Enhanced Recovery After Surgery

  • ERAS describes a bundle of interventions designed to improve perioperative care through standardisation and protocolisation
    May reduce:
    • LOS by 30-50%
    • Complications by 10-20%
  • Specific interventions are centre and surgery dependent
    Critics argue lack of RCTs and this variability ↓ strength of evidence.
  • Much of ERAS has been subsumed by good perioperative care and it can be difficult to distinguish ERAS pathways from normal management

ERAS describes a bundle of care designed to attenuate the perioperative surgical response, facilitate return to premorbid function, and reduce complications.

Elements of ERAS

Not all appropriate for all operations

Preoperative:

  • Assessment
    • Shared decision making
    • Pre-operative counselling
  • Optimisation
    • Pre-existing comorbidities
    • Anaemia
    • Smoking cessation
    • Alcohol cessation
    • Nutrition
      • Pre-operative carbohydrate loading
      • Avoid prolonged fasting
      • Avoid bowel preparation

Intraoperative:

  • Laparoscopic surgery
  • Minimise:
    • Chest drains
    • NGT
  • Goal-directed fluid therapy
  • Opioid-sparing analgesia
    • Paracetamol
    • NSAIDs
    • Tramadol
    • Regional
    • Epidural
      Controversial due to impaired mobility.

Postoperative:

  • Early mobilisation
  • Nutrition
    • Early nutritional support
    • Early hydration
  • VTE prophylaxis
  • Antimicrobial prophylaxis

ERAS+

Recent addition designed to prevent post-operative pulmonary complications. The mnemonic is ICOUGH:

  • Incentive Spirometry
  • Cough/deep breathing
  • Oral care
  • Understanding (patient education)
  • (Get) out of bed
  • Head of bed elevation

Establishing ERAS Pathways

Involves:

  • Consultation and need assessment
    • Benefits
    • Costs
    • Regulatory authority involvement
    • Review local hospitals with similar services and their guidelines
    • Review specialty hospitals for advice and review
    • Review college guidelines
  • Plan and formulation
    • Set up MDT group to consider implementation and appropriate scope of practice
    • Develop local policy
    • Consider requirement for:
      • Staff training
      • Facilities required
    • Safety concerns
  • Implementation
    • Slow rollout
  • Review
    • Ongoing formal review and audit of effectiveness, safety, and cost

References