nutritional optimization with carbohydrate loading up to 2 hours before surgery, as recommended by 1 and 1
- Minimal fasting, with clear liquids allowed up to 2 hours before anesthesia, as recommended by 1 and 1
- Preemptive analgesia, which may include acetaminophen, gabapentin, and celecoxib, as suggested by the example answer
Intraoperative Phase
During surgery, the ERAS protocol emphasizes:
- Minimally invasive techniques, as recommended by 1 and 1
- Goal-directed fluid therapy to maintain euvolemia, as recommended by 1 and 1
- Prevention of hypothermia, as recommended by 1 and 1
- Multimodal analgesia with regional anesthesia techniques, such as epidurals or nerve blocks, to minimize opioid use, as recommended by 1 and 1
Postoperative Phase
Postoperatively, the ERAS protocol prioritizes:
- Early mobilization, ideally within 24 hours, as recommended by 1 and 1
- Early oral nutrition, as recommended by 1 and 1
- Prompt removal of drains and catheters, as recommended by 1 and 1
- Continued multimodal pain management, as recommended by 1 and 1
- Nausea prevention, which may include dexamethasone and ondansetron, as suggested by the example answer These protocols reduce complications, hospital stays, and readmission rates by minimizing the surgical stress response and organ dysfunction, as recommended by 1, 1, 1, 1, and 1. Implementation requires multidisciplinary coordination between surgeons, anesthesiologists, nurses, and other healthcare providers to ensure all elements are consistently applied, as recommended by 1, 1, 1, 1, and 1.
From the Research
Specific Eras Protocol Surgery
The specific eras (Enhanced Recovery After Surgery) protocol for surgery, particularly in the context of appendectomy, involves several key components aimed at reducing complications and improving patient outcomes.
- Antimicrobial Prophylaxis: The use of antimicrobial prophylaxis is a crucial aspect of eras protocols in surgery, including appendectomy 2, 3. This involves the administration of antibiotics to prevent surgical site infections. The choice of antibiotic and the duration of prophylaxis can vary depending on the type of surgery and the patient's risk factors.
- Surgical Technique: The surgical technique used for appendectomy, whether open or laparoscopic, is also an important consideration in eras protocols 4, 5. Laparoscopic appendectomy is often preferred due to its minimally invasive nature, which can lead to less pain, shorter hospital stays, and quicker recovery times.
- Postoperative Care: Postoperative care is another critical component of eras protocols, including pain management, early mobilization, and early oral feeding 6. The goal is to minimize the stress of surgery, reduce complications, and accelerate recovery.
- Antibiotic Duration: The optimal duration of antibiotic use following appendectomy, especially in cases of complicated appendicitis, is an area of interest 6. Research suggests that limiting antibiotic treatment to 3-6 days may be sufficient for most cases, with no added benefit for longer durations.
Key Considerations
- Patient Selection: The decision to perform an appendectomy and the choice of surgical technique depend on patient selection, including the diagnosis of appendicitis and the presence of any complications 4.
- Antibiotic Regimens: Different antibiotic regimens have been studied for their efficacy in preventing postoperative infections in appendectomy patients 2, 3, 5. The choice of regimen can depend on factors such as the severity of appendicitis and patient allergies.
- Outcome Measures: Outcome measures for eras protocols in appendectomy include rates of surgical site infections, length of hospital stay, and postoperative complications 6. These measures help in evaluating the effectiveness of the protocol and identifying areas for improvement.