The mainstay of success of ERAS is preoperative prehabilitation , opioid sparing analgesia , preservation of organ function and the concept of a multidisciplinary team working in concert to continuously audit implementation and measure outcomes .
Preoperative Prehabilitation :
Assessment and referral for smoking cessation – Pharmacotherapy and counseling should be offered early in the preoperative period and continued postoperatively . Smoking cessation for four weeks can reduce post-operative pulmonary complications by 23 %.
Assessment for frailty – In patients in the US , who are older than age 70 , physical frailty is a more relevant predictor of morbidity and mortality , including the onset of postoperative delirium , than is chronological age . A simple preoperative screening test such as measurement of gait speed may help identify older patients at increased risk . Normal gait speed for men age 60-69 is 1.34 meters / second and for women , 1.23 meters / second . After 80 , these decline to under 1 meter / second for both . In one prospective cohort study of more than 15,000 cardiac surgical patients ≥60 years of age , gait speed was an independent predictor of adverse outcomes with an 11 % relative increase in mortality for each 0.1 meter / second decrease in speed . 5
Assessment for malnutrition – Perioperative management of nutritional support is important prior to elective surgery . As with patients undergoing other major surgeries , preoperative screening for malnutrition involves assessment of body mass index , recent changes in weight or decrease in dietary intake , and measurement of albumin level . Preoperative vitamin D deficiency has been associated with delirium after cardiac surgery . Preoperative diet can be improved to treat malnutrition and anemia .
Preanesthetic consultation – Includes reassurance , checking of preoperative recommendations as outlined , and optimization of comorbidities as possible . Education of the patient and family is vital : we discuss management of perioperative medications , planned use of multimodal analgesic techniques , and expectations for early extubation and postoperative recovery .
Carbohydrate loading two hours prior to procedure attenuates postoperative insulin resistance , reduces nitrogen and protein losses , preserves skeletal muscle mass and reduces preoperative thirst , hunger and anxiety .
Opioid sparing multimodal analgesia :
Opioid use should be minimized by using opioid-sparing analgesic approaches . Combinations of acetaminophen and an NSAID or COX-2 specific inhibitor should be used , unless contraindicated . Ketamine and dexmedetomidine have a role in opioid reduction .
The Enhanced Recovery After Cardiac Surgery ( ERAS Cardiac ) Society recommends a perioperative multimodal , opioid-sparing age-adjusted pain management plan as an essential component of any comprehensive program . Opioids are associated with multiple adverse effects , including respiratory depression , sedation , hypoventilation , nausea , vomiting and ileus . A multimodal pain management plan of non-opioid systemic analgesic agents , regional anesthetic techniques and judicious use of opioids is recommended . Implementation of such multimodal pain management programs have reduced perioperative opioid use by as much as 30 %. Also associated is a substantial reduction in the rate of postoperative opioid refills six to 12 months postop , to under < 10 % at one year .
Preservation of organ function :
FEATURE
Neurocognitive function – Screening for post-operative delirium is essential . We minimize or avoid benzodiazepines , anticholinergics like scopolamine , diphenhydramine , metoclopramide and opioids ( particularly meperidine ). Agents that may cause serotonin syndrome can increase risk for postoperative delirium and other types of perioperative neurocognitive disorder ( PND ). Use of raw or processed electroencephalography ( EEG ) such as the bispectral index ( BIS ) is recommended as is cerebral oximetry ( near infrared spectroscopy [ NIRS ] technology ). These may be useful to detect abnormalities in autoregulation of cerebral blood flow .
Pulmonary function – We employ a lung-protective ventilation strategy with low tidal volume , low driving pressure and positive end-expiratory pressure ( PEEP ) to potentially reduce the incidence of pulmonary complications .
Fluid management , hemostasis and renal protection – Goal directed fluid management with zero balance and maintenance of euvolemia .
Early mobilization after surgery : – Early mobilization through patient education and encouragement is an important component of enhanced recovery after surgery programs . Prolonged bed rest is associated with risk for developing pulmonary complications , decreased skeletal muscle strength , thromboembolic complications and insulin resistance . Early mobilization has therefore been an integral component of enhanced recovery after surgery .
Multidisciplinary team that works in concert to audit implementation and measures outcomes .
In an effort to expand the implementation of ERAS pathways and improve perioperative care , the Agency for Healthcare Research and Quality , in collaboration with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality , designed the “ Safety Program for Improving Surgical Care and Recovery .”
In Summary :
ERAS was developed with the goal of reducing variations in patient care processes and improving outcomes while keeping the cost down . ERAS programs are becoming the standard of care and best practice in many surgical specialties throughout the world . The concept is to mitigate the consequences of surgical stress using a comprehensive perioperative program that can be divided into Preadmission , Intraoperative and Postoperative elements .
The University of Louisville hospital system is at the forefront and is dedicated to the widespread adoption of ERAS .
References :
1 . Kehlet H . ERAS implementation — time to move forward . Ann Surg . 2018 ; 267 ( 6 ): 998-999
2 . Kehlet H , Joshi GP . Enhanced recovery after surgery : current controversies
and concerns . Anesth Analg . 2017 ; 125 ( 6 ): 2154-2155 .
3 . Joshi GP , Kehlet H . Enhanced recovery pathways : looking into the future .
Anesth Analg . 2019 ; 128 ( 1 ): 5-7 .
4 . Aarts MA , Rotstein OD , Pearsall EA , et al . Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery : Experience With Implementation of ERAS Across Multiple Hospitals . Ann Surg 2018 ; 267:992 .
5 . Engelman DT , Ben Ali W , Williams JB , et al . Guidelines for Perioperative Care in Cardiac Surgery : Enhanced Recovery After Surgery Society Recommendations . JAMA Surg 2019 ; 154:755 .
Dr . Bhatia is a Professor of Anesthesiology at UofL Health - Jewish Hospital .
JANUARY 2021 19