Enhanced Recovery After Surgery (ERAS) programs, initiated by Professor Henrik Kehlet in the 1990s, aim to improve postoperative recovery by addressing physiological and psychological responses to surgery. These multimodal care pathways involve pre-operative education, minimal fasting, and post-operative early mobilization, leading to reduced complications and shorter hospital stays. The ERAS approach has been applied successfully across various surgical disciplines, including colorectal, gynecological, cardio-thoracic, and urological surgeries.

1. ENHANCED RECOVERY
AFTER SURGERY ( ERAS )
PRESENTATION BY : DR.SANJITH, PGY-1, GE

2. WHAT IS
ERAS?
Initiated by Professor Henrik Kehlet in the 1990
ERAS, enhanced recovery programs (ERPs) or
“fast-track” programs have become an importa
focus of perioperative management. These
programs attempt to modify the physiological
and psychological responses to major
surgery and have been shown to lead to a
reduction in complications and hospital stay,
improvements in cardiopulmonary function,
earlier return of bowel function and earlier
resumption of normal activities

3. Enhanced recovery after surgery (ERAS)
protocols are multimodal perioperative
care pathways designed to achieve early
recovery after surgical procedures by
maintaining pre-operative organ function

4. PRE -
OP
INTRA
- OP
POST - OP
COMPONENTSOF ERAS

5. PRE - OPERATIVE
PATIENT EDUCATION AND PRE ADMISSION
COUNSELLING
CARBOHYDRATE LOADING
NO PROLONGED FASTING
AVOID BOWEL PREPARATION
NAUSEA AND VOMITTING
PROPHYLAXIS
THROMBOPROPHYLAXIS

6. INTRA - OPERATIVE
MINIMALLY INVASIVE SURGERY
REGIONAL ANAESTHESIA
NORMOTHERMIA
NO DRAINS
MULTIMODAL PAIN
MANAGEMENT
SHORT ACTING ANAESTHETICS

7. POST – OPERATIVE
EARLY MOBILIZATION
EARLY ENTERAL FEEDING
NO NG TUBES
EARLY URINARY CATHETER
REMOVAL
MULTIMODAL PAIN
MANAGEMENT
NAUSEA AND VOMITTIN
PROPHYLAXIS

8. GOALS OF ERAS
• REDUCTION OF STRESS RESPONSE
TO SURGERY
• ACCELERATION OF RECOVERY
• DECREASED LENGTH OF HOSPITAL
STAY
• DECREASED POST OPERATIVE
MORTALITY AND MORBIDITY
• REDUCTION OF THE RATE OF RE-
ADMISSIONS FOLLOWING SURGERY

9. MEMBERS OF THE
ERAS TEAM
• SURGEONS
• NURSES
• ANAESTHESIOLOGISTS
• OCCUPATIONAL THERAPIST
• PAIN MANAGEMENT SPECIALIST
• PHYSIOTHERAPIST
• DIETICIAN
• HOSPITAL MANAGEMENT
• AUDIT TEAM

10. ERAS IN
MODERN
SURGICAL
PRACTICE

11. IN COLORECTAL SURGERY
(ELECTIVE)
CARBOHYDRATE LOADING :
DRINKS UP TO 2 HOURS PRE-
SURGERY REDUCE INSULIN
RESISTANCE
MINIMIZED FASTING :
CLEAR FLUIDS UNTIL 2
HOURS , SOLIDS UNTIL 6
HOURS PRE-SURGERY
SELECTIVE BOWEL PREP :
AVOIDED UNLESS
NECESSARY ( SINCE IT
CAUSES DEHYDRATION )
MULTIMODAL ANALGESIA :
LOCAL ANAESTHESIA ,
NSAIDS AND EPIDURALS
MINIMIZE OPIOID USE
EARLY MOBILIZATION AND
FEEDING : PATIENTS
ENCOURAGED TO MOVE
AND EAT WITHIN HOURS
POST-SURGERY TO ENHANCE
RECOVERY
THROMBOPROPHYLAXIS :
LMWH AND MECHANICAL
DECOMPRESSION DEVICES
AVOIDANCE OF DRAINS /
TUBES : ROUTINE
NASOGASTRIC TUBES AND
DRAINS ARE DISCOURAGED
UNLESS NECESSARY

12. IN EMERGENCY LAPAROTOMY
RAPID RISK STRATIFICATION : EARLY IDENTIFICATION OF HIGH RISK
PATIENTS FOR TAILORED PERIOPERATIVE MANAGEMENT
IMMEDIATE ANTIBIOTICS: BROAD-SPECTRUM ANTIBIOTICS ARE GIVEN
PROMPTLY IN SUSPECTED SEPSIS CASES
GOAL-DIRECTED FLUID THERAPY : FLUID RESUSCITATION IS INDIVIDUALISED
TO ENSURE OPTIMAL PERFUSION WITHOUT OVERLOAD
TIMELY SURGERY : RAPID INTERVENTION , PARTICULARLY IN CASES OF
BOWEL ISCHEMIA
MULTIMODAL ANALGESIA : USE EPIDURALS OR NERVE BLOCKS
EARLY MOBILIZATION : PATIENTS ARE ENCOURAGED TO MOVE EARLY POST-
SURGERY TO PREVENT COMPLICATIONS.
EARLY CATHETER REMOVAL : PROMPT REMOVAL OF URINARY CATHETER
AND NASOGASTRIC TUBES
EARLY NUTRITION : ENTERAL FEEDING IS INITIATED WITHIN 24 HOURS TO
SUPPORT GUT FUNCTION AND RECOVERY

13. IN GYNECOLOGICAL
SURGERY
PREOPERATIVE OPTIMIZATION :
NUTRITIONAL AND PHYSICAL
PREHABILITATION
REDUCED FASTING AND
CARBOHYDRATE DRINKS :
ENCOURAGE CARBOHYDRATE
DRINKS 2 HOURS PRE-SURGERY TO
ENHANCE METABOLIC RESPONSE.
MULTIMODAL ANALGESIA : USE
REGIONAL ANAESTHESIA, NSAIDS
AND MINIMISE OPIOIDS.
THROMBOPROPHYLAXIS : TAILORED
USE OF LMWH AND PNEUMATIC
COMPRESSION.
EARLY MOBILIZATION AND
NUTRITION : PATIENTS BEGIN
MOVING AND EATING WITHIN 24
HOURS
MINIMIZATION OF DRAINS AND
CATHETERS: EARLY REMOVAL AND
LIMITED USE.

14. IN CARDIO-THORACIC SURGERY
LUNG-PROTECTIVE
VENTILATION : USES LOW
TIDAL VOLUMES DURING
SURGERY TO MINIMIZE
VENTILATOR-ASSOCIATED
LUNG INJURY
EARLY EXTUBATION:
EXTUBATION WITHIN
HOURS POST-SURGERY
REDUCES RESPIRATORY
COMPLICATIONS AND ICU
STAY.
MULTIMODAL PAIN
CONTROL : EPIDURAL AND
REGIONAL ANAESTHESIA
ARE PRIORITIZED OVER
OPIOIDS.
EARLY ENTERAL
NUTRITION: FEEDING IS
STARTED AS SOON AS
POSSIBLE
CHEST DRAIN
MANAGEMENT : EARLY
REMOVAL OF CHEST TUBES
WHEN SAFE.

15. IN UROLOGICAL SURGERY
PRE-OPERATIVE COUNSELLING
CARBOHYDRATE LOADING
MINIMIZED FASTING
MULTIMODAL ANALGESIA
MINIMALLY INVASIVE SURGERY
THROMBOPROPHYLAXIS
EARLY MOBILIZATION
EARLY NUTRITION
EARLY CATHETER REMOVAL
POST-OPERATIVE MONITORING