Enhanced Recovery After Surgery - Who Gets Benefited and Key Components

Introduction:

An organized strategy called Enhanced Recovery After Surgery (ERAS) aims to speed up recovery and enhance postoperative results. ERAS was primarily created for colorectal surgery, but it has since been extended to other surgical specialties. The 2010 founding of the ERAS Society is dedicated to improving perioperative care through research and instruction. Early adopters of ERAS were professors Kehlet and Wilmore, who addressed issues such as delayed bowel function in the late 20th century. Since they were introduced in the early 2000s, ERAS protocols have demonstrated beneficial impacts on the body's reaction to major surgery and its psychological reaction. Physicians, anesthesiologists, nurses, and patients must coordinate for ERAS implementation to be successful. In preoperative patient screening, anesthetic selection, fluid management, and pain management, anesthesiologists are essential participants.

What Is Enhanced Recovery After Surgery (ERAS)?

In the 1990s, Professor Henrik Kehlet introduced Enhanced Recovery After Surgery (ERAS) programs, also known as "fast-track" programs. These focus on improving how the body responds to major surgeries, aiming to reduce complications, shorten hospital stays, and enhance recovery. ERAS principles involve:

• Pre-operative counseling.

• Nutrition.

• Avoiding fasting.

• Specific anesthesia and pain management.

• Early mobilization.

While widely applied in various surgeries, there is limited data on ERAS in urological procedures. In the UK, applying ERAS to radical cystectomy resulted in shorter hospital stays with comparable outcomes. ERAS is a global initiative to improve care quality before, during, and after surgery. It originated in colorectal surgery, reducing postoperative hospitalization duration. Established in 2010, the ERAS Society has released guidelines for different surgical procedures. ERAS involves a collaborative team, including surgeons, coordinators, anesthetists, and surgical care personnel. Fundamental ERAS principles include preoperative counseling, no bowel preparation, avoiding sedatives, no fasting, preoperative carbohydrates, personalized anesthesia, controlled fluid administration, non-opioid pain control, selective use of drains and tubes, early nutrition, catheter removal, and mobilization. Various ERAS protocols facilitate same-day discharge, emphasizing minimally invasive techniques and awake surgery. Avoiding prolonged fasting is stressful, recommending light meals up to six hours pre-surgery and clear liquids up to two hours before. The study highlights proactive diet progression during surgery, allowing patients to eat and drink shortly after the procedure.

Why Use Enhanced Recovery After Surgery (ERAS)?

Enhanced Recovery After Surgery (ERAS) instead of traditional perioperative care can improve healthcare value, especially considering the increasing costs in the United States. ERAS has been shown to reduce the time patients spend in the hospital after surgery, leading to significant cost savings. For instance, in minimally invasive spinal surgery, the ERAS protocol saved an average of $3,444 per patient, a more than 15% cost reduction. Despite concerns that shorter hospital stays might increase emergency room visits, a study on colorectal surgery patients in 15 academic hospitals found no increase in visits or readmissions for those with stays under 5 days.

ERAS promotes judicious opioid use and employs a multimodal approach to anesthesia, using techniques like regional anesthesia and non-opioid medications. This not only benefits patients by reducing the risk of opioid addiction but also addresses the ongoing opioid crisis. Studies show a significant decrease in opioid needs after surgery with ERAS, such as in renal transplant patients. However, the culture of prescribing opioids postoperatively remains a challenge, and change will require shifts in physician prescribing practices.

Who Gets Benefited From Enhanced Recovery After Surgery (ERAS)?

Enhanced Recovery principles can be applied to various surgeries, but some conditions and procedures have specially designed programs for better results. These include surgeries like breast removal for cancer, bowel procedures for bowel cancer, hysterectomy for gynecological issues, hip or knee replacements for musculoskeletal problems, and prostatectomy for prostate cancer. Some hospitals even provide enhanced recovery programs for heart or chest surgeries. These tailored approaches help patients recover more effectively and quickly based on the specific surgery or condition they're dealing with.

What Are the Key Components of Enhanced Recovery After Surgery (ERAS)?

Preoperative Components:

1. Early Optimization: Before surgery, quit smoking and limit alcohol for 4 weeks. Primary care support is crucial. Stop oral contraceptives to reduce complications.

2. Diet: Carbohydrate loading improves insulin sensitivity. Nutritional supplements before surgery show positive outcomes. ERAS challenges traditional fasting practices.

3. Preoperative Bowel Prep: Evidence supports oral antibiotics for colorectal surgery. Pelvic surgery often avoids routine bowel preparation.

4. Preoperative Medications: Varied preoperative meds; sedatives, not routine. Optimize antiemetics; cautious use of NSAIDs in colorectal resections.

5. Antibiotics and Decontamination: Administer cefazolin before incision; additional doses for prolonged surgery. Consider increased antibiotics for morbid obesity. Chlorhexidine washing reduces infections and costs.

Intraoperative Components:

1. Normothermia: Maintain normal body temperature during surgery to reduce infections and blood loss. Use warming techniques like blankets and warm IV fluids.

2. Euvolemia (Proper Fluid Levels): Provide adequate fluids during surgery to prevent issues like acute kidney injury. Goal-directed fluid therapy can be beneficial, especially for cancer patients undergoing surgery.

3. Avoidance of Tubes and Drains: Avoid routine use of nasogastric tubes in bowel surgery to reduce pneumonia risk. Peritoneal drains have not shown clear benefits in preventing complications.

Postoperative Components:

1. Diet: Early feeding after surgery speeds up bowel function and reduces hospital stays. Chewing gum postoperatively may also aid recovery, but more research is needed for confirmation.

2. Intravenous Fluids: Maintain proper fluid levels postoperatively. Intravenous fluids can be stopped on the first day after surgery with a shift to oral intake, preventing fluid overload and aiding mobilization.

3. Activity: Early mobilization is crucial for preventing complications, enhancing recovery, and reducing muscle atrophy. Protocols often include mobilization within 24 hours of surgery.

4. Venous Thromboembolism Prophylaxis: Combining mechanical and medical methods helps prevent blood clots after surgery. Extended prophylaxis is considered, especially for high-risk patients, and the Caprini risk score calculator assists in decision-making.

5. Analgesia: Pain management is evolving towards a narcotic-sparing approach with scheduled doses of NSAIDs and acetaminophen, reducing opioid use and associated side effects.

6. Urinary Drainage: Early removal of urinary catheters, often within hours to a day postoperatively, reduces urinary tract infection rates and facilitates early mobility.

7. Antiemetics: Efficient prevention and treatment of nausea postoperatively are crucial for early recovery. A multimodal approach and minimizing narcotics help in managing nausea and vomiting.

8. Bowel Management: Some centers include routine postoperative laxatives in ERAS protocols to aid bowel function, based on studies showing modest benefits in hospital stay and time to first stool.

Conclusion:

ERAS protocols, initially for colorectal surgery, benefit various surgical areas like urology. Despite the evidence, implementing them faces challenges due to limited awareness, inadequate support, and resistance to change. Successful adoption requires a dedicated, knowledgeable, and motivated team of healthcare professionals embracing ERAS principles. The evidence prompts a reevaluation of perioperative care, particularly in procedures like radical cystectomy.