I presented this case an intern doctor in my surgery rotation as a part of the department's monthly presentation. It is a good guide for undergraduate students and intern doctors to understand basics on Enhanced Recovery After Surgery.

1. Welcome.

2. SCIENTIFIC SEMINAR ON ERAS

3. Chaired by
Dr. Ehsanur Reza Shovan
Associate professor
Dept of Surgery
MMC
Presented by Dr. Ashmita Yadav
Intern doctor
Surgery Unit 2, MMCH

5. ERAS?
• ERAS stands for Enhanced Recovery After Surgery.
• HISTORY
• THE ERAS SOCIETY
• 2001- Ken fearon and olle ljungvist met in London at a nutrition
symposium and decided to start a collaborative group on peri
operative care.
• Further ideas were put forward in 2003 by professor Kehlet Henrick
concerning the concept of multimodal care.

6. Professor Kehlet Henrick
Henrik Kehlet was Professor of Surgery at
Copenhagen University and is now
Professor of Perioperative Therapy at
Rigshospitalet, Copenhagen University,
Denmark.

7. WHAT DOES IT ENCOMPASS ?
It includes the intervals prior to surgery to the day of discharge.
It can be best described as a quality improvement tool to
To develop perioperative care
To improve recovery through research, education,
audit and implementation of evidence based practices.

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 ERAS team
• Surgeons
• Nurses
• Anaesthesiologist
• Occupational therapist
• Pain management specialist
• Physiotherapist
• Dietician
• Hospital management
• Audit team

10. ERAS PERIOPERATIVE PATHWAY
PRE OPERATIVE
Pre admission counseling
Fluid and carbohydrate loading
No prolonged fasting
No or selective bowel preparation
Antibiotic prophylaxis
Thromboprophylaxis
Premedication

11. Minimal access surgery
Short acting anaesthetic agents
Mid thoracic epidural
Avoidance of salt and water overload
Maintenance of normothermia
INTRA OPERATIVE

12. POST OPERATIVE
Mid thoracic epidural
No NG tube
Prevention of PONV
Avoidance of salt and water overload
Early removal of foley’s catheter
Early oral nutrition
Use of non opioid pain medication
Early mobilization
Respiratory exercise
Stimulation of gut motility.

13. PRE EXISTING HEALTH CONDITIONS
• Optimatisation of pre existing health conditions such as
-Hypertension
-Diabetes
-Smoking
-Alcohol
-Anaemia and anxiety

14. • Hypertension should be controlled and blood pressure should be
brought to a baseline level.
• Diabetes should be monitored carefully depending on whether the it
is controlled by diet, oral hypoglycaemic agents or insulin.
• Patients on insulin should be monitored with GLUCOSE POTTASIUM
INSULIN sliding scale regimen.
• Smoking cessation 4 weeks prior , nicotine replacement therapy and
counseling should be done.

15. • A minimum of 4 weeks abstinence of alcohol should be done.
• Blood transfusions should be done at least 1 week before to bring
haemoglobin to a baseline level.
• Iron ,vitaminB12 and folate supplementation should take place at least 4
weeks prior for the effect to take place.
• Education and counseling with preoperative analgesics and anxiolytics.
• Any co-morbid cardiac or pulmonary condition should be carefully
assessed.

16. ORAL INTAKE
Oral intake prior to any surgery and post operatively depends on the
type of surgery.
There is not enough evidence to support that by ensuring an empty
stomach the risk of aspiration is less.
Studies have shown that fasting after midnight increases insulin
resistance, patient discomfort and decreases intravascular volume.

17. • With ERAS protocol in place , the patient is given sips of water or clear
liquid on the day of surgery. The diet is then progressed to a regular
diet.

18. • Early oral feeding has not been shown to increase post operative
complications, readmission rates and the incidence of anastamotic
leak.
• On the other hand patient who start early feeding protocol have
fewer surgical complications and are less likely to be admitted.

19. POST OPERATIVE NAUSEA AND VOMITING
 Incidence -20 to 30 %
 Reduction of post operative fasting, carbohydrate loading and
hydration decreases PONV.
 Serotonin antagonists or application of scopolamine patch or
dopamine antagonists.

20. ANALGESIA
• Thoracic epidural is the gold standard.
• Avoidance of opioid analgesics.
• Patient controlled analgesia is the new approach
• NSAIDS and COX -2 inhibitors such as celecoxib have shown to
improve post operative analgesia by reducing opioid consumption.

21. DELIRIUM
• Post operative delirium is common in critical care and post operative
patients.
• Non pharmacological interventions and use of haloperidol may be
necessary to treat post operative delirium.

22. MOBILIZATION
Early mobilization is one of the leading factors of ERAS.
Instructions detailing the daily mobilization goals should be given to
the patient and families prior and it should be ensured even after the
surgery.
Early mobilization helps in prevention of DVT .

23. RESPIRATORY EXERCISE
• Respiratory exercises are encouraged to prevent pulmonary
atelectasis.

24. REFERENCES
• Bailey and love’s short practice of surgery 28th edition
• Enhanced recovery after surgery ( LISA PARKS, MS,RN, MEGHAN
ROUTT,MSN,ACNS BC,ALLISON DE VILLERS)
• The ERAS PROTOCOLS BY PROF.LOANA GRIGORA S
• Multimodal approach to control post operative pathophysiology and
rehabilitation- Henrik kehlet , Brit J A.