Enhanced Recovery After Surgery

Introduction

Enhanced Recovery After Surgery (ERAS) is a modern approach to help people recover quicker following surgery. Guidelines consist of a combination of evidence-based perioperative care elements designed to reduce post-surgical complications, length of hospital stay, and overall costs, by modifying the psychological and physiological responses to major surgery.

The elements that form ERAS consist of strategies that focus on patient engagement, pre-surgical medical optimisation, optimal anaesthetic protocols, and postoperative nausea prophylaxis.

From the surgical side, key elements in ERAS include minimally invasive surgery, avoiding dehydrating bowel preparation where possible, early removal of drains and catheters, and early post-operative mobilisation.

The ERAS Protocol

The ERAS protocol can be divided into the 3 stages of the patient journey, each comprising several elements

Pre-Operative

• Patient education regarding the surgery and the expected post-operative course and milestones
  • Most units will have developed a handbook for the patient so they know what to expect every day
• Ensuring the patient is as healthy as possible prior to surgery, through exercise and weight loss
• Optimising medical management, including smoking and alcohol cessation
• Optimal pre-operative fasting guidelines
  • Altered diet prior to surgery to enhance bowel recovery and avoid bowel prep if appropriate
  • Solids allowed until 6 hours pre-operatively (unless contra-indicated)
  • Intake of clear fluids until 2 hours prior to surgery, with some centres moving towards being able to drink clear fluids up to the time of leaving the ward
  • Loading with 12.5% carbohydrate beverage within 2 hours of surgery

Intra-Operative

• Use of multimodal and opioid-sparing analgesia, including regional anaesthesia*
  • Includes avoidance of short-acting benzodiazepines in the elderly
• Use of multimodal postoperative nausea and vomiting prophylaxis
• Use of minimally invasive surgery
• Targeting a goal-directed fluid therapy regime, including goal-directed haemostasis management

*Regional anaesthesia includes spinal and epidural anaesthesia, rectus sheath catheters, and local anaesthetic regional blocks

Post-Operative

• Ensure adequate pain control is achieved to allow for early mobilisation
• Early oral intake and optimising nutrition
• Multi-disciplinary post-operative patient follow-up, including in the post-acute care phase

Certain centres now have booklets with daily targets for patients to meet along their ERAS post-operative pathway, to provide realistic goals for the patient to work toward