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

What is ERAS Protocol

ERAS (Enhanced Recovery After Surgery) is a multimodal, transdisciplinary perioperative care pathway designed to minimize surgical stress, maintain physiological function, and accelerate patient recovery through evidence-based interventions spanning the entire surgical journey. 1, 2

Core Definition and Purpose

ERAS represents a fundamental shift from traditional perioperative care by implementing approximately 22-25 coordinated interventions across preoperative, intraoperative, and postoperative phases. 1, 2 The protocol aims to reduce the profound stress response following surgery while promoting early return to normal activities. 1, 3

The clinical impact is substantial: ERAS protocols consistently demonstrate 29-50% reduction in overall complications, 1.9-2.5 days shorter hospital length of stay, and significant cost savings compared to conventional perioperative management. 1, 2, 4

Preoperative Components

The preoperative phase establishes the foundation for successful recovery:

• Patient education and counseling detailing the surgical procedure, expected recovery timeline, and the patient's active role in recovery is essential. 2, 5, 4

• Minimize preoperative fasting: clear fluids are allowed up to 2 hours and solid food up to 6 hours before anesthesia to reduce insulin resistance and catabolism. 5, 4

• Carbohydrate loading with 400ml oral carbohydrate-rich drinks (50g CHO) administered 2 hours before surgery reduces insulin resistance and postoperative catabolism. 5, 4

• No routine mechanical bowel preparation is recommended, as it does not improve outcomes and can lead to dehydration and electrolyte disturbances. 1, 5, 4

• Nutritional screening identifies patients at risk of malnutrition who require additional support, as malnourished patients have worse outcomes. 2, 4

• Smoking and alcohol cessation 4 weeks before surgery in patients who smoke or abuse alcohol reduces complications. 2

• Thromboprophylaxis with well-fitting compression stockings and pharmacological prophylaxis with low molecular weight heparin. 5, 4

• Antimicrobial prophylaxis with single-dose antibiotics administered within 60 minutes before incision. 5, 4

Intraoperative Components

The intraoperative phase focuses on minimizing surgical trauma and physiological disruption:

• Minimally invasive surgical approach (laparoscopic when feasible) reduces inflammatory response, decreases morbidity, and accelerates recovery compared to open surgery. 2, 5, 4

• Standardized anesthetic protocol using short-acting agents allows rapid awakening. 2, 5, 4

• Goal-directed fluid therapy with cardiac output monitoring optimizes hemodynamics and avoids fluid overload. 5, 4 For hepatic resection specifically, maintain low central venous pressure. 2, 4

• Maintenance of normothermia using active warming devices and warmed intravenous fluids to maintain body temperature >36°C. 5, 4

• Prevention of postoperative nausea and vomiting (PONV) with a multimodal approach for patients with ≥2 risk factors. 5, 4

• No routine use of nasogastric tubes, with removal before reversal of anesthesia. 5, 4

• No routine drainage of the peritoneal cavity after colonic anastomosis. 5, 4

Postoperative Components

The postoperative phase emphasizes rapid functional recovery:

• Multimodal analgesia combining regional techniques (thoracic epidural analgesia T7-10 for open surgery), acetaminophen, and NSAIDs to minimize opioid requirements. 2, 5, 4

• Early mobilization with patients out of bed within 24 hours after surgery and at least 6 hours per day thereafter. 5, 4

• Early oral feeding with resumption of oral diet within 24 hours after surgery. 5, 4

• Early removal of urinary catheter within 1-2 days postoperatively, regardless of epidural use duration. 2, 5, 4

Implementation Across Surgical Specialties

ERAS protocols have expanded beyond the original colorectal surgery application to multiple surgical disciplines including cardiac, urologic (cystectomy), hepatic, pancreatic, thoracic, gynecologic, orthopedic (spine), bariatric, and emergency surgery. 1, 6, 7

Surgery-specific adaptations are necessary: rectal/pelvic surgery requires maintaining all core ERAS elements but anticipating longer recovery times, while emergency laparotomy patients need additional focus on rapid assessment and sepsis treatment. 2, 4

Implementation Strategy and Monitoring

A phased implementation approach starting with high-impact components facilitates successful adoption, as attempting to implement all 22-25 elements simultaneously can be overwhelming. 2, 4

• Regular audits of protocol compliance and clinical outcomes identify areas for improvement, with greater compliance directly correlating with improved outcomes. 2, 5, 4

• Multidisciplinary team coordination is essential, incorporating outpatient clinical staff, preoperative nurses, anesthesiologists, operative nurses, postoperative recovery staff, inpatient nurses, dieticians, physical therapists, social workers, and surgeons. 6

Common Pitfalls

The primary challenge in ERAS implementation is that these protocols fundamentally challenge traditional surgical doctrine, which has slowed adoption despite strong evidence. 8 Mean compliance rates are often lower than 75%, emphasizing the need for continuous monitoring and team education. 4 Additionally, ERAS protocols require coordinated interventions across all perioperative phases—failure to implement the complete multimodal approach diminishes effectiveness. 1, 3