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ERAS Protocol
1. Enhanced Recovery After Surgery
The ERAS protocol
Ankit Raj
Postgradutate Student(2nd Year)
Unit-III
Dept. of General Surgery
LHMC & associated Dr RML Hospital
New Delhi-110001
2. THE DOGMA
What Is a Dogma?
/ˈdɒɡmə/
noun
‘a principle or set of principles laid down by an
authority as incontrovertibly true’;applies to some strong belief
whose adherents are not willing to rationally discuss it
Dogmas in General Surgery-
• Preoperative prolonged fasting
• MBP
• NGT’s
• Drains
• Prolonged bed rest
5. What is ERAS?
• Proposed by Dr. Henrik Kehlet, a Danish Surgical Gastroenterologist in
1990’s
“Why is the patient in hospital today?”
• “Patient-centered,evidence based,outcome driven,multidisciplinary
team developed pathways for a surgical specialty and facility culture
to maintain pre-operative organ function and reduce the profound
stress response following surgery,optimize their physiologic
function,and facilitate recovery”
• Fast Track Surgery
• These form an integrated continuum, as the patient moves from
home through the pre-hospital / preadmission, preoperative,
intraoperative, and postoperative phases of surgery and home again
6. Objectives of ERAS
• Reducing complications and LOS
• Reducing variability
• Reducing cost
• Improving quality of care
• Increasing value = quality/cost
7. Traditional Care VS
• Provider focused
• High variability
• Physician driven
ERAS® Care
• Patient focused
• Outcome ddriven
• Standardised
• Evidence based
• Interdisciplinary
8. Recommendations of ERAS® Society
• Based on quality of evidence
– High
– Moderate
– Low
– Very low
Strong recommendation- Means panel is confident that
desirable effects outweigh the undesirable effects
Weak recommendation’s-Panel is less confident that
desirable effects outweigh undesirable effects.
9. Enhanced Recovery in Practice
Referral from
Primary Care
Pre-
Operative
Admission
Operative
Post-
Operative
Follow-up
• Fluid management
• Postoperativ glycaemic control
• Postoperative nutrition
• Early mobilisation
• Rapid hydration / nourishment
• Appropriate iv therapy
• Catheters removed early
• Regular oral analgesia
• Avoid opiates
• Antimicrobial
prophylaxis
• Multimodal analgesia
• PONV
• Optimal fluid therapy
• Hypotermia
prophylaxis
• Optimised
medical
conditions
• Nutrition
• Fasting time
• Carbohidrate
drinking
• Pre-anesthestic
medication
• Anti-thrombotic
prophylaxis
17. Patient information
Preadmission education and counselling
• Decrease fear and anxiety
• Improve
wound healing
perioperative feeding
postoperative mobilisation
pain control
• Reduce the prevalence of complications
Enhance
Postoperative
Recovery
and Discharge
Evidence Low
Recommendation High
19. Preoperative Alcohol Consumption?
Preoperative Smoking Cessation?
• Does it make any difference?
• If yes for how long?
Alcohol consumption should be stopped
4 weeks before surgery
Smoking should be stopped 4 weeks
Before surgery
Smoking should be stopped 4 weeks before surgery
Smoking should be stopped 4 weeks before surgery
24. Who should receive preoperative nutrition support?
• moderately/severely malnutrished
• nutrition support has been shown to improve
outcome – thoraco-abdominal surgery
• elective surgery and safe to delay for 7-10 days
• enteral route is always prefered (when possible)
• combination with postoperative nutrition
• immune-enhancing formulas
26. Preoperative fasting
• Standard practice – fasting from midnight
reduce the volume and acidity of stomach contents
decrease the risk of pulmonary aspiration
But …
• Cochrane review of 22 RCTs-fasting from
midnight
no reduction in gastric content
no rise in pH of gastric fluid
Clear fluids until 2h before anesthesia
Thirst, headaches, hunger
27. Why challange
fasting by midnight?
• Normal physiology
• Is no guarantee of an empty stomach
• The same gastric volume with/without clear fluids
• Improved well being
28. Preop Fasting and Periop Fluids
• If fasted – risk of dehydration
• Dehydration and anesthesia --> hypotension
• Hypotension --> more fluids infused
• Overload of fluids
• Preop clear fluids --> less iv fluids -->
improved outcomes
Gustafsson et al Arch Surg, 2011
29. Metabolic effects of overnight fasting
Day Night
Hormones Insulin + Insulin –
Glucagon
Cortizol
Substrates Storage Breakdown
Utilization CHO > Fat Fat > CHO
31. Insulin resistance cause complications
Complications increase with insulin resistance:
50% reduction in insulin sensitivity:
• 5-6 fold increase risk of complications
• 10 fold risk for infections
Sato et al, JCEM 2010, 95; 4338-44
33. Carbohydrate treatment
• 20% glucose iv
• 12.5% carbohydrate drink
– 400 ml 2h before anesthesia
+ 800 ml evening before
• Induce insulin release
34. Effects of Preoperative Carbohydrates
• Reduces the metabolic stress of surgery
• Effectively reduces insulin resistance
• Improves pre/postoperative well being
• Improves postoperative muscle function
• Reduce lean body mass losses
• May result in faster recovery
36. Pre-anesthetic medication
Education
Short-acting iv drugs
Prior epidural/spinal analgesia
No sedative medication
before surgery
Avoid starvation CHO loading
U.O. Gustafsson et al. Clin Nutr 2012; 31: 783-800
42. Anesthesia Protocol
• Tri-modal approach
-A regional anesthesia block used in addition to GA
• Reduced post-op use of opiates
• Rapid awakening from anesthesia
• Early enteral intake and mobilization
• Use of epidural analgesia is superior to opioids
51. Perioperative fluid management
What type of fluid ?
Is there an indication for vasopressors ?
When iv fluids should be discontinued ?
Apparently, fluid management is an art of medicine and
based on personal judgments.
Is fluid therapy vital for outcome ?
Are the fluid requirements the same ?
What about fluid shifts ?
What amount ?
52. Perioperative fluid management
• Type of fluid
• Vasopressors are indicated in hypotensive normovolemic
patients
• Iv fluids should be discontinued as soon as practicable
Goal directed Therapy
• Fluid therapy is vital for outcome
• Fluid requirements are different
• Fluid shifts should be minimised
• Fluid administration must be goal directed
54. • Hypothermia – central temperature < 36 C
• Risk factor for
wound infections, prolonged cicatrisation
cardiac events
shivering – increase O2 consumption
bleeding
coagulation disorders
trombocites dysfunction
postoperative ileus
increase pain
prolonge emergence time
• Methods -
warming devices
(forced air warming blankets)
warmed iv fluids
warm gases in laparoscopic surgery
Hypothermia Prophylaxis
55. Postoperative ERAS components
• Postoperative analgesia
• Fluid management
• Postoperative glycaemic control
• Postoperative nutrition
• Early mobilisation
56. Postoperative analgesia
• Optimale analgesic regimen
– Good pain relief
– Reduction of cardiovascular, cognitive, endocrino
– metabolic complications in at risk patients
– Decrease the risk of chronic pain
– Allow early mobilisation
– Allow early return of gut function and feeding
57. Postoperative analgesia
• Principles of Multimodal Analgesia
– Avoidance of iv opioids
– Regional anesthesia techniques
• Thoracic epidural analgesia (TEA)
• Spinal analgesia
– Local anesthetic techniques
• Transversus abdominis plane (TAP) block
• The analgesic regimen is specific to the type of
surgery/incision
58. Postoperative ERAS components
• Postoperative analgesia
• Fluid management
• Postoperative glycaemic control
• Postoperative nutrition
• Early mobilisation
59. Postoperative ERAS components
• Postoperative analgesia
• Fluid management
• Postoperative glycaemic control
• Postoperative nutrition
• Early mobilisation
60. Hyperglycemia in Surgical Stress
• Insulin resistance is the key
• Traditional belief
Hyperglycemia in the acutely stressed patient is
”not dangerous”
Glucose levels treated > 200 mg/dl
61. • Elective major surgery-opportunity to prevent /attenuate
metabolic responses to surgeryrather than having to treat
them with insulin.
• Several stress-reducing interventions in ERAS attenuate
insulin resistance as single interventions:
•preoperative oral carbohydrate treatment
•epidural blockade
•minimally invasive surgery
• If interventions are combined in ERAS protocol,
hyperglycaemia can be avoided even during full enteral
feeding starting immediately after major colorectal
surgery.
62. Postoperative ERAS components
• Postoperative analgesia
• Fluid management
• Postoperative glycaemic control
• Postoperative nutrition
• Early mobilisation
66. Surgeon
No bowel prep
Food after surgery
No drains or KAD
No iv fluids, no lines
Early discharge
All evidence based!
Anesthetist
Carbohydrates
No fasting
No premedication
Epidural Anesthesia
Balanced fluids
Vasopressors
No or short acting opioids
67. BOWEL PREPARATION
• PRO
– Avoids massive contamination !?!
– Minor inconvenience to the patient !?!
– Looks better inside !?!
• CON
– Preoperative dehydration !!!
– Modification of enteral flora !!!
– Delayed gut motility !!!
68. Rectal cancer – TME (total mesorectum excision)
• Standardised Enhanced Recovery Programme for the
EnROL Trial Day before surgery avoidance of oral bowel
preparation except in patients undergoing total
mesorectal excision (TME) and reconstruction.
Kennedy et al. BMC Cancer 2012, 12:181
69. Reduce surgical injury
Minimally invasive surgery
• FAST TRACK Surgery
• Early postoperative recovery
– Decreased stress response
– Decreased inflammatory response
– Decreased pain
– Early bowel movement
70. NO routine NGT
• 28 multicenter trials >4000 pts
– Decreased duration of postoperative ileus
– Decreased risk of postoperative pulmonary
complications
– Increased patient QOL
– No increase in anastomotic leak
Nelson, R. at all Systematic review of prophylactic nasogastric
decompression after abdominal operations.
Br. J. Surg., 2005, 92, 673–680.
71. No drains
• Rationale of drains:
• A surgical tradition
• Difficult to be abandoned
• For how long? 24h / 48h / 7days ???
• In majority of cases – serous drained fluid
(physiological reabsorption)
“When in doubt, drain”
Lawson Tait, english surgeon
“The drain= the surgeon eye in the patients abdomen”
72. No drains
• RCTs:
– Unreliable indication of anastomotic leak
– Underestimates the significance of anastomotic leak
– Underestimates the postoperative bleeding
– Does not influence the rate of anastomotic leak
– Increases the contamination risk
– Prolongs the duration of postoperative ileus
– Prolongs the hospital lenght of stay
Petrowsky, H. at all: Evidence-based value of prophylactic drainage in
gastrointestinal surgery: A systematic review and meta-analyses.
Ann. Surg., 2004, 240, 1074–1085.
