Enhanced Recovery After Surgery (ERAS) [advanced]

ERAS (Enhanced Recovery After Surgery) protocols are sets of guidance consisting of a combination of evidence-based perioperative care elements. Surgical doctors play a vital role in the post-operative parts of these protocols. This includes prescribing post op ERAS protocol medications and looking after these patients on the surgical ward. 

ERAS was originally developed for colorectal surgery, but now widely used to include pathways for musculoskeletal, urological and gynaecological surgery.

The benefits of ERAS are:

• Improved patient experience and satisfaction
• Reduced length of hospital admission 
• Reduced postoperative complications 
• Reduced readmissions to critical care 
• Reduced long term opiate use
• Reduced readmissions after discharge. 

Pre-operative Interventions

Pre-hospital

• Pre-op Assessment: 
  • Seen in anaesthetic pre-operative clinic
  • Assess risk of individual patient.
• Pre-op Education: 
  • Manage expectations for surgery and anaesthetic
• Medical Management: 
  • Focus on optimisation of medical conditions. 
  • Requesting further investigations (Echo, CXR, ECG, blood tests)
  • This may include referrals to specialists for options on managements. For example:
    • Cardiology for arrhythmia management, assessment of murmurs
    • Endocrinology for advice regarding medications / peri-operative medication advice
    • Respiratory 
    • Diabetic specialist nurses – for patients with high HbA1c / complex insulin regimes (specific advice for insulin doses in the peri-operative period)
    • Pain team – particularly if patients are on high dose subutex, complex analgesia requirements
    • to address reversible or chronic issues such as anaemia, hypertension and diabetes.
  • Cessation of smoking /Alcohol
• Physical activity : Aims to improve patients physiological reserve
  • Physiotherapists create exercise prescriptions
  • Dieticians create dietary modifications

Immediately Pre op 

• Carbohydrate loading: by ingesting a clear carbohydrate drink 2 hours prior to surgery.
  • Aim is to prevent catabolic state resulting from preoperative & intra-operative fasting.
• Avoid use of bowel preparation and premedication if possible.

Intra-op Interventions

Anaesthetic focused: 

• Short acting anaesthetic agents
  • Goal directed fluid therapy (to avoid fluid overload – which has associated complications including acute respiratory distress syndrome, increased hospital stay, electrolyte / metabolic derangement)
  • Maintenance of normothermia (monitor with oesophageal temperature probe)
    • Use warming device
    • Warmed IV fluids 
    • Warm ambient temperature
    • Minimise patient area open to atmosphere
  • Multimodal antiemetics to prevent PONV (post – op nausea and vomiting) 
  • Prophylactic Antibiotics to reduce risk of surgical site infection

Surgeon: 

• Use of minimally invasive surgery
  • Judicious use of surgical drains
  • Avoid NG tubes if possible

Post-op Interventions

• VTE (Thromboprophylaxis)
  • Reduces risk of thromboembolic events.
• Early Enteral nutrition
  • Improves insulin resistance, wound healing and lowers incidence of surgical site infections.
• Early Mobilisation: 
  • Improves muscle strength, promotes functional organ recovery and reduces risk of respiratory and thromboembolic events.
• Early removal of catheter promotes early mobility.
• Multimodal Pain management
  • Reduces short term and long-term opiate use and their complications 
  • Important to ensure patients have:
    • Regular paracetamol
    • Ibuprofen if no contraindications
    • PRN short-acting opioid (i.e oral morphine or oxynorm)
      • There is a move in acute pain circles to not use long-acting opioid prescriptions including M/R preparations for acute pain. We should be focusing on PRN short-acting opioids to help achieve functional outcomes
    • Anaesthetic doctors may prescribe PCA (patient controlled analgesia) 
  • Some patients may have local anaesthetic infusions
    • For example:
      • Laparotomy patients may have rectus sheath catheters – these are a fantastic pain intervention to reduce surgical site pain. They are typically only sited for 72 hours. 
      • Vascular patients: Epidural catheter – these give an infusion of local anaesthetic and some have a PCA option to “top-up” the infusion level. 
    • Less commonly: patients may have lidocaine infusions (these should only be used in a monitored area – practically this is in a ITU area only)

Remember the acronym DrEaMing when managing post op patients!

• Drinking
• Eating
• Mobilisation 

Further reading

https://www.apsf.org/article/eras-roadmap-for-a-safe-perioperative-journey/