This document outlines the components of an Enhanced Recovery After Surgery (ERAS) protocol presented by Dr. Sanjay Dange. The goals of ERAS are to decrease postoperative stress, maintain physiological function, and enable early mobilization to reduce recovery time and length of stay without increasing complications. Key elements include preoperative education and optimization, minimally invasive surgery when possible, goal-directed fluid management, multimodal analgesia including epidural anesthesia, early feeding and mobilization within 24 hours of surgery.

1. Enhanced Recovery After
Surgery (ERAS)
Presented by Dr. Sanjay Dange
Guide & Mentor – Dr. Ajit Sawant (Professor & HOD)
Mentor – Dr. Prakash Pawar(Professor)
Mentor – Dr. Sunil Patil (Associate Professor)
03/07/2021

2. What is ERAS?
• Enhanced recovery / fast track protocol
• Improves post-op outcome – decreased Length of stay(LOS),
accelerated recovery, without increase in re-admission or
complication rate

3. AIMS
• ↓ post op stress
• Maintain perioperative physiological functions
• Enable early mobilization
• ↓morbidity, recovery time and LOS

4. PHASES OF ERAS
• Pre-operative
• Intra-operative
• Post-operative

5. PRE-OPERATIVE- COMPONENTS
• Patient counseling and education
• Pre-operative optimization
• Bowel preparation
• Thromboembolic prophylaxis
• Pre-operative fasting and carbohydrate loading
• Anti-microbial prophylaxis and skin preparation

6. Patient counseling and education
• Decrease fear , anxiety, fatigue
• Stoma education (decreased LOS: 6 days vs 9 days)

7. Pre-operative optimization
• Assessment & improvement of medical conditions
• Pre-op smoking cessation for minimum 4 weeks 
• ↓ risk of pneumonia
• mechanical ventilation > 48 hrs
• unplanned tracheal intubation
• Alcohol cessation for minimum 4 weeks
• Correct anemia, hypoproteinemia

8. Bowel Preparation
• No added advantage in recovery or complication
occurrence
• Safely omitted as per ERAS protocol

9. Thromboembolic prophylaxis
• DVT incidence – 5%
• Pharmacotherapy- LMWH/ Heparin
• Non pharmacological –
• compression stockings
• intermittent pneumatic compression device
• Thromboprophylaxisextended 4 weeks post-op↓ incidence of
DVT
• LMWH 40mg s/c OD or Heparin 5000 U s/c TID

10. Pre-operative fasting and
carbohydrate loading
• ↓pre-op fasting enhances patient comfort , ↓thirst and anxiety
• Clear liquids  2 hrs
• Solid foods  6 hrs
• Carbohydrate loading  ↓ peri-op insulin resistance (role in diabetics
not studied)
• Insulin resistance proportional to blood loss and magnitude of
surgery

11. Anti- microbial prophylaxis and
skin preparation
• 2nd/3rd gen cephalosporins + metronidazole/clindamycin
• 1 hour prior to skin incision
• Repeat dose 3-4 hrly
• Skin preparation with chlorhexidine-alcohol ↓ surgical site infection

12. INTRAOPERATIVE COMPONENTS
• Anesthesia protocol
• Surgical approach
• Fluid management
• Preventive intra-op hypothermia
• Pelvic drainage

13. Anesthesia protocol
• Management of stress response, fluids and analgesia
• ERAS protocol suggests
• thoracic epidural analgesia (T9-T11)
• Minimal opioid usage , inhalational anesthesia
• Low dose remifentanil or morphine + bupivacaine
• Duration : 48 to 72 hrs
• ↓ Post operative Nausea & Vomiting (PONV)
• Decreased LOS and narcotic use; early feeding

14. Surgical approach
• Morbidity with open surgery – 65%
• Minimally Invasive surgery (MIS)
• Complication rate similar to open surgery
• No conclusive data

15. Fluid management
• Hyper /hypovolemia splanchnic hypoperfusion ileusincreased
morbidity increased LOS
• Goal directed fluid therapy (GDFT): intra- op doppler to maintain
intravascular volume, cardiac output and tissue perfusion while
avoiding fluid overload.
• Monitoring urine output is difficult.

16. • Alternative: CVP , heart rate and arterial pressure
• GDFT decreases post-op ileus(POI) and PONV at 24 and 48 hrs
• Decreased blood loss, LOS and complications

17. Prevent Intra-op Hypothermia
• Prolonged exposure temp <36 degrees  increased wound
infections, blood loss and complications.
• Maintain normothermia using external heaters and warm iv
fluids.

18. Pelvic drainage
• Traditional standard of care
• No study specific to cystectomy

19. Post operative components
• NG intubation
• PONV
• POI
• Urinary drainage
• Post op analgesia
• Early mobilization
• Early oral diet
• Discharge & follow up

20. Nasogastric intubation (NGI)
• Prophylactic NGI post surgery ↑ post-op complications, no added
advantage
• Delayed GI recovery
• Routine prolonged NGI not recommended
• NG decompression recommended in prolonged Post op Ileus (POI)

21. Post operative Nausea
Vomiting(PONV)
• 25- 35% of patients
• PONV leads to mobilization difficulty, delayed oral intake, ↓ LOS,
↑ pulmonary aspiration risk
• High risk patients: females, non-smokers, motion sickness

22. • Non pharmac measures-
• ↓ pre-op anxiety
• adequate pre-op hydration
• decreased pre-op fasting
• avoid inhalational anesthetics
• Pharmacological:
• epidural analgesia, propofol
• NSAIDS
• anti-emetics (dexamethasone, ondansetron)

23. Prevent Post Op Ileus (POI)
• 4- 31% -incidence
• Inability to tolerate solids by POD 5 , need to place NGT and need to
stop oral intake due to abdominal distension , nausea and vomiting
• Epidural analgesia vs opioids
• Avoid intra-op and post-op fluid overload

24. • Alvimopan
• Oral Magnesium
• Chewing gum
• MIS

25. Urinary drainage
• No study for the need or duration of catheterization
• Uretero-ileal stenting : improved drainage of upper tract, bowel
recovery and lesser metabolic acidosis, decreased PONV
• Duration: 5 – 14 days ( not investigated)

26. Post-op analgesia
• Multimodal opioid sparing suggested
• Decreased POI, PONV, LOS
• Improved bowel recovery , early mobilization
• Decreased stress response and cardio-pulmonary complications

27. • Loco-regional blocks- eg: TAP
• Paracetamol / NSAIDS
• No data for cystectomy

28. Early mobilisation
• reduce thromboembolism, muscle breakdown, pulmonary
complication, LOS, neuropsychological changes and insulin resistance
• Ambulate POD 1 increase to three times per day

29. Early oral diet
• Start < 24 hrs with high carbohydrate , high protein fluids: positive
effect on wound healing, insulin resistance and muscle function
• Oral liquids within few hours post op soft to regular diet POD 2
• If oral intolerance >7 days TPN
• Early TPN avoided

30. Discharge and follow up
• Discharge criteria
• Pain control with oral analgesics
• Adequate mobilization
• Return of GI function
• LMWH and stoma care teaching complete
• Normal blood chemistry
• Follow-up: once weekly visit and stent removal after 10-14 days