Enahanced Recovery After Surgery (ERAS)

1. Enhanced Recovery After Surgery
Presenter : Dr Sunil Mokashi
Moderator: Dr Kolli Chalam.
SSSIHMS , WHITEFIELD BANGALORE.

2. • Definition
• Introduction
• History
• ERAS interventions
• Anesthetic considerations
• Conclusion

3.  ERAS is a multimodal perioperative care pathway designed to achieve early
recovery for patients undergoing major surgery.
 Designed to accelerate patient recovery by reducing the surgical stress
response and supporting the physiologic function.
 ERAS represents a paramount shift in perioperative care in two ways.
Re-examines traditional practices, replacing them with
evidence-based best practices when necessary.
Comprehensive in its scope, covering all areas of the
patient’s journey through the surgical process.

4. Introduction
Enhanced recovery after surgery (ERAS) is a creative approach to the
perioperative management of patients who undergo major surgical
procedures. Also referred to as Fast Track Surgery
This concept was first described in 1990s by Henrik Kehlet, MD, PhD,
Surgical Gastroenterologist.
ERAS is designed to enhance recovery by managing the entire course of
care by using evidence-based practices to optimize outcomes.

5. • The program was initially developed and promulgated for use in colorectal
surgery.
• Recently it has been effectively expanded to various surgical sub-
specialties.
• Surgical intervention leads to an endocrine and metabolic stress reaction,
which slows down recovery.

6. HISTORY
• Danish Professor Henrik Kehlet in 1993, ER was initially adopted to manage
patients undergoing colorectal surgery.
• 2000, the ERAS collaboration was formed between five centers in Northern Europe:
Kehlet’s group in Denmark, the Netherlands, Norway, Sweden, and England. The goal of
this collaboration was to develop and implement a set of standardized perioperative
protocols
• In 2009, the Department of Health in England established the Enhanced Recovery
Programme across eight elective surgical procedures in four specialties—orthopedics,
colorectal surgery, gynecology, and urology.
• To evaluate the program, key outcome measures (e.g., patient experience, length of
hospital stay, and readmission rates) were collected. The findings showed an improved
patient experience (e.g., increased patient participation in their care) and a significant
reduction in length of stay (170,000 fewer bed days compared to the year before).

7. Professor Henrik Kehlet had been the Guest Editor “Anesthesiology” journal in 2015,
With lead topic ACCELERATED RECOVERY.

8. • In 2010, the ERAS Society was founded and headquartered in Kista,
Sweden.
The mission of the ERAS Society is to “develop perioperative care and to
improve recovery through research, audit education and implementation
of evidence-based practice.”
The Society website (http://www.erassociety.org/) offers procedure-specific
guidelines, useful information, and resources related to enhanced recovery.

10. Goals of ERAS
Reduction of stress response to surgery
Acceleration of recovery and reduction
in duration of hospital stay

11. ERAS emphasizes a multidisciplinary approach to perioperative care with
particular emphasis on preoperative education, pain management, and
early rehabilitation, particularly for patients who undergo laparoscopic
surgery and colorectal procedures.
Documented reductions in hospital length of stay and postoperative
complications of30% and 50%, respectively.

12. MultidisciplanaryTeam Members ERP
Surgeons
Anesthetists
Nurses
Dietitians
Hospital management
Physiotherapists
Occupational therapists
Pain team
Theatre staff
Audit team

13. WHY ERAS?
• The basic principle behind ERAS is successfully delivering surgical care with
minimum deviation from normal physiology/functioning.
• It may be better understood by plotting the physiologic or functional state
versus time in the peri-operative period.
• When undergoing surgery,
the fall from normal physiologic state actually exceeds a
level caused by illness alone. This is due to the endocrine
and metabolic impact of the surgical stress.
• This is followed by a slow recovery back to a pre-existing level of functioning.
• When ERAS is implemented a graph is likely to show an earlier recovery as
shown in the graph (vide infra)

14. Effectively modulating these responses to attenuate the impact of surgery
may help promote an early recovery and has been associated with reduced..
• length of stay
• complication rates
• costs for patients
• increased patient comfort and satisfaction

15. Three distinct phases in the graph
pre
intra
post-operative phases.
In the pre-operative phase, the upswing in the graph is a reflection of the
attempt to optimize the patient-‘prehabilitation’.
In the intra-operative phase surgical and anesthetic maneuvers are used to
minimize the downswing i.e. the surgical stress response.

16. The small vertical arrow demonstrates a reduced impact observed as a
smaller fall in functional status.
Post-operative rehabilitation seeks to hasten recovery demonstrated
by shortening of the recovery to pre-existing functioning (long
horizontal arrow).
It may be ideal to rehabilitate the patient to a level as close to
optimum as possible (dotted line).

18. Interventions in ERAS

20. Surgical and Anaesthestic considerations
Pre admission counseling:
• A clear explanation of what is to happen during hospitalization
• Explanation of role of the patient about food intake, oral
nutritional supplements and mobilization after surgery

21. Selective Bowel Preparation:
• Avoid mechanical bowel preparation
• 6 hour fast for solid food and liquids containing fat or
particulate material
• Clear fluids can be taken until 2 hour before induction of
anesthesia.

22. BOWEL PREP protocol
MORNING LIST
DIET AND FLUIDS
4 high protien drinks till
midnight
Clear fluids
2hrs prior to surgery
than f/b NBM
Evaluation by
multidisciplanery Team
Evaluation by
multidisciplanery Team
AFTERNOON LIST
Diet and Fluids
4high protien drinks until 6hrs pre-op
Early light breakfast 07:00 hr/6hr
prior to surgery
Clear fluids 11:30am/2hrs prior to
surgery

23. Pre operative carbohydrate loading and metabolic conditioning:
Clear carbohydrate-rich beverage i.e. Nutricia Preop™ before midnight and
2–3 hour before surgery .
“This reduces preoperative thirst, hunger and anxiety, and
significantly reduce postoperative insulin resistance.”
If indicated, patients may also receive antibiotic prophylaxis to reduce the
risk of infection related to the surgical procedure.

24. Avoid pre anesthetic sedatives or anxiolytics if possible
Nasogastric Tubes in GI Surgery- (Avoid)
• Can impair return of gut function.
• Are disliked by patients.
• Increase the incidence of postoperative fever, atelectasis and
pneumonia.
• Lower GI surgery: Only insert if gastric distension or
requested by surgeon.
• Upper GI Surgery: May be necessary

25. Thoracic Epidural Anesthesia:
• Reduces pain and the dosage of general anesthetic agents.
• Blocks stress hormone release and decrease postoperative
insulin resistance.
• In colonic surgery the epidural catheter in mid-thoracic level
(T7/8) blocks sympathetic nerves and prevents gut paralysis

26. Short acting anesthetic agents:
Use Propofol, Remifentanil instead of Fentanil or
Morphine.
Short acting Inhalational anesthesia is an alternative to
Total intravenous anesthesia (TIVA)
multimodal pain management strategies that eliminate
or significantly reduce use of opioids to facilitate early
mobilization and return to normal diet while also
reducing postoperative nausea and vomiting (PONV).
Regional anesthesia should be used whenever
possible.
A preoperative, multimodal regimen
may include non-steroidals, acetaminophen,
gabapentin, and/or tramadol to reduce or
eliminate the need for opioids.

27. Individualized perioperative fluid
administration:
Avoid Na and Fluid overload
Goal directed fluid therapy via
Oesophageal Doppler(OD) monitoring
Fluid overload is associated with delayed
gut function and increased complication
rates.

28. Avoid Perioperative Hypothermia
• Warm air blowers on the patients during
surgery and warm IV fluids administered.
• Continue warming into the postoperative
period. Keep Temp. > 96.7˚F
• Monitor temperature, avoid hyperthermia.
• Hypothermia increases the risk of wound
infection, bleeding and transfusion
requirements

29. To maintain euvolemia and minimize salt and water
overload fluid during surgery, balanced crystalloid
solution is infused at 1 to 3-mL/kg per hour
Maintainance of electrolyte balance, correction of
blood gas/pH changes.

30. Imp ERSA recommendations
Short, Transverse Incision/ Laparoscopic Colon surgery:
• reduce in-patient stays,
• lessen morbidity
• and lower postoperative pain
Avoid Drain Tubes in routine colonic resections above peritoneal
reflections and consider short-term (<24 h) drainage for low anterior
resections.

31. Prevention of Postoperative Nausea and Vomiting (PONV)
• PONV is unpleasant, delays gut function, affects mobility and
has metabolic consequences.
• Give prophylactic anti-emetics i.e. Ondansetron during
anesthesia around 30 min before the end of surgery.
• Avoiding salt and water overload.

32. Encourage Early Postoperative Oral Intake
• Facilitates early return of bowel function,
• Allows stopping of intravenous drips,
• Aids mobilization,
• Leads to faster recovery.
• Reduces postoperative morbidity and is not associated with an
increased risk of anastomotic dehiscence

33. Early mobilization
Bed rest
• ↑ insulin resistance , muscle loss and risk of
thromboembolism.
• ↓ muscle strength, pulmonary function and tissue oxygenation
.
• The aim is for patients to be out of bed for 2 h on the day of
surgery, and for 6 h a day until discharge.

34. Non-opiate Analgesics/NSAIDs
Opiates are associated with decreased gut motility.
Short term NSAIDs use can avoid Gastric irritation.

35. POSTOPERATIVE PHASE,
Non-opioid oral analgesia.
Early mobilization and being out of bed is encouraged.
Patients are discharged after they meet specific discharge criteria
Receive detailed instructions to engage in self-care to facilitate fast
recovery

36. The term Enhanced Recovery After Anesthesia (ERAA), is used
or the anesthetic protocols in optimum Recovery of patients
from major surgery.
ERAA ladder gives stepwise idea regarding protocols designed
for ERAS.

37. Ref:Eldawlatly, Abdelazeem. “Is Enhanced Recovery after Anesthesia a Synonym to Enhanced Recovery after Surgery?” Saudi Journal of
Anaesthesia 10.2 (2016): 119–120. PMC. Web. 25 June 2017.

39. ERAS – Discharge Criteria
Patients can be discharged when they meet the following
criteria:
• Good pain control with oral analgesia
• Taking solid food, no intravenous fluids
• Independently mobile or same level as prior to admission
• All of the above and willing to go home.

40. Nutrition in ERAS
• Almost all the interventions in ERAS are either directly or
indirectly related to the nutrition of the patient.
University of Virginia Health System’s Transitional Diet
How to order the diet:
• Diet order entered as “Transitional”
• Description:
• This diet is designed to be used after surgery and indicated in
patients who have nausea or are just beginning to take an oral
diet after a prolonged period NPO, prior to advancing to
regular diet.

41. • It consists of patient and
research-reported tolerable foods
and beverages after surgery and is
more nutritionally adequate than
the traditionally used clear liquid
diet.
• Once the patient demonstrates
tolerance to this diet, their diet
can be advanced to a regular diet
or another therapeutic diet based
on the patient’s clinical condition.
Nutritional Adequacy:
The Transitional Diet nutritional adequacy
varies significantly based on the items
selected by patients. This diet is meant to
be used for a short period of time.

44. CONCLUSION
• Developments in ERAS have highlighted the importance of
peri-operative care.
• The ability to achieve a reduced hospital stay, patient
satisfaction, and reduced rate of complications without an
increase in re-admissions has demonstrated how powerful a
tool ERAS can be.
• ERAS has resulted in a significantly increased understanding
of peri-operative physiology and how to modulate it to
improve outcomes.

45. • This has led to the belief among some that the role peri-
operative care plays may be so crucial that it warrants
recognition as a separate sub-specialty.
• Until ERAS becomes a routine reality, it may be in the best
interest of all those involved in the peri-operative care of the
surgical patient to be familiar with ERAS and its principles.

46. REFERENCES
1. Miller’s Anesthesia ;8th edition.
2. Nanavati AJ, Prabhakar S (2014) Anaesthesia in Fast Track Gastrointestinal
Surgeries. J Anesth Clin Res 5:384. doi: 10.4172/2155-6148.1000384
3. Mariette C. Role of the nutritional support in the ERAS programme. J Visc Surg.
2015;152:S18-S20.
4. Carli F. Physiologic considerations of Enhanced Recovery After Surgery (ERAS)
programs: implications of the stress response. Can J Anaesth 2015; 62:110-9.
5. http://www.anesthesiallc.com/publications/blog/entry/enhanced-recovery-after-
surgery-and-anesthesia
6. The enhanced recovery after surgery (ERAS) pathway for patients undergoing
major elective open colorectal surgery: A meta-analysis of randomized controlled
trials ;Varadhan, Krishna K. et al. Clinical Nutrition , Volume 29 , Issue 4 , 434 -
440

47. Thank you