Conference Lectures

Guidelines for implementation of Enhanced Recovery After Surgery (ERAS) Protocols

Dr. Harihar V. Hegde
Associate Professor
Department of Anaesthesiology
SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India

 

Introduction
Perioperative care is undergoing a paradigm shift. We anaesthetists are quite familiar with Day-care procedures and Fast-tracking of cardiac surgical patients where the anaesthetic management of these patients is an important cog in the quick recovery of patients. By using potent, short acting drugs and modifying the anaesthesia techniques to suite the requirements of these relatively new concepts, anaesthesia as a speciality has contributed in improving the efficiency of the existing healthcare system. Traditional practices such as prolonged pre-operative fasting (‘nil by mouth from midnight’), long-acting heavy sedation, bowel cleansing and the use of nasogastric decompression are being shunned.

Enhanced Recovery After Surgery (ERAS)
What is ERAS?
Enhanced Recovery After Surgery (ERAS) protocols, also known as ‘fast-track surgery’ or ‘multimodal optimisation’ are a combination of evidence based peri-operative strategies delivered by a multi-professional health care team which work synergistically to expedite recovery after surgery. This expedited discharge is not achieved by lowering the prerequisites for discharge from hospital, but rather by fulfilling standard discharge criteria earlier, due to an accelerated post-operative phase. Professor Henrik Kehlet, a surgeon from Denmark, pioneered the concept about two decades ago.1

Aims of ERAS
The main goal of this concept is a reduction in the postoperative length of hospital stay (LOS). The underlying aim of ERAS is to ensure that patients are in optimal condition for surgery, receive innovative care during surgery and experience optimal postsurgical rehabilitation.

Programmes differ widely but share common elements such as patient education and involvement in preoperative planning processes, preoperative oral carbohydrates, and improved anaesthetic and postoperative analgesic techniques to reduce the physical stress of the operation, early oral feeding and mobilisation.

Although ERAS was started initially in patients undergoing colorectal surgery, in 2009, a collaborative initiative, the Enhanced Recovery Partnership Programme (ERPP), was established in England with the aim of promoting spread and adoption of ERAS, in colorectal, musculoskeletal, gynaecology and urology major elective surgical pathways.

Components of ERAS and current recommendations2
Pre-operative recommendations
1) Pre-operative counselling and training.
2) A curtailed fast (6 hours to solids and 2 hours to clear liquids) and pre-operative carbohydrate loading.
3) Avoidance of mechanical bowel preparation.
4) Deep vein thrombosis prophylaxis using low molecular weight heparin.
5) A single dose of prophylactic antibiotics covering both aerobic and anaerobic pathogens.

Peri-operative recommendations
1) High (80%) inspired oxygen concentration in the peri-operative period.
2) Prevention of hypothermia.
3) Goal directed intra-operative fluid therapy.
4) Preferable use of short and transverse incisions for open surgery.
5) Avoidance of post-operative drains and nasogastric tubes.
6) Short duration of epidural analgesia and local blocks.

Post-operative recommendations
1) Avoidance of opiates and the use of Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDS).
2) Early commencement of post-operative diet.
3) Early and structured post-operative mobilisation.
4) Administration of restricted amounts of intravenous fluid.
5) Regular audit.

How safe is ERAS?
The safety of ERAS protocols has been demonstrated in numerous randomised trials, and a number of studies and meta-analyses have shown the efficacy of ERAS.3, 4 Reduced length of stay, reduction in morbidity in the elderly, faster return of bowel function, earlier mobilisation and lower pain scores have all been demonstrated compared with the traditional management5, 6

Special circumstances
Elderly patients and those with comorbidities
Such patients, including ASA 3 and 4 patients have been shown to benefit from ERAS7 and should be included in these programmes.

Emergency surgery
ERAS pathways have been primarily studied in the elective setting. Although implementation of the preoperative components is not possible during emergencies, every effort should be made to implement as many components as possible.

How to set up an ERAS pathway and improve compliance?
Requirement of multidisciplinary approach and co-ordination in ERAS may render their initiation and implementation difficult. Compliance has often been reported to be low, especially in the postoperative period. Factors which can improve implementation and compliance with ERAS protocols include

  1. Selected anaesthetic input: Patients should be managed by a selected group of anaesthetists who are committed to the concept of ERAS.
  2. Patients should be managed on specific wards by a select group of medical and nursing staff trained in the principles of enhanced recovery. Specialised units called ‘Enhanced Recovery Units’ should be set up. Such units can also play a role in patient education.
  3. Continuous staff education
  4. A multidisciplinary team approach: should comprise one or more surgeons, anaesthetists, nurses, dieticians and physiotherapists.
  5. A local champion: Such a person, may be any senior member of the ERAS multi-disciplinary team, is required to coordinate various aspects of enhanced recovery.
  6. Audit and research: Regular audit and research can facilitate the development of local ERAS protocols tailored to the specific requirements of the institution.

 

Future research
The safety and applicability of ERAS is well established from well designed randomised controlled trials and meta-analyses. However, certain issues related to ERAS need further clarification:

  1. Influence on patient satisfaction and quality of life (QoL)
  2. Role of laparoscopic surgery within the ERAS programme: Both laparoscopic surgery and ERAS programme are known to reduce the postoperative length of stay. However, it is not known whether or not the inclusion of laparoscopic surgery within a successful ERAS programme offers any further advantage to that of ERAS alone.
  3. Inclusion of gut specific nutrients: Role of Glutamine in enhanced recovery needs to be evaluated.
  4. Cost-benefit analysis: Although it is quite obvious that ERAS should be cost-effective, studies investigating the cost-benefit interplay are conspicuously scarce.

Conclusion
ERAS is an effective programme aimed at quicker recovery of surgical patients which requires a multidisciplinary coordination and a team approach. It can be achieved by modifying the existing resources and protocols tailored to the requirement of the institute. Anaesthetists have an important role in the implementation of ERAS protocols.

References

  1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–17.
  2. Khan S, Gatt M, Horgan A, Anderson I, MacFie J. Guidelines for implementation of enhanced recovery protocols. Publication date: December 2009. Available at www.asgbi.org.uk
  3. Varadhan KK, Neal KR, Dejong CH, et al. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434–40.
  4. Adamina M, Kehlet H, Tomlinson GA, et al. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011;149:830–40.
  5. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189–98.
  6. King PM, Blazeby JM, Ewings P, et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006;93:300–8.
  7. Delaney C P, Fazio V W, Senagore A J, Robinson B, Halverson A L, Remzi F H. ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88:1533-8