What is the Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing major surgery?

Enhanced Recovery After Surgery (ERAS) Protocol

ERAS is a comprehensive, evidence-based multimodal perioperative care pathway that reduces surgical stress, maintains physiological function, and accelerates recovery through standardized interventions spanning the preoperative, intraoperative, and postoperative periods. 1

Core Principles

ERAS protocols fundamentally shift perioperative care by dampening the surgical stress response and supporting early return of normal physiological functions that traditionally delay recovery. 2, 3 This approach has demonstrated consistent reductions in complications (29-50% decrease), hospital length of stay (1.9-2.5 days shorter), and overall costs across multiple surgical specialties. 1, 4

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Preoperative Components

Patient Education and Optimization

• Provide structured preoperative counseling detailing the surgical procedure, expected recovery timeline, and the patient's active role in recovery. 1, 5, 4
• Stop smoking and alcohol consumption 4 weeks before surgery in patients who smoke or abuse alcohol to reduce complications. 1
• Screen for malnutrition and provide nutritional support to at-risk patients, as malnourished patients have worse outcomes. 4

Fasting and Carbohydrate Loading

• Allow clear fluids until 2 hours before anesthesia induction and solid food until 6 hours before to reduce insulin resistance and catabolism. 1, 5, 4
• Administer oral carbohydrate-rich drinks (400ml with 50g carbohydrate) 2 hours before surgery to further reduce insulin resistance and postoperative catabolism. 1, 5, 4
• Carbohydrate loading can be given to diabetic patients along with their diabetic medication. 1

Bowel Preparation

• Do not use routine mechanical bowel preparation for colonic surgery, as it provides no benefit and causes dehydration and electrolyte disturbances. 1, 5, 4

Thromboprophylaxis

• Use well-fitting compression stockings, intermittent pneumatic compression, and pharmacological prophylaxis with low molecular weight heparin (LMWH). 1, 5, 4
• Extend prophylaxis for 28 days in patients with colorectal cancer. 1

Antimicrobial Prophylaxis

• Administer intravenous antibiotics 30-60 minutes before surgical incision, with additional doses during prolonged operations based on drug half-life. 1, 5, 4
• Use chlorhexidine-alcohol for skin preparation. 1

Premedication

• Avoid routine long- or short-acting sedative premedication, as it delays immediate postoperative recovery. 1

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Intraoperative Components

Surgical Approach

• Perform laparoscopic surgery when expertise is available, as it reduces inflammatory response, decreases morbidity, and accelerates recovery compared to open surgery. 1, 5, 4

Anesthesia Protocol

• Use a standardized anesthetic protocol with short-acting agents allowing rapid awakening. 1, 5, 4
• For open surgery: Use mid-thoracic epidural blocks (T7-10) with local anesthetics and low-dose opioids to control the stress response and provide superior analgesia. 1, 5
• For laparoscopic surgery: Spinal analgesia or morphine patient-controlled analgesia (PCA) is an acceptable alternative to epidural anesthesia. 1

Fluid Management

• Administer intraoperative fluids (colloids and crystalloids) guided by cardiac output monitoring to optimize hemodynamics and avoid fluid overload. 1, 5, 4
• Use vasopressors for epidural-induced hypotension when the patient is normovolemic. 1
• For liver surgery specifically: Maintain low intraoperative central venous pressure to reduce blood loss and improve outcomes. 1, 4

Temperature Management

• Maintain normothermia using active warming devices and warmed intravenous fluids to keep body temperature >36°C throughout surgery. 1, 5, 4

Nasogastric Tubes

• Do not use routine postoperative nasogastric tubes. 1, 5, 4
• Remove nasogastric tubes inserted during surgery before reversal of anesthesia. 1, 5

Surgical Drains

• Avoid routine drainage of the peritoneal cavity after colonic anastomosis, as drains impair mobilization without proven benefit. 1, 5, 4

PONV Prophylaxis

• Use a multimodal approach to prevent postoperative nausea and vomiting (PONV) in all patients with 2 or more risk factors undergoing major surgery. 1, 5, 4

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Postoperative Components

Analgesia

• Implement multimodal analgesia combining regional techniques (epidural for open surgery), acetaminophen, and NSAIDs to minimize opioid requirements. 5, 4
• Note: NSAIDs including ketorolac should NOT be administered perioperatively in patients with epidural catheters due to bleeding risk; wait until catheter removal and adequate hemostasis. 6

Urinary Catheter Management

• Remove transurethral bladder catheters within 1-2 days postoperatively, regardless of epidural use duration. 1, 5, 4

Early Mobilization

• Get patients out of bed within 24 hours after surgery and encourage at least 6 hours of mobilization daily thereafter. 5, 4

Early Oral Nutrition

• Resume oral diet within 24 hours after surgery and discontinue intravenous fluids as soon as practicable. 1, 5, 4
• Use oral laxatives postoperatively to promote bowel recovery. 1

Prevention of Postoperative Ileus

• Implement multimodal ileus prevention including gum chewing, PONV prevention, and minimally invasive techniques. 1

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Surgery-Specific Adaptations

Liver Surgery

• Goal-directed fluid therapy with low central venous pressure maintenance is critical during hepatic resection. 1, 4
• No routine abdominal drainage after liver resection. 1

Rectal/Pelvic Surgery

• Recognize higher complication rates compared to colonic surgery and adapt protocols accordingly. 1, 5
• Maintain all core ERAS elements but anticipate longer recovery times. 1

Bariatric Surgery

• Apply standard ERAS principles with attention to obesity-specific considerations. 1
• Early mobilization is particularly important to prevent thromboembolic complications. 1

Cystectomy

• Doppler-guided fluid administration reduces morbidity in this population. 1
• Early nasogastric tube removal reduces complications and accelerates bowel recovery. 1

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Implementation and Monitoring

Protocol Adoption

• Use a phased implementation approach starting with high-impact components to facilitate successful adoption. 4
• Expect mean compliance around 75% initially, with improvement over time through education and feedback. 4

Audit and Quality Improvement

• Conduct regular audits of protocol compliance and clinical outcomes to identify areas for improvement. 5, 4
• Greater compliance with ERAS elements directly correlates with improved outcomes, making monitoring essential. 4

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Clinical Pitfalls to Avoid

Do not cherry-pick individual ERAS elements—the protocol's effectiveness depends on comprehensive implementation of multiple components working synergistically. 2, 3

Do not continue traditional practices like prolonged fasting, routine nasogastric tubes, or delayed mobilization alongside ERAS elements, as this undermines the protocol's stress-reduction benefits. 1

Do not assume ERAS is only for low-risk patients—high-risk and elderly patients often benefit most from the structured, evidence-based approach. 1, 4

Do not neglect the preoperative phase—optimization before surgery is as critical as intraoperative and postoperative care for achieving optimal outcomes. 1, 4