ERAS program key elements

黄建宏

Enhanced Recovery After Surgery (ERAS) Key Elements

Enhanced recovery after surgery (ERAS) has proven efficacious in improving the quality and efficiency of surgical care.  There are more than 20 key elements in ERAS protocol.

Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) published a comprehensive evidence-based consensus review of ERAS perioperative care and recommendations of each elements.

Preadmission information, education and counseling
Patients should routinely receive dedicated preoperative counseling (can only be beneficial and not harmful).
Evidence level: Low (study quality, uncertain endpoints)
Recommendation grade: Strong

Preoperative optimization
Increasing exercise preoperatively may be of benefit. Smoking should be stopped 4 weeks
before surgery and alcohol abusers should stop all alcohol consumption 4 weeks before surgery (can only be beneficial and not harmful).
Evidence level: Prehab: Very low (inconsistency)
Alcohol: Low (only one high-quality RCT)
Smoking: High
Recommendation grade:
Alcohol: Strong
Smoking: Strong

Preoperative bowel preparation
Mechanical bowel preparation (MBP) has adverse physiologic effects attributed to dehydration. MBP should not be used routinely.
Evidence level: High
Recommendation grade: Strong

Preoperative fasting and carbohydrate treatment
Clear fluids should be allowed up to 2 h and solids up to 6 h prior to induction of anesthesia.
Evidence level: Solids and fluids (overall): Moderate (study
quality)
Recommendation grade: Fasting guidelines: Strong

Preanaesthetic medication
Patients should not routinely receive long- or short-acting sedative medication before surgery because it delays immediate postoperative recovery
Evidence level: Sedative medication: High
Recommendation grade: Strong

Prophylaxis against thromboembolism
Patients should wear wellfitting compression stockings, have intermittent pneumatic
compression, and receive pharmacological prophylaxis with LMWH.
Evidence level: Antibiotic prophylaxis, chlorhexidine-alcohol
preparation: High
Recommendation grade: Strong

Antimicrobial prophylaxis and skin preparation
Routine prophylaxis with intravenous antibiotics should be given 30-60 min before
initiating  surgery.
Evidence level: Antibiotic prophylaxis, chlorhexidine-alcohol
preparation: High
Recommendation grade: Strong

Standard anesthetic protocol
A standard anesthetic protocol allowing rapid awakening should be given. The anesthetist should control fluid therapy, analgesia and haemodynamic changes to reduce the metabolic stress response. Mid-thoracic epidural blocks using local anesthetics and low-dose opioids should be considered for open surgery. In laparoscopic surgery,
spinal analgesia or morphine PCA is an alternative to epidural anesthesia. If intravenous opioids are to be used the dose should be titrated to minimize the risk of unwanted effects
Evidence level: Rapid awakening: Low (lack of data),
Reduce stress response: Moderate (extrapolated data)
Open surgery: High
Laparoscopic surgery: Moderate (study quality)
Recommendation grade: Strong

PONV
A multimodal approach to PONV prophylaxis should be adopted in all patients with >2 risk
factors undergoing major colorectal surgery. If PONV is present, treatment should be given using a multimodal approach.
Evidence level: Low (multiple interventions)
Recommendation grade: Strong

Laparoscopy and modifications of surgical access
Laparoscopic surgery for colonic resections is recommended if the expertise is available.
Evidence level: Oncology: High.
Recommendation grade: Strong

Nasogastric intubation
Postoperative nasogastric tubes should not be used routinely. Nasogastric tubes inserted during surgery should be removed before reversal of anaesthesia.
Evidence level: High
Recommendation grade: Strong

Preventing intraoperative hypothermia
Intraoperative maintenance of normothermia with a suitable warming device (such as forcedair heating blankets, a warming mattress or circulating-water garment systems) and warmed intravenous fluids should be used routinely to keep body temperature >36 C. Temperature monitoring is essential to titrate warming devices and to avoid hyperpyrexia.
Evidence level: Maintenance of normothermia: High.
Recommendation grade: Strong

Perioperative fluid management
Balanced crystalloids should be preferred to 0.9% saline. In open surgery, patients should receive intraoperative fluids (colloids and crystalloids) guided by flow measurements to optimize cardiac output. Flow measurement should also be considered if: the patient is at high risk with comorbidities; if blood loss is >7 ml/kg; or in prolonged procedures.
Vasopressors should be considered for intra- and postoperative management of epidural-induced hypotension provided the patient is normovolaemic. The enteral route for fluid postoperatively should be used as early as possible, and intravenous fluids should be discontinued as soon as is practicable.
Evidence level: High
Recommendation grade: Strong

Drainage of the peritoneal cavity after colonic anastomosis
Routine drainage is discouraged because it is an unsupported intervention that probably impairs mobilization.
Evidence level: High
Recommendation grade: Strong

Urinary drainage
Routine transurethral bladder drainage for 1-2 days is recommended. The bladder catheter
can be removed regardless of the usage or duration of TEA.
Evidence level: Low (few studies, extrapolated data)

Prevention of postoperative ileus (including use of postoperative laxatives)
Mid-thoracic epidural analgesia and laparoscopic surgery should be utilized in colonic surgery if possible. Fluid overload and nasogastric decompression should be avoided. Chewing gum can be recommended, whereas oral administration of magnesium and alvimopan (when using opioid-based analgesia) can be included.
Recommendation grade: Thoracic epidural, fluid overload, nasogastric decompression, chewing gum, alvimopan (when using opioids): Strong

Postoperative analgesia
TEA using low-dose local anesthetic and opioids should be used in open surgery. For
breakthrough pain, titration to minimize the dose of opioids may be used. In laparoscopic surgery, an alternative to TEA is a carefully administered spinal analgesia with a low-dose, long acting opioid. In connection with TEA withdrawal, NSAIDs and Paracetamol should be used.
Evidence level: Thoracic epidural, laparoscopy: High
Recommendation grade: Strong

Perioperative nutritional care
Patients should be screened for nutritional status and, if deemed to be at risk of undernutrition, given active nutritional support. For the standard ERAS patient, preoperative fasting should be minimized and postoperatively patients should be encouraged to take normal food as soon as possible after surgery.
Evidence level: Postoperative early enteral feeding, safety: High
Recommendation grade: Postoperative early feeding and perioperative: Strong

Early mobilization
Prolonged immobilization, however, increases the risk of pneumonia, insulin resistance, and muscle weakness. Patients should therefore be mobilized.
Evidence level: Low (extrapolated data, weak effect)
Recommendation grade: Strong

Audit
A systematic audit is essential to determine clinical outcome and measure compliance to establish successful implementation of the care protocol. The system should also report patient experience and functional recovery, but validated tools are required for this aspect.
Evidence level: Systematic audit: Moderate
Recommendation grade: Strong

Reference
Gustafsson UO, Scott MJ, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):783-800

printhome

I do agree that ERAS is of vital importance for our patients. ERAS is also important for surgeons, ICU physicians, nurses and us. However, obstacles should be break down to make a collaboration. We should let the surgeons know that ERAS will improve their efficiacy and improve the safety or even prognosis of patients.

It's difficult to do an ERAS program in China, but worth a try.

docsusieliu

cannot agree any more.