Enhanced Recovery After Surgery (ERAS)

ERAS is a multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery.

ERAS represents a paradigm shift in perioperative care in two ways.  First, it re-examines traditional practices, replacing them with evidence-based best practices when necessary. Second, it is comprehensive in its scope, covering all areas of the patient”s journey through the surgical process.

The key factors that keep patients in the hospital after surgery include the need for parenteral analgesia, the need for intravenous fluids secondary to gut dysfunction, bed rest caused by lack of mobility.

The central elements of the ERAS pathway address these key factors, helping to clarify how they interact to affect patient recovery. In addition, the ERAS pathway provides guidance to all involved in perioperative care, helping them to work as a well-coordinated team to provide the best care. (www.erassociety.org)

Gan, Tong J., et al. “Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting.” Anesthesia & Analgesia, vol. 131, no. 2, Aug. 2020, pp. 411–48. Doi:10.1213/ANE.0000000000004833.

Bottom Line:

This consensus guideline builds on the previous 2014 iteration and details new evidence on PONV based on systematic literature review from 2011-2019. Recommendations are made by an international panel of experts from the American Society of Enhanced Recovery and Society for Ambulatory Anesthesia and focus on PONV risk stratification, prevention, and treatment in both adults and children.

 

Major points:

1. Risk factors for PONV in adults include female sex, history of PONV or motion sickness, non-smoking status, younger age, general vs regional anesthesia, use of volatile anesthetics and nitrous oxide, post-operative opioids, duration of anesthesia, and type of surgery (cholecystectomy, laparoscopic, gynecological).

2. Strategies to reduce baseline risk include: avoidance of GA by use of regional anesthesia, use of propofol for induction and maintenance of anesthesia, avoidance of nitrous oxide for surgeries over 1 hour, avoidance of volatile anesthetics, adequate hydration and using sugammadex instead of neostigmine for reversal of neuromuscular blockade.

3. Multimodal systemic analgesia is recommended to minimize intraoperative and postoperative opioids using acetaminophen, NSAIDS, ketamine, dexmedetomidine and regional/neuraxial techniques.

A) Adult patients with ≥ 1 risk factors for PONV should receive combination (multimodal) antiemetic prophylaxis. Classes of antiemetic drugs for prophylaxis include: 5-HT3 receptor antagonists, corticosteroids, NK1 receptor antagonists, antidopaminergics, antihistamines and anticholinergics.

B) If there is PONV, patients should receive antiemetic treatment from a different pharmacologic class than that received for prophylaxis. A repeated dose of antiemetic from the same class within 6 hours is no better than placebo.

Makaryus R, Miller TE, Gan TJ. Current concepts of fluid management in enhanced recovery pathways. Br J Anaesth. 2018;120(2):376-383. doi:10.1016/j.bja.2017.10.011

Bottom line: The goals of perioperative fluid therapy are to enhance patient, outcomes, decrease complications and decrease hospital LOS. The perioperative physician can intervene pre-operatively, intra-operatively and post-operatively to achieve these goals. 

Major points:

1. Pre-operatively, PO hydration should be encouraged right up until 2 hours pre-operatively. Hydration in this period with complex carbohydrate drinks has multiple benefits (including reducing anxiety, PONV and LOS) while not increasing the risk of aspiration. 

2. Intra-operative fluid management balances the risk of too little fluids (i.e. hypotension and low perfusion states) with excess fluids (i.e. edema and fluid excess states). Ideally, there is a happy medium of euvolemia that is the goal. Although goal-directed therapy (GDT) has not shown any benefit in patient outcomes, it is not associated with harm, has the potential to improve outcomes by maintaining hemodynamic stability, and is currently embedded in most institutions' Enhanced Recovery Programs (ERP). More well-designed studies are needed on GDT. 

3. Post-operative fluid management focuses on encouraging early PO hydration (over IV fluids). While anuria is worrisome and should be treated accordingly, oliguria should be considered a normal response to the stress of surgery and should not be treated with aggressive IV fluids - some studies suggest a threshold of 0.3mL/kg/hr in major abdominal surgery.

Myles P, Bellomo R, Corcoran T, et al. Restrictive versus liberal fluid therapy in major abdominal surgery (RELIEF): rationale and design for a multicentre randomised trial. BMJ Open. 2017;7(3):e015358. Published 2017 Mar 3. doi:10.1136/bmjopen-2016-015358

Bottom line: This randomized control trial enrolled 3000 ERAS and high risk patients undergoing a major abdominal surgery with different volumes of IV fluids being administered. They compared disability (WHODAS) at 1, 3, 6, and 12 months after surgery. Disability free survival, septic complications and death were the same. 

Major points:

1. The liberal group received 10 ml/kg at induction and 8 ml/kg/hr followed by 1.5 ml/kg/hr for  24 hours with a median cumulative total for IVF is 6146 ml. 

2. The restrictive group received a 5 ml/kg bolus or less and 5 ml/kg/hr followed by 0.8 ml/kg/hr for 24 hours with a median cumulative total dose for IVF is 3671 ml.  This group had a high rate of acute kidney injury.

Carmichael JC, Keller DS, Baldini G, et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2017;60(8):761-784. doi:10.1097/DCR.0000000000000883