ERAS protocol

1. ENHANCED RECOVERY AFTER SURGERY (ERAS)
PROTOCOL
Dr. Tanmoy Roy
Consultant Anaesthesiologist
C.M.R.I, Kolkata

2. THE ERAS SOCIETY
• 2001 – Dr. Ken Fearon and Dr. Olle Ljungqvist met in London at a nutrition
symposia and decided to start a collaborative group on peri-operative care.
• 2003 - The 1st ERAS Symposia was held in Stockholm at Ersta hospital
• 2005 - ERAS Study Group developed and published an evidence-based consensus
protocol for patients undergoing colonic surgery
“to develop perioperative care and to improve recovery through research, education, audit and
implementation of evidence-based practice”

3. A.k.a Fast track surgery; Evidence based multimodal
interventions under a single program, applied to the care of the
surgical patient in the peri-operative period
• Initially developed and promulgated for use in colorectal surgery1
• Targeted at impact of surgery on the metabolic and endocrine response
• Reduces complications without a rise in re-admissions
• Multi-disciplinary team with representatives from all specialties involved in patient
care
• Nutrition and Fluid management plays a central role in ERAS

4. WHY IMPLEMENT ERAS???
• 35-40% reduction in length of hospital stay2
• Fall in surgical, as well as non-surgical complications (nosocomial infections, etc.) in
the post-operative period3
• ERAS has also been associated with an earlier return to work and productivity4
• Both developed, as well as developing countries, have noted a 30-40% fall in
healthcare costs incurred5
• Institutes benefit from ERAS as implementation of a structured peri-operative
program streamlines patient care. Early discharge means patient turnover times are
reduced and institutes may be able to serve more patients within the available
infrastructure

5. HOW ERAS WORKS?
Prehabilitation

6. KEY COMPONENTS OF ERAS
ACTIVE PATIENT INVOLVEMENT
PRE-OPERATIVE INTRA-OPERATIVE POST-OPERATIVE
Preadmission Education
Early discharge planning
Reduced fasting
No / Selective bowel prep
Carbohydrate loading
Venous
thromboprophylaxis
Antibiotic Prophylaxis
Pre-warming
Active warming
Opioid sparing technique
Minimally invasive surgery
Avoiding prophylactic NG
tubes and drains
Early oral nutrition
Early catheter removal
Early Ambulation
Chewing gum
Defined discharge
criteria
GOAL DIRECTED PERIOPERATIVE FLUID
MANAGEMENT
MANAGEMENT OF PAIN AND NAUSEA
AUDIT OF COMPLIANCE AND OUTCOME
WHOLE TEAM INVOLVEMENT

7. FLUID BALANCE IN ERAS
• Preoperative- Fasting guidelines, Clear Carbohydrate Beverage(CCB)
• Intraoperative- Goal is zero-balance therapy with the aim of maintaining euvolemia while minimizing excess salt and
H20- Goal Directed Therapy(GDT)
Maintain both blood flow and blood pressure; GDT uses a combination of fluids and inotropes to optimize flow through
measurement of cardiac output and stroke volume
All patients have an individualized plan for fluid and haemodynamic management that matches monitoring needs with
patient and surgical risk
Balanced salt solution; Avoid Hyperosmolar and high salt containing solution.
Baseline infusions < 2 ml/kg/hr based on ideal body weight; If there is clinical indication that the patient is hypovolemic,
bolus with 3ml/kg of IBW and reassess
If no monitor used, then “acceptable” volume likely in the range of 4-8 ml/kg/hr
Monitoring: Esophageal doppler, Cardiac Index, Stroke Volume Variation, Systemic Vascular Resistance Index, Central
Venous Oxygen Saturation
• Postoperative- Early transition to oral hydration; recommended that patients receive 25-35 ml/kg/day of water in the
recovery period6 . Expect Oliguria, but don’t accept Anuria. Minimum urine output of 0.3ml/kg/hr

8. NUTRITION IN ERAS
• ERAS protocols do not recommend specific tools for nutrition screening or assessment
• Preoperative carbohydrate loading is also shown to be safe in NIDDM, no adverse effects
such as hyper-glycaemia or delayed gastric emptying are shown in these patients and
thus its use is recommended in such patients also

9. • In the post-operative period nutritional management is carried out in the form of
early oral or enteral nutrition (EEN). Oral or Enteral nutrition can be started as
early as 6-8 hours after surgery
Our protocol at Pinderfields
Hospital, Wakefield, UK
Normal dinner + 50-100gms
of complex maltodextrin
based formula, upto 2 hours
before surgery + Prokinetic
before surgery

10. ERAS IN DIFFERENT SURGICAL DISCIPLINES
• Combination of ERAS and laparoscopy was associated with significant improvements in postoperative recovery.
Introduction of ERAS to colorectal surgery decreased postoperative morbidity by 40–50% (mainly non-surgical).( Greco
M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of
randomized controlled trials. World J Surg. 2014;38:1531–41.)
• While proposed for gastric surgeries, ERAS protocol implementation is still being studied.(Yamada T, Hayashi T, Cho H,
Yoshikawa T, Taniguchi H, Fukushima R, et al. Usefulness of enhanced recovery after surgery protocol as compared with conventional
perioperative care in gastric surgery. Gastric Cancer. 2012;15:34–41)
• ERAS has also been shown to be beneficial in liver surgery and its implementation has started in many centers.
(Hughes MJ, McNally S, Wigmore SJ. Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford)
England. 2014;16:699–706.)
• A study on ERAS care post pancreaticoduodenectomy was published in 2012. Literature reviews agree that ERAS may
be introduced without compromising patients’ safety, although there is still a need for large-scale, multicenter
randomized trials.(Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced recovery after pancreatic surgery: a systematic review of
the evidence. HPB. 2015;17:11–6.)

11. DIFFICULTIES IN ERAS IMPLEMENTATION
• Challenge to traditional surgical doctrine has led to slow implementation
• Institutional barriers, such as a lack of nursing staff and financial resources
• Lack of communication and collaboration within the team
• Surgeons were not willing to change their practice but were supportive of changes in
anesthesiologist-dependent elements of perioperative care that did not interfere
with their own work, such as restrictive fluid therapy and the use of transversus
abdominis plane blocks

12. CONCLUSION
Developments in ERAS have highlighted the importance of peri-operative care.
ERAS has already demonstrated the ability to:
• achieve a reduced hospital stay
• patient satisfaction
• reduced rate of complications without an increase in re-admissions
Until ERAS becomes a routine reality, it may be in the best interest of all those
involved in the peri-operative care of the surgical patient to be familiar with ERAS
and its principles

13. REFERENCES
1. Kehlet H, Bardram L, Funch-Jensen P, et al. Recovery after laparoscopic colonic surgery with epidural analgesia, and early
oral nutrition and mobilisation. Lancet 1995;345:763–4.), ( Miller TE, Thacker JK, White WD, et al. Reduced length of hospital
stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg. 2014;118:1052-61
2. Wind J, Polle SW, Fung KonJin PH, et al.; Laparoscopy and/or fast track multimodal management versus standard care
(LAFA) study group; Enhanced Recovery after Surgery (ERAS) group. Systematic review of enhanced recovery programmes
in colonic surgery. Br J Surg 2006;93: 800–9
3. Muller S, Zalunardo MP, Hubner M, et al; Zurich Fast Track Study Group. A fast-track program reduces complications and
length of hospital stay after open colonic surgery. Gastroenterology 2009;136:842–7
4. Gustafsson UO, Hausel J, Thorell A, et al; Enhanced Recovery after Surgery study group. Adherence to the enhanced
recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011;146:571–7
5. Nanavati AJ, Nagral S, Prabhakar S. Fast track surgery in India. Natl Med J India 2014;27:79-83
6. Varadhan KK, Lobo DN. A meta-analysis of randomized controlled trials of intravenous fluid therapy in major elective open abdominal
surgery: getting the balance right. Proc Nutr Soc 2010; 69: 488e98

14. THANK YOU
“Don’t be afraid to stand for what you believe in,
even if that means standing alone”