Description
Enhanced recovery after surgery (ERAS)
Ritu V Jain
Consultant – Shri Mahaveer Hospital, Raipur,CG,India.
Assistant Professor- RIMS Medical College, Raipur,CG,India.
Enhanced recovery after surgery (ERAS), a multidisciplinary care pathway composed of evidence-based interventions, has challenged the traditional perioperative care paradigm with a goal of enhancing recovery and improving perioperative outcomes 1.
Enhanced recovery” or “fast track” surgical principles were first described in 1990s.by European anesthesiologists and surgeons most notably Dutch professor, Henrik Kehlet.1,8 They introduced the concept (1) limit the degree of the surgical injury itself and (2) find ways to help the body cope by decreasing its stress response to injury. The response to surgical stress is mediated by neurohormonal pathways and complement pathways leading to increased catabolism, immunosuppression, relative hypoxia, insulin resistance, and generalized organ dysfunction that can delay the body's ability to recover.
The first pathway was developed in Europe for colorectal surgery and has since been adapted for other surgical specialties, including gynecology.3,4 The most studied population in gynecology are oncology patients undergoing laparotomies with hospitalizations longer than 2 days.5,After ERAS implementation these patients experienced decreased length of admission, hastened return of bowel function, and decreased narcotic use, resulting in better postoperative pain control, and high patient satisfaction.1,6,7
Central to ERAS are the core components of patient education, preoperative optimization, avoidance of preoperative fasting, carbohydrate loading, intraoperative euvolemia, standardized opioid-sparing anesthesia, prevention of postoperative pain and nausea, and early mobilization.1-2 "Fast-track" protocol, aims to minimize the physiologic stress of surgery and optimize the rehabilitation of patients.This is a multidisciplinary team effort and requires active patient participation in the process.
ERP has been rigorously studied in many surgical specialties. Data showing benefit of ERP principles and protocols is most robust in colorectal surgery, but it has also been implemented with similar positive outcomes in a variety of other surgical specialties including vascular surgery, thoracic surgery, cardiac surgery, urology, hepatobiliary surgery, orthopedics, as well as in gynecologic oncology. However, there is limited data in obstetrics and benign gynecology.
ERAS components 1- ERP protocol for gynecology and gynecologic oncology patients.
Preoperative optimization
Assessment preoperative office visit or phone call
Screen for chronic conditions and assess optimization for surgery
Screen for tobacco and alcohol abuse- cessation 4-6 weeks prior to surgery
Assess for weight loss and malnutrition
Assess postoperative nausea and vomiting risk using simplified Apfel criteria
Perioperative expectations, reinforcing the patient’s role in their own recovery
Provide ERAS brochure and nutrition patient information
Exercise 30 minutes of walking daily until surgery
Diet Protein and carbohydrate-rich foods 1 week prior to surgery
Regular diet until midnight the night before surgery
Clear liquids until 3 hours prior to surgery (water, black coffee, clear tea, carbonated beverages, fruit juice without pulp, Gatorade)
Patients with diabetes should avoid sugar-containing liquids
Verification Preoperative phone call the day prior to surgery
Nothing by mouth instructions reviewed
Medications reviewed
Shower with soap the night before surgery
Day of surgery- Preoperative –
Multimodal pain management:
Celecoxib 400 mg PO (200 mg if age >65 y); omit if GFR <60
Acetaminophen 1000 mg PO (omit if hepatic dysfunction)
Morphine sulfate ER 30 mg PO (15 mg if age >65 y)
Postoperative nausea and vomiting prevention:
Perphenazine 8 mg PO
Anesthesia can add scopolamine patch if age <65 y
Antibiotic prophylaxis - Cefotetan 2 g IV within 60 minutes of incision
No routine fluid administration
No IV opioid premedication
Intraoperative Induction:
Propofol (1-2 mg/kg or titrate to amnesia and anesthesia)
Ketamine 20 mg
Lidocaine 100-200 mg bolus
Muscle relaxant (no opioids)
For spinal block-Bupivacaine + hydromorphone (40-100mcgm)
Dexamethasone 4-5 mg IV (avoid if diabetes)
Maintenance:
Ketamine 10 mg q 1 hour (avoid in final hour)
Lidocaine boluses q 1 hour (1 mg/kg)
Avoid opioids intraoperatively unless patient c/o pain at emergence
Avoid routine use of NGT
Fluid management: Goal is euvolemia: 2 mL/kg per hour, Boluses for MAP <60 mm Hg or 20% of baseline
Emergence:
Propofol titration
Ondansetron 4 mg IV
No IV ketorolac (unless celecoxib not given preoperatively)
No IV acetaminophen (unless not given preoperatively)
Postoperative Transition from IV to PO opioids for rescue pain management
Avoid patient controlled anesthesia
Ketorolac and acetaminophen scheduled
Start ice chips/sips of clear liquids as tolerated
IV fluids at 40 mL/h until tolerating oral fluids
Discharge checklist Tolerating oral fluids without nausea and emesis
Pain controlled (pain score <5)
Voiding trial complete
Independent ambulation
No signs of delirium (oriented to person, place, time, current events)
Postoperative follow-up
Assessment POD 1 Phone call from office nurses
Home health if required (urinary retention, DVT prophylaxis)
Benefits of ERP-
Meta-analyses & RCTs of ERP pathways have shown benefit.1, 3-6, and 8.
• Improved routine postoperative care
• Reduction in length of stay, with no difference in readmissions.
• Significant reduction in postoperative morbidity and mortality
• Improvement or no change in rates of postoperative complication and readmission.
• A recent meta-analysis across variety of surgical subspecialties confirmed that ERPs are cost-effective.
• Data on patient satisfaction and quality of life are more limited, but the available information suggests a benefit to ERP.
• ERP is consistently associated with improvements in pain scores.
• Rapid return to baseline functional status.
• Improved symptom scores
• Decreased rates of fatigue
• Study of gynecologic patients found improvements in “autonomy”, “physical complaints” and “postoperative pain”
Conclusion-
Implementation of an ERP is difficult, not only due to the high degree of coordination that is required, but because many of these interventions run counter to the current practice patterns. Practice patterns can be ingrained and difficult to change. As such, auditing and monitoring ERP implementation is crucial to achieving success. Incidences of protocol deviation must be examined. Parameters audited should include protocol compliance and deviation, measuring clinical outcomes of ERP, and measuring the patient's quality of life and satisfaction.
Future of ERP -
In a health care world that is increasingly focused on evidence-based medicine, resource use, and measuring the quality of delivered care, ERP seems a natural fit across the surgical specialties.The cost to implementation an ERP are few whereas the benefits are tangible. As we, move towards quality metrics, bundled payments, benchmarks, and pay for performance models, ERP is the future. The NHS Britain has embraced ERP as a quality improvement and service tool and considers it standard of care following surgery.
References :
1. Carter-Brooks CM, Du AL, Ruppert KM, et al. Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway. Am J Obstet Gynecol 2018;219:495.e1-10.
2.Kalogera E, Dowdy SC. Enhanced recovery pathway in gynecologic surgery: improving outcomes through evidence-based medicine. Obstet Gynecol Clin NorthAm2016;43:551–73.
3. Ljungqvist O. ERAS-enhanced recovery after surgery: moving evidence-based perioperative care to practice. JPEN J Parenter Enteral Nutr 2014;38:559–66.
4. Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS). Society recommendations—part II. Gynecol Oncol 2016;140:323–32.
5. Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/ oncology surgery: Enhanced Recovery After Surgery (ERAS). Society recommendations— part I. Gynecol Oncol 2016;140:313–22.
6. Slieker J, Frauche P, Jurt J, et al. Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery. Int J Colorectal Dis 2017;32:215–21.
7. 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.
8. Emma L Barber. Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology. Obstet Gynecol Surv. 2015 Dec; 70(12): 780–792.
Corresponding Author :
Ritu V Jain
Consulting Laparoscopic Gynaecologist & Infertility Expert.
Shri Mahaveer Hospital.
B- Building, Dani VILLA,
Bhagat Singh Square,
Opp Pahuna- State Guest House,
Main Rd Shankar Nagar, Civil Lines,
Raipur, CG,India - 492001.
Email- bijaleejain@yahoo.com
Phone- 9669673000.
