FEATURE
ENHANCING AND ACCELERATING POST-SURGICAL RECOVERY , IMPROVING OUTCOMES : ROLE OF ENHANCED RECOVERY AFTER SURGERY ( ERAS )
AUTHOR Aneeta Bhatia , MD
Post-operative complications are
one of the most important drivers of morbidity and mortality , prolonged length of stay , hospital readmissions and increased health care costs .
The institution of Enhanced Recovery After Surgery ( ERAS ) presents a paradigm shift in the perioperative care of patients undergoing surgery . ERAS is a multidisciplinary , multimodal evidence based perioperative intervention . It is designed to maintain a physiological state during surgery with an aim to accelerate recovery . The multimodal approach to recovery was first outlined by a Danish surgeon , Henrik Kehlet in 1995 . 1 , 2 Later , this approach was advanced for patients undergoing colonic surgery . Today , it has been adopted for most major operations and medium size surgeries .
This topic discusses elements of ERAS that involve anesthetic and surgical collaboration to accelerate and enhance recovery after cardiac and major abdominal surgery . Surgeons and anesthesiologists on the front line have a great role to play in its implementation .
While some postoperative adverse events may be related to largely unmodifiable factors like age , frailty , comorbid conditions and complexity of the surgical procedure , some adverse events are preventable . 1 , 2 , 3 A recent study showed that institutions that adopted ERAS programs demonstrated faster post-operative recovery of their patients , which reduced the length of hospital stay by about 30 %. Despite earlier discharge from the hospital , readmissions did not increase . ERAS has reduced major non-cardiac complications after abdominal surgery by as much as 40 %. 4
The ERAS protocols have outlined evidence-based care elements that are designed to reduce the humoral stress reactions caused by injury .
Specific aims of ERAS for cardiac and major abdominal surgery are :
» Minimizing humoral and metabolic stress responses to surgery and anesthesia .
» Using multimodal analgesic strategies to control postoperative pain . » Achieving early extubation . » Expediting recovery . » Reducing postoperative complications . » Decreasing hospital length of stay . » Improving clinical outcomes .
THE CORE COMPONENTS FOR THE SUCCESS OF AN ERAS PROGRAM IN REDUCING COMPLICATIONS INCLUDE THE FOLLOWING :
PREADMISSION RECOMMENDATIONS
Dedicated preoperative counseling of patients with communication of expectations
Optimizing medical co-morbid conditions
Smoking cessation for ≥4 weeks to reduce post op pulmonary complications
Prehabilitation to improve functional capacity thereby reducing complications
Improving nutrition 7-10 days prior in patients at risk of malnutrition .
Correction of anemia
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PREOPERATIVE RECOMMENDATIONS
Light meal up to six hours and clear fluids up to two hours prior to surgery
Carbohydrate-rich liquid up until two hours prior to a procedure .
Multimodal approach to prophylaxis of postoperative nausea and vomiting ( PONV )
Preoperative pharmacologic anxiolysis medications to be avoided in the elderly
IV antibiotic prophylaxis ≤ 60 minutes before incision
Oral antibiotics be given to patients receiving oral mechanical bowel preparation ( MBP )
Skin disinfection to be performed
INTRAOPERATIVE RECOMMENDATIONS
Short-acting anesthetics , neuromuscular monitoring , and complete reversal of neuromuscular block recommended
Goal-directed fluid therapy ( GDFT ) to be adopte
Inotropes and pressors may be considered for management of pharmacologically induced hypotension in euvolemic patients
Active warming methods to prevent inadvertent perioperative hypothermia
Minimally invasive surgery where possible
Hyperglycemia to be avoided
Pelvic and peritoneal drains to be avoided routinely
POSTOPERATIVE RECOMMENDATIONS
Nasogastric ( NG ) tubes to be avoided routinely
Opioids to be avoided to the extent possible .
Early extubation
Early ambulation
Multimodal analgesia be used in combination with regional analgesia .
Nerve blocks , Epidural analgesia or transversus abdominis plane ( TAP ) blocks