What are the key components of an Enhanced Recovery After Surgery (ERAS) protocol?

Enhanced Recovery After Surgery (ERAS) Protocol Components

ERAS protocols are structured, evidence-based perioperative care pathways organized into preoperative, intraoperative, and postoperative phases that reduce hospital stay by 30-50%, decrease complications by 29%, and lower costs while maintaining or improving patient outcomes. 1, 2

Preoperative Components

Patient Preparation and Education:

• Provide structured patient education about the surgical procedure, expected recovery timeline, and the patient's active role in their recovery process 1
• Screen all patients for malnutrition risk and provide additional nutritional support to those identified as at-risk 1
• Implement prehabilitation programs incorporating nutritional optimization, physical exercise, and stress-reduction techniques, particularly for high-risk patients 1

Fasting and Carbohydrate Loading:

• Allow clear fluids up to 2 hours before anesthesia and solid food up to 6 hours preoperatively to reduce insulin resistance and catabolism 1, 3
• Administer oral carbohydrate-rich drinks 2 hours before surgery to further reduce insulin resistance and postoperative catabolism 1

Bowel Preparation and Prophylaxis:

• Avoid routine mechanical bowel preparation as it does not improve outcomes and causes dehydration and electrolyte disturbances 1
• Administer antimicrobial prophylaxis within 60 minutes before surgical incision 1
• Implement thromboprophylaxis using compression stockings combined with low molecular weight heparin 1

Intraoperative Components

Surgical Technique:

• Utilize minimally invasive surgical approaches whenever feasible to reduce inflammatory response and improve outcomes 1

Anesthesia Management:

• Use standardized anesthesia protocols with short-acting anesthetic agents that allow rapid awakening 1
• Implement multimodal strategies to prevent postoperative nausea and vomiting in at-risk patients 1

Fluid and Temperature Management:

• Apply goal-directed fluid therapy with cardiac output monitoring to optimize hemodynamics and avoid fluid overload 1
• Maintain normothermia (body temperature >36°C) using warming devices and warmed intravenous fluids 1

Tube and Drain Management:

• Avoid routine nasogastric tube placement; if used, remove before reversal of anesthesia 1
• Avoid routine peritoneal drainage after anastomosis 1

Postoperative Components

Pain Management:

• Implement multimodal analgesia combining regional anesthetic techniques, acetaminophen, and NSAIDs as first-line agents to minimize opioid requirements 1, 4
• Reserve opioids as last-resort agents used in low doses 4

Mobilization and Activity:

• Mobilize patients out of bed within 24 hours after surgery, with at least 6 hours of activity per day thereafter 1
• Begin ambulation with at least 30 minutes on the day of surgery to prevent venous thromboembolism and promote faster recovery 4

Nutrition and Bowel Function:

• Resume oral diet within 24 hours after surgery 1, 3
• Start oral fluids as soon as the patient is lucid, with solid foods introduced within 4 hours postoperatively if tolerated 4

Catheter Management:

• Remove urinary catheters within 1-2 days postoperatively 1

Implementation and Quality Assurance

Phased Implementation Approach:

• Begin with a limited number of high-impact components initially to facilitate successful protocol adoption 1, 3
• Recognize that mean compliance is typically lower than 75%, but greater compliance correlates with improved outcomes 1

Continuous Monitoring:

• Conduct regular audits of outcomes and protocol compliance to identify areas for improvement 1, 3
• Provide ongoing feedback to the multidisciplinary team 3

Special Population Considerations

Emergency Laparotomy:

• Apply ERAS principles with additional focus on rapid assessment, optimization, and treatment of sepsis 1, 5

Liver Surgery:

• Adapt protocols to include goal-directed fluid therapy with maintenance of low intraoperative central venous pressure 1

Pediatric Robotic Surgery:

• Implement age-appropriate deep vein thrombosis prophylaxis using mechanical and/or pharmacological methods 3
• Use restricted, balanced, and individualized fluid replacement strategies to prevent fluid overload 3

Clinical Outcomes

The implementation of ERAS protocols demonstrates substantial benefits: hospital length of stay reduces by an average of 1.9 days, complications decrease by 29%, and both readmissions and costs are reduced 1, 2. These improvements result from dampening the surgical stress response and supporting early return of normal physiological functions 6.