Abstract
Abstract
Enhanced Recovery After Surgery (ERAS®) is a multimodal, multidisciplinary approach to surgical care. The ERAS Society has issued recommendations for many surgical procedures that address best practices in preoperative, intraoperative, and postoperative management. When implementing a new ERAS protocol, the length and detail of the recommendations can be overwhelming. In this study, the general principles of the ERAS guidelines are summarized and workload is distributed among the different members of the care team. This compartmentalized approach provides an easier way to involve key personnel in the ERAS process and assigns a role for everyone in making ERAS a success.
Introduction
E
Guideline Structure
Most guidelines are published with input and endorsements from other medical societies, such as The European Society for Clinical Nutrition and Metabolism and the International Association for Surgical Metabolism and Nutrition, part of the International Surgical Society. The guidelines are produced by an expert panel of contributors after a literature search of the best available published evidence on perioperative practice for a given procedure type. Greater weight is given to meta-analyses and randomized clinical trials, but where Level I evidence is lacking, the panel does consider retrospective studies and other forms of lower-level evidence. Each element of the ERAS protocol is explained, concluding with a summary and recommendation. The quality of evidence behind the recommendations is then evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system. 9 The panel then assigns a level of strength to each recommendation. Strong recommendations indicate that the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects. Weak recommendations indicate that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is less confident.
Simplifying the Guidelines
Despite the diverse specialties and procedures covered by ERAS guidelines, the recommendations can be summarized into five basic elements: (1) patient education, (2) surgical preparation and optimization, (3) early feeding, (4) judicious fluid management, and (5) early mobilization. Given the multiple providers involved in each patient's care, we have found it most conducive to assign five tasks related to these elements to each member of the care team, beginning with the patient (Table 1).
ERAS, Enhanced Recovery After Surgery; NSAIDs, non-steroidal anti-inflammatory drugs; POD, post-operative day; PONV, post-operative nausea vomiting.
Patient
ERAS begins with the patient. The patient should be counseled to prepare for surgery similar to training for a marathon or any other physical stress. Key to this preparation is the knowledge that the patient's personal efforts before surgery will improve the chances of a successful recovery.
1. Tobacco: In the preoperative counseling, the patient should be counseled about the importance of tobacco cessation before surgery. This should include education that smoking increases risks of poor wound healing, infection, prolonged length of stay, readmission, prolonged intubation, and perioperative organ dysfunction. Evidence is strong that elective surgery offers an incentive for patients to modify these behaviors and that even brief interventions led by the surgeon or anesthesiologist are effective.10–12
2. Alcohol: Patients should also be counseled to reduce alcohol intake before surgery. As with smoking, patients should be instructed that cutting back on alcohol consumption may reduce the risk of complications. Screening for alcohol misuse and referring to interventions as appropriate appear to reduce perioperative morbidity. 13
3. Mobility: Patients should be assessed for baseline function by using a simple test such as the 2- or 6-minute walk test and the timed get up and go test.14,15 Providing patients with baseline results empowers the patient to “train” for surgery, which has been associated with improved outcomes. 16 Several apps exist that can assist patients in monitoring these results.
4. Avoidance of overnight fasting: Despite two decades of recommendations from the American Society of Anesthesiologists to avoid overnight fasting for most procedures, many patients continue to have this preconception. Patients should be reminded both at the initial preoperative visit and on the day before surgery to avoid fasting.
5. Carbohydrate loading: Patients should be encouraged to build up glycogen stores in the days before surgery. Patients should also take a complex carbohydrate concentrated drink 2–4 hours before surgery and present to the surgery well hydrated. 17
Preop Staff
The office staff can educate the patient and screen for modifiable risk factors before surgery. Normalizing the surgical experience and setting expectations establish the tone for the subsequent interactions.
1. Explain ERAS: Patients must be adequately counseled about the surgical process and the key elements of the ERAS protocol. Many patients have had surgery under older treatment paradigms and may not be aware of changes in best practice. Patients should be provided with written, visual, and online materials to reinforce teaching.
2. Psychological preparation: Surgery is a time of anxiety and fear for most patients. 18 Anesthesia is poorly understood and imposing for the lay public. 19 Acknowledging these concerns and providing simple information to address the most common fears is an effective way to reduce anxiety before surgery. 20
3. Nutrition assessment: The preoperative assessment should include a nutritional screen. Formal nutritional screening has been shown to reveal a substantial proportion of patients with nutritional deficiency. 21 Simple screening tools can help identify patients who should receive formal referral to a dietitian and are considered for preoperative supplementation. 22
4. Functional status assessment: Patient mobility should be formally assessed and documented before surgery by using a validated metric. In addition, patients should receive questionnaires addressing the capacity for physical activity. Formal assessment has shown significant discrepancies between physician impression of functional status (≥4 METS) compared to either patient assessment or validated scoring tools. 23
5. Make a discharge plan: Even when an ERAS protocol is perfectly implemented, patients may have prolonged hospital stays due to poor discharge planning. 24 Transportation, disposition, medications, and home assistance should be decided before admission with advice from the preoperative staff.
Anesthesiologist
Intraoperative management predicts the patient recovery in the first days after surgery. Emphasis should be on avoidance of prophylactic interventions (whether for pain, fluids, anxiety) and instead assessment of medical need.
1. Avoid sedatives in the preoperative area: Sedative premedication before surgery does not improve patient satisfaction and delays time to extubation and cognitive recovery. 25 Although short-acting agents such as midazolam before epidural placement or line placement may be appropriate, long-acting agents should be avoided.
2. Opioid minimization: For patients with a working regional block, routine administration of intraoperative opioids should be avoided. Opioid requirements can be further reduced by use of multimodal analgesia, including preoperative non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and gabepentinoids. 26
3. Temperature regulation with fluid warmers and forced air warmers: Inadvertent intraoperative hypothermia is common and is associated with adverse outcomes. Active body warming should include both warmed fluids and forced air warmers.27,28
4. Postoperative nausea and vomiting prophylaxis: Patients should receive at least three antiemetic interventions. 29 Compliance with ERAS elements reduces nausea risk. Total intravenous anesthesia (TIVA) as opposed to volatile anesthetics has been associated with decreased rates of postoperative nausea and vomiting. 30 In the setting of ERAS protocols, TIVA also appears to promote shorter hospital stay. 31
5. Judicious use of fluids to void sodium/chloride/fluid overload: Excessive weight gain from intravenous fluids is an independent predictor of all-cause mortality after surgery. 32 A zero net fluid balance, whether through stroke volume variation monitoring or restrictive practices, is essential.33,34
Surgeon
Surgical management should focus on optimizing the patient's fluid status before surgery and increasing the patient's ability to ambulate after surgery.
1. No bowel prep or minimization of bowel prep: Although in select cases (such as when on table colonoscopy is planned) bowel preparation may be required, routine mechanical preparation of abdominal surgery patients should be avoided.35,36
2. Avoidance of drains: Prophylactic abdominal drains have not been shown to reduce complications and should not be placed.37,38
3. Local analgesia: For patients not receiving regional blocks, the surgeon should instill local anesthetic in the wound or place a wound catheter.
4. Written orders for standing NSAIDs and Acetaminophen: Minimization of opioids should continue postoperatively by writing for standing multimodal analgesia. NSAIDs and acetaminophen are synergistic and should be coadministered, not alternated. 39
5. Written orders for early diet and stimulation of gut motility: Intake of liquids and light solids should begin as soon as the patient is awake enough for oral intake. It is well established that early oral feeding is safe across surgical types.40–42
Nursing
The nursing teams, in both the recovery unit and the ward, dictate much of the success of the patient. Nurses should be actively trained in ERAS principles and encouraged to participate in quality improvement initiatives and auditing. Although nursing workload may be higher on the day of surgery by using ERAS, overall nursing workload is lower over the course of the hospital stay. 43
1. Turn off intravenous fluids within 8 hours of surgery: Once the patient is fully awake, the intravenous fluids should be removed, even if the patient has not taken oral fluids. Most patients can drink within 3 to 4 hours of surgery. Postoperative urine output goals have historically been too high, leading to fluid excess. For most procedures, the immediate postoperative urine output goal should be 0.25 mL/(kg·h).
2. Provide chewing gum and oral fluids to bedside on postoperative day 0: Chewing gum appears to lower the rate of postoperative ileus. 44 Patients should be provided fluid to drink and gum in the recovery unit.
3. Patients should mobilize out of bed on postoperative day 0: Patients should be out of bed for all meals and should begin to ambulate within 12 hours of surgery.45,46 Early mobilization is a strong independent predictor of successful recovery and avoidance of readmission.
4. Daily weights: Postoperative weight gain directly correlates to poor patient outcome. 47 Daily weights are essential for monitoring volume status.
5. Remove urinary catheters either in the operating room or on postoperative day 1: Urinary catheter removal is safe in patients receiving low thoracic epidural analgesia and results in lower rates of urinary tract infection. 48
Conclusion
ERAS guidelines address preoperative, intraoperative, and postoperative care. No individual team member can implement a full ERAS protocol. Understanding the guidelines is easier when one approaches them as a division of labor among the care team members. Assigning ERAS tasks also allows team members to feel invested in the protocol success and empowers team members, including the patient, to participate in continuous quality improvement. Once a set of guidelines is in place, an auditing system is essential to provide feedback. Compliance and outcome data should be provided to all team members. Not only does this encourage adherence, but also it provides opportunities to adjust the protocol to meet the needs of a given clinical practice.
Footnotes
Acknowledgment
ERAS® is a registered trademark of the ERAS® Society.
Disclosure Statement
No competing financial interests exist.