The document discusses Enhanced Recovery After Surgery (ERAS) protocols. It describes how ERAS aims to reduce surgical stress on patients through multimodal perioperative care, facilitating early recovery. This includes optimizations in pre-, intra-, and postoperative care such as shortened fasting times, carbohydrate loading, minimized fluid administration, and early mobilization. The document provides examples of procedures that can be done as day surgeries and details the key elements of ERAS protocols.

1. ENHANCED RECOVERY
AFTER SURGERY (ERAS)
Moderator:- Dr Amol Sir
Conductor:- Dr. Chandak Mam
Presenter:- Dr. Deepak

2. Enhanced recovery after surgery (ERAS) is a
systematic multimodal perioperative care aimed at
reducing the immense surgical stress of the patient and
thereby facilitating early recovery.

3. DAY CARE SURGERIES / PROCEDURES :-
• Day Care surgeries are for patients who require a surgical procedure without
an overnight admission to the hospital. There are many advantages to a Day
Care admission:
• Less time spent in the hospital
• Less time lost at work
• The ability to return to a familiar setting for your recovery.
ERAS and Day care surgeries:-

4. DAY CARE SURGERY WHICH INCLUDES MINOR SURGERIES OR
LOW RISK PROCEDURES ARE AS FOLLOW:-
CARDIOLOGY PROCEDURES:
• Angiography
EAR, NOSE & THROAT:
• Coblation adenoidectomy
• Coblation tonsillectomy
• Coblation adenotonsillectomy

5. GASTROENTEROLOGICAL PROCEDURES:
• Fissurectomy
• Fistulectomy
• Laparoscopic inguinal hernia repair
• Laparoscopic umbilical hernia repair
• Laparoscopic ventral hernia repair
• Laparoscopic appendicectomy
• Laparoscopic adhesiolysis
• Hemorrhoidectomy
• Pilonidal sinus excision

6. GYNECOLOGY PROCEDURE:
• Diagnostics Laparoscopy
• Diagnostics Hysteroscopy
• Operative Hysteroscopy
• Colposcopy
• Fresh Embryo Transfer
• Frozen Embryo Transfer
• Trans vaginal Ovarian Cyst Aspiration
• Proximal Tubal Catheterization
• Cyrocoti of cervix
• IUDI – Intra Uterine Device Inserts
• Laparoscopic Tubal Sterilization

7. • Conventional surgeries which are high risk surgeries are included under ERAS
protocol:
Open Procedures like:-
• Abdominal surgery
• Open Adrenalectomy
• Open Appendectomy
• Craniotomy
• CABG
• Thoracotomy
• Colon resection
• Nissen fundoplication
• Roux en-Y procedure
• Whipple procedure

8. Enhanced recovery is a combination of elements of care for elective surgery
which aims to:
• Optimise pre-operative preparation for surgery
• Avoid iatrogenic problems such as postoperative ileus
• Minimise the stress response to surgery
• Speed recovery and return to normal function
• Early recognition of abnormal recovery and intervention if necessary
AIM OF ERAS PROTOCOL:-

9. • ERAS protocol can be broadly classified into:-
1. Preoperative care
2. Intraoperative care
3. Postoperative care

10. The key principles of the ERAS protocol include :-
• pre-operative counselling
• preoperative nutrition
• avoidance of perioperative fasting and carbohydrate loading up to 2 hours
preoperatively
• standardized anesthetic and analgesic regimens (epidural and non-opiod
analgesia) and early mobilization .

11. • 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.

12. Preoperative nutrition :
It is well-known that poor nutrition is detrimental to outcomes postoperatively.
It frequently occurs with comorbidities and with underlying disease such as
cancer.
Inadequate nutrition, particularly for cancer patients undergoing surgery, is an
independent risk factor for complications, increased hospital stay and costs.
The importance of nutritional status in patients undergoing radical cystectomy
has long been noted with reported complications rates as high as 80% in
patients with poor nutrition.
More recently data suggest that nutritional deficiency preoperatively is a strong
predictor of 90-day mortality and poor overall survival. It is therefore
unsurprising that assessment and treatment of poor nutrition is an essential
component of ERAS protocols.

13. • Correction of preoperative nutritional deficiencies may sometimes require
prolonged parenteral, or a combination of parenteral and enteral nutrition
depending on the severity of the problem and the patient’s gastrointestinal
function. However, in most cases patients can be managed with appropriate
input from a dietician or nutritionist, and the use of a standard whole protein
liquid nutritional supplement.

14. Key features in Pre-operative care in hospital:
• Admission on the day of surgery
• Avoidance of prolonged fasting
• Avoidance of bowel preparations
• Carbohydrate drinks
• Avoidance of sedative premedication
Admission on the day of surgery can occur as the patient has been fully prepared
for surgery in the prehospital period of their care. Traditional pre-operative
preparations, such as fasting from midnight or bowel preparation, are avoided
unless there is evidence to suggest benefit from these interventions.

15. For colorectal surgery a key factor in recovery is the return of normal bowel
function, which is affected by pre-operative fasting, bowel preparation, analgesia
and anaesthetic approaches as well as any complications that may develop,
accordingly many enhanced recovery interventions are aimed at reducing the
incidence of postoperative ileus.

16. There is also very poor evidence for fasting from midnight on the night
before surgery. Recent study shows strong evidence to support reducing
these periods to two hours preoperatively for clear fluids in elective
situations, although a six hour fast is still recommended for solid food.

17. Carbohydrate loading and early enteral feeding
The stress response is initiated by a variety of physical insults such as :-
1. Tissue injury
2. Infection
3. Hypovolemia
4. Hypoxia.
The ERAS program is aimed at attenuating the body’s response to
surgery which is characterized by its catabolic effect. Autonomic afferent
impulses from the area of injury or trauma stimulate the hypothalamus-
pituitary-adrenal axis and mediate the body’s subsequent endocrine
response.

18. Increased cortisol levels stimulate gluconeogenesis and glyconeogenesis in
the liver, with triglyercides being converted to glycerol and fatty acids
providing the substrates for gluconeogensis.
Adrenocorticotropic hormone and cortisol production leads to protein
catabolism, weight loss, muscle (skeletal and visceral) wasting and
nitrogenous loss.

19. There is also a relative lack of insulin and peripheral insulin resistance occurs
due to alpha-2-adrenergic inhibition of pancreatic B cells (facilitated by
catecholamines) and defects in the insulin receptor/intracellular signalling
pathway.
Hyperglycaemia is therefore a significant finding after surgeries and the
observed insulin resistance is a major variable influencing length of stay, poor
wound healing and increased risk of infective complications.

20. The degree of insulin resistance is associated with the extent of surgery,
and if postoperative hyperglycaemia is controlled, mortality and morbidity
can be reduced by half. Methods which reduce the insulin resistance
include :-
1. Adequate pain relief
2. Avoiding a prolonged period when oral intake is interrupted
3. The use of carbohydrate loading.

21. The practice of fasting patients from midnight is used to avoid pulmonary
aspiration after elective surgery; however, there is no evidence to support
this. Preoperative fasting actually increases the metabolic stress,
hyperglycemia and insulin resistance which the body is already prone to
during the surgical process.
Changing the metabolic state of patients by shortening preoperative fasting
not only decreases insulin resistance, but reduces protein loss and improves
muscle function.

22. A review of 22 RCTs comparing different perioperative fasting regimens
and perioperative complications revealed that there is no evidence to suggest
a shortened fluid fast results in an increased risk of aspiration, regurgitation
or related morbidity compared to the standard fasting from midnight policy.
Furthermore, if patients are allowed to take solids up to 6 hours
preoperatively and clear fluids up to 2 hours, there is no increase in
complications.

23. As mentioned previously, the use of carbohydrate loading attenuates
postoperative insulin resistance, reduces nitrogen and protein losses, preserves
skeletal muscle mass and reduces preoperative thirst, hunger and anxiety.
It involves the use of clear carbohydrate drinks the day prior to surgery and up
to 2 hours before.
In addition to the metabolic effects, it facilitates accelerated recovery through
early return of bowel function and shorter hospital stay, ultimately leading to an
improved perioperative well-being.
As a result, it is an important element of the nutritional aspects of ERAS and
should replace the practice of overnight fasting.

24. Intraoperative care
Patient care should be individualised with the use of minimally invasive
techniques where possible.
Laparoscopic colonic resection has been shown to reduce the length of hospital
stay, initial wound complications and time to return of gastrointestinal tract
function.
If an open procedure is required for abdominal surgery, transverse incisions
should be made preferentially to reduce postoperative pain.
The use of wound drains is avoided as there is no evidence of beneficial effect
for most types of colonic surgery.

25. Nasogastric tubes are actually associated with increased morbidity and increased
time to return of bowel function and should also be avoided in elective situations.
Overhydration has previously been common in the perioperative period, and
comparisons of liberal and restrictive fluid regimes suggest that this may be
detrimental, with prolonged time for return of gastrointestinal tract function,
impaired healing and increased length of hospital admission.

26. Fluid therapy intraoperatively can be goal directed using cardiac output
monitoring such as oesophageal doppler in high risk patients to optimise
cardiac output without overloading the patient.
Early commencement of oral intake means that intravenous fluids can be
discontinued much more quickly than has conventionally been the case.
If postoperative hypotension secondary to epidural analgesia is a problem, this
may be best treated with vasopressors rather than large quantities of
intravenous fluids.

27. Intraoperative care in nutshell:-
Short-acting anaesthetic agents
Avoid long-lasting opiates where possible
Use of thoracic epidurals for colorectal surgery
Avoid the use of drains and nasogastric tubes
Avoid overhydration
Attention to temperature control
Thromboprophylaxis
Risk stratification of PONV and aggressive prophylaxis and treatment

28. Postoperative
Post-operative care involves maintenance of hydration by encouraging the
discontinuation of intravenous fluid therapy and early commencement of oral
intake, including carbohydrate drinks.
These can be continued beyond the return of normal intake if pre-operative
nutritional status is poor.
Similarly to pre-operative fasting, prolonged post-operative fasting is also
detrimental as early resumption of oral intake is associated with fewer wound
infections and shorter hospital admissions.
Oral intake must be combined with the above measures to reduce ileus.

29. Any drains, and urinary catheters present are removed as early as possible.
Multimodal analgesia is used with regular oral paracetamol and non-steroidal
anti-inflammatory drugs where tolerated.
Excessive intravenous opioids are avoided because of increased sedation, ileus
and respiratory complications, although small doses of oral opioids for
breakthrough pain are appropriate.
The use of analgesic adjuncts such as gabapentin or pregabalin has been
shown to have a beneficial opioid sparing effect post-operatively.

30. Mobilisation should occur early in accordance with the pre-operative plan
agreed by clinicians and patients.
The aim is to reduce skeletal muscle loss and improve respiratory function and
oxygen delivery to tissues.
Patients should be encouraged to achieve daily procedure specific goals which
can be guided by specific day-by-day proformas to ensure all areas of care
receive attention.
Ideally, patients should sit out of bed for 2 hours on the day of surgery and for at
least 6 hours a day until discharge.
The success of this aspect of the program depends on the pre-operative setting
of expectations including the concept of patients being partners in their care and
taking part-ownership of post-operative rehabilitation.

31. The involvement of physiotherapy and rehabilitation departments is vital to
help with patient motivation and safety. Best results are achieved when the
whole multidisciplinary team have belief and interest in the program. This can
be achieved by ensuring that all disciplines are consulted when
developing an enhanced recovery program.
Criteria-based rather than time-based discharge should be used with
appropriate community support.
Telephone follow up should occur at around 24 hours to confirm that recovery
is still proceeding according to plan, identify any potential problems and
answer any questions that the patients may have.
A contact number is also given to patients to enable them to contact an
experienced, specialty specific healthcare professional if necessary.

32. Finally, audit and regular reviews of the processes involved and compliance
with all aspects of the pathway should be undertaken.
These should ideally include comparisons between hospitals offering
the enhanced recovery service to ensure equivalent levels of care are being
provided in different areas.
These processes are vital to detect successful or failing interventions, determine
the reasons why this may be happening and identify areas of care that need
reviewing or improving.

33. They also provide motivation for staff and patients. The enhanced recovery
approach represents a major change to the way in which surgery is approached
and carried out.
It is therefore essential to have robust data to provide evidence of improved
outcomes, which can then be used to support business cases for ongoing
development of these services.
Many of the traditional approaches to peri-operative care have recently
been found to be detrimental and such data is important to ensure that all
interventions performed have an evidence base and we do not fall into the traps
of the past.

34. FUTURE STRATEGIES
A recent concept implicating ERAS in craniotomy called neurosurgery ERAS,
value and safety (NERVS) is in the developmental stage which has also been
tested in microvascular decompression procedures for trigeminal
neuralgia patients.
Basically, NERVS consists of a multidisciplinary team, which has process
mapped the way the ongoing healthcare being delivered throughout
the entire episode of care.

35. ERAS guidelines for gynaecological surgeries in brief :-
Preoperative Optimization:-
Smoking and alcohol consumption should be stopped 4 weeks before surgery.
Smoking and hazardous drinking affect human physiology in different ways even in the absence
of end-stage disease. The systems most commonly affected by smoking are pulmonary function,
cardiovascular function, the immune response, and tissue healing. In addition to the well-known
alcohol-induced disorders of the liver, pancreas, and nervous system, heavy drinking affects
cardiac function, immune capacity, haemostasis, metabolic stress response, and induces
muscular dysfunction. Both smoking and drinking can alter the hepatic metabolization of
commonly used drugs.

36. The most common perioperative complications related to smoking are impaired
wound and tissue healing and wound infection, and cardiopulmonary complications.
For alcohol, postoperative infections, cardiopulmonary complications, and bleeding
episodes dominate the list of complications.
Preoperative bowel preparation:-
Machanical bowel preparation should not be routinely used even when bowel
resection is planned.
Bowel preparation is a procedure usually undertaken before a diagnostic procedure
or treatment can be initiated for certain colorectal diseases. Bowel preparation is a
cleansing of the intestines from fecal matter and secretions.
Preoperative fasting and carbohydrate treatment:-
Solid food – fasting for 6 hours
Clear fluids- fasting for 2 hours

37. Allowing infants, children and adults to have oral intake closer to the time of
surgery can help reduce patient irritability, parental stress, and risk of dehydration.
It is extremely important that those giving and receiving instruction on preoperative
food and fluid intake clearly understand the terminology (i.e., what constitutes a
clear liquid), timing, and need for adherence to the guidelines. A clear liquid is a
solution (as opposed to a suspension) that contains no particulate matter. Examples
of clear liquids include water, clear tea, ORS/Pedialyte , fruit juices without pulp.
The normal stomach can empty 80% of a clear liquid load within 1 hour after
ingestion. Whereas the stomach continues to secrete and reabsorb fluid throughout
NPO time, ingested clear liquids are completely passed into the duodenum within
2.25 hours.

38. Several researchers have therefore sought to demonstrate that children may safely be
allowed to drink clear liquids until just 2 to 3 hours before elective surgery( 2 hours
according to ERAS guidelines).
However, solid or semisolid foods are not cleared from the stomach as rapidly as clear
liquids.
Meakin and associates found that a light breakfast of biscuits or orange juice with pulp,
taken 2 to 4 hours before induction, did increase the volume of gastric aspirate in
healthy children, adult compared with those who had fasted for 4 hours or longer.
Fasting period for breast milk is considered to be four hours for both neonates and
infants.

39. As fasting times become shorter, the consequences of preoperative fasting are less
problematic.
Additionally, the patient who is to be discharged home may not be interested in
drinking large amounts of fluids in the hours immediately after surgery. It is useful,
therefore, to provide adequate hydration not only to correct the fluid deficit but also to
provide a cushion for the postoperative period.
This is particularly the case for operations that may disrupt the ability to drink easily,
such as tonsillectomy. Isotonic fluids should be administered, and the IV catheter may
be kept in place until just before discharge.

40. It is rarely necessary to provide glucose supplementation in the IV fluids in children
outside the neonatal period.
The deficit plus current maintenance requirements should be repleted within 2 to 3
hours.

41. Surgical stress:-
Surgical stress is the systemic response to surgical injury and is characterized by activation
of the sympathetic nervous system, endocrine responses as well as immunological and
haematological changes.
Insulin resistance is one of the marker of surgical stress.
Carbohydrate loading reduces postoperative insulin resistance.

42. Preoperative medication:-
Routine administration of sedatives to reduce anxiety preoperatively should be avoided.
Administration of sedatives can influence the depth and duration of sedation.
Thromboembolism prophylaxis:
Patients at risk of Venous Thromboembolism should receive prophylaxis with either LMWH
or heparin, commenced preoperatively, combined with mechanical methods.
Patients should be advised to consider stopping Harmonal replacement therepy or consider
alternative preparations before surgery

43. Antimicrobial prophylaxis and skin
Preparation
IV antibiotics (1st generation cephalosporin or amoxi–clav) should be
administered routinely within 60 min before skin incision; additional doses should
be given during prolonged operations, severe blood loss and obese patients.
Hair clipping is preferred if hair removal is mandatory. Chlorhexidine–alcohol is preferred to
aqueous povidone-iodine solution for skin cleansing.
Standard anesthetic protocol:-
Short acting anesthetic agents should be used to allow rapid awakening.
A ventilation strategy using tidal volumes of 5–7 ml/kg with a PEEP of 4–6 cmH2O
should be employed to reduce postoperative pulmonary complications

44. Nasogastric intubation :-
Routine nasogastric intubation should be avoided.
Nasogastric tubes inserted during surgery should be removed before reversal of
anesthesia.
Preventing intraoperative hypothermia:-
Maintenance of normothermia with suitable active warming devices should be
used routinely

45. Prophylaxis against thromboembolism :-
Patients should wear well-fitting compression stockings and have intermittent pneumatic
Compression.
Extended prophylaxis (28 days) should be given to patients after laparotomy for
abdominal or pelvic malignancies.
Postoperative fluid therapy:-
Intravenous fluids should be terminated within 24 h after surgery; balanced crystalloid
solutions are preferred to 0.9% normal saline

46. Postoperative glucose control:-
ERAS elements that reduce metabolic stress should be employed to reduce insulin
resistance and the development of hyperglycemia.
Perioperative maintenance of blood glucose levels (b180–200 mg/dL) results in
improved perioperative outcomes; glucose levels above this range should be treated
with insulin infusions and regular blood glucose monitoring to avoid the risk of
hypoglycemia.
Peritoneal drainage
Peritoneal drainage is not recommended routinely in gynecologic/oncology surgery
including for patients undergoing lymphadenectomy or bowel surgery.

47. Urinary drainage
Urinary catheters should be used for postoperative bladder drainage for a short period
preferably 24 h postop.
Early mobilization:-
Patients should be encouraged to mobilize within 24 h of surgery

48. Perioperative nutritional care:-
A regular diet within the first 24 h after gynecologic/oncology surgery is
recommended
Prevention of postoperative ileus :-
The use of postoperative laxatives should be considered.

49. ERAS protocol for GI surgeries in nutshell:-
ERAS guidelines for GI surgeries is more or less similar to that of gyaenacological surgeries. It is
highlighted as follows:-
Area Guideline
Pre-admission Oral and written information
explaining the patient’s role in their
own recovery.
Bowel preparation Not used routinely
Preoperative fasting and 6 hours fast for solids, but to
Carbohydrate loading receive clear carbohydrate drinks
up to 2 hours preoperatively
This reduces the stress response
outlined above

50. Premeds No long-acting sedatives after
midnight
Venous thromboembolism Given subcutaneously to
prophylaxis everyone
Antibiotic prophylaxis Single dose within the hour
preincision
Standard anaesthetic Short-acting anaesthetic agents
techniques allow more rapid recovery.
Avoid long-acting opiates
use of neuro-axial block or other
regional blocks depending on
local protocol.

51. Postoperative nausea and Prevention with combinations of drugs
Vomiting
Surgical incision Use of smaller or transverse
incisions crossing less dermatomes
or laparoscopic techniques
Nasogastric tube Not used routinely
Preventing intraoperative Forced air warming
hypothermia

52. Perioperative fluid Avoid fluid overload. Consider use
management of cardiac output monitor to guide
fluid boluses.
Stop intravenous fluids as soon as
possible postoperatively.
Not routinely used except low
Drains anterior resections
Urinary catheter Avoid if possible. Remove as soon
as possible if required.

53. Prevention of postoperative Avoid fluid overload and
hypovolaemia intraoperatively.
Chewing gum four times daily and
low-dose laxative ileus.
Analgesia Initial strict use of epidurals has
evolved with many centres using
spinals, wound infusion catheters
or abdominal field blocks.

54. Minimize long-acting opiates Adopt multimodal analgesic regimen
Nutrition Oral diet as soon as possible
Oral supplements until normal diet
resumed, and continued in
malnourished patients

55. CONCLUSION
The application of ERAS has certainly changed the perioperative practice to
have a smoother ride for the patients throughout the perioperative period of
stress.
ERAS is simply a careful coordinated multidisciplinary approach, adherence to
which has better clinical outcome.
The application of ERAS to craniotomy population has significant potential
for better outcome.
In patients undergoing craniotomy considerations such as techniques for scalp
blocks, non-opioid alternatives for pain control and improved outcomes with
minimally invasive surgery are little different from the traditional ERAS
concept.

56. Adherence to ERAS for craniotomies may improve patient outcomes, accelerate
functional recovery and decrease length of stay.
However, prior testing an ERAS model for craniotomies is needed. The value
and safety of such a strategy is to be tested before full implementation.
More researches are needed in future to formulate a proper strategy for
craniotomy patients to have a better perioperative outcome.
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