4. Background
JAMA Surg. 2019;154(8):755-766.
doi:10.1001/jamasurg.2019.1153
ERAS protocols published in other surgical specialities
Reduced complications
Reduce LOS upto 50%
Early return to normal activity
5. Class (strength) of
recommendation
I (strong): benefit many times greater than risk
IIa (moderate): benefit much greater than risk
IIb (weak): benefit greater than risk
III: no benefit (moderate): benefit equal to risk
III: harm (strong): risk greater than benefit
6. Level (Quality) of evidence
A – High quality RCT or meta analysis of high quality
RCT (1 or more)
B-R – Moderate quality RCT or meta analysis of
moderate quality RCT (1 or more)
B-NR - Well designed non randamosied trials
C-LD - RCTor nRCT of limited design
C-EO – Consensus of expert opinion
7. Preoperative strategies
Preoperative measure of HbA1c for risk stratification
Class IIA Level C-LD
Preoperative measure of Albumin for risk stratification
Class IIA Level C-LD
Preoperative correction of nutritional deficiency Class
IIa Level C-LD
Consumption of clear liquids before GA Class II b Level
C-LD
Preop carbohydrate loading Class II b Level C-LD
8. Preop strategies
Patient engagement tools Class II a Level C-LD
Prehabililation Level Iia Level B-NR
Smoking and hazardous substance Consumption Class
I Level C-LD
9. Intraoperative strategies
Infection Control Class 1
Topical intranasal decolinisation Class 1A
Antibiotics fewer than 60min before skin incision Class
1a
Clipping > shaving Class 1c
Use of chlorhexidine/alcholol based skin prep Class IIa
Removal of operative wound dressing after 48 hours
Class IIa
10. Intraoperative strategies
Hyperthermia Class III Level B-R
Rigid sternal fixation Class II Level B-R
Use of Tranexamic acid/ Epsilon aminocaproic acid
Class I Level A
11. Post operative strategies
Perioperative glycaemic control Class I Level B-R and
insulin infusion Class II a Level B-NR
Pain management Class I Level B-NR
Post operative Delirium screening Class I Level B-NR
Post operative hypothermia Level I Class B-NR
Chest tube patency Class IIIa Level B-R
12. Post operative strategies
Thromboprophylaxis Class II a Level C-LD
Chemical prophylaxis
Aspirin/Clopidogrel are not effective agents
Mechanical devices if feasible
Extubation strategies Class II a Level B-NR
Kidney stress and AKI Use of biomakers Class II a Level
B-R
Goal directed fluid therapy Class 1 Level B-R
13. Summary
ERAS –CS relatively new
Involves broad based multi-disciplinary approach
Mostly involves small achievable targets
Reasonable evidence available for the standard of care
17. MIOT’s satellite unit in
Lautoka hospital Fiji
Planning to set up unit March 2022
Out patient services from September 2022
Total OPD census till Dec 2023 – 523
235/523 new patients referred for surgery
Pre-op assessment and risk stratification
Patient and family involvement
18. In patient services
Surgery from Oct 2022
122 patients operated upon till 31st Dec 2023
All CABG except two emergency LA myxomas
97.5% patients discharged home
Follow up 1w/1m/3m
19. Post op care
Intensive glycaemic control
Extubation 70% within first 6 hours
90% mobilised to chair within 24 hours
Pain management - Multimodal
20.
21. Post op care
Intensive glycaemic control
Extubation 70% within first 6 hours
90% mobilised to chair within 24 hours
Pain management – Multimodal
Early resumption of normal diet
Discharged home on 5th/6th post op day
