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REPORT

Enhanced Recovery After Surgery

Surgical Services Taskforce and Anaesthesia Perioperative Care Network

Introduction

Enhanced Recovery After Surgery (ERAS) utilises strategies to optimise the patient’s condition for surgery and recovery. In particular, the aim is to achieve an earlier discharge from hospital for the patient and a more rapid resumption of normal activities after surgery, without an increase in complications or readmissions. This is underpinned by collaboration between surgical and anaesthetic teams. While elements of ERAS may vary between surgical units and hospitals, there are many common features in the preoperative, intraoperative and postoperative phases.

A literature search was conducted by the Brian Tutt Library for the ACI and a review of the literature has been completed. It has been recognised that ERAS is now considered by many to be standard care (Nelson, Kalogera & Dowdy 2014). Through this review, the benefits associated with ERAS were identified. Bona et al (2014) noted these benefits to be quicker postoperative recovery and decreased length of stay in comparison to conventional care. It has also been found that while length of stay is decreased, this has not compromised readmission rates (Coolsen et al 2013). Other benefits show that ERAS is associated with lower rates of complication and does not compromise patient safety (Shao et al 2014; Ly, Shao & Zhou 2012).

The key components of ERAS programs are the perioperative management for patients beginning preoperatively, through the intraoperative process and continued postoperatively (Figure 1). Notably, the production and utilisation of ERAS guidelines/protocols simplifies and demystifies care for patients, clinicians and allied health staff, promoting inter-disciplinary care. Certain innovations in patient care have accompanied the use of ERAS programs, including the use of explicit discharge criteria that allow advanced planning of discharge timing/arrangements with all staff and patients able to appreciate and work towards these criteria. Ideally, discharge criteria are best agreed locally by consensus. For example, some clinicians support patients being discharged before their bowels have been opened after colorectal surgery, while others are less keen on this approach.

Additionally, ERAS programs have introduced alterations to traditional care, such as the use of:

  • chewing gum in the postoperative period to stimulate gut function (Short et al. 2015)
  • administering Alvimopan (Ehlers et al., 2016), a drug that acts as a peripherally acting μ-opioid antagonist
  • using bedside ultrasound of the stomach to confirm gastric emptying and allowing safe introduction/progression of feeding in the postoperative period (Mirbagheri et al., 2016).

One unanswered question from these research studies remains - which combination of elements provides the best outcomes in terms of length of stay, quality of life, postoperative morbidity, complications and readmission rates (Sturm & Cameron 2009).

While the ERAS Society describes a comprehensive list of elements needed to implement ERAS, it is not uncommon for sites to adopt local guidelines and policies to incorporate as many of these components as possible. This is important as benefits to patients, clinicians and managers have been identified in ERAS programs that do not contain all of the elements recommended by the ERAS Society. A 75 to 80 per cent compliance with ERAS may mean 30 to 40 per cent fewer complications (Gustafsson et al 2011).

Fig 1: ERAS Components Utilised Across Different Specialties

A number of the components utilised in ERAS are common across different specialties. In the preoperative phase, common components include optimising the patient’s condition through cessation of smoking and alcohol and through identification and treatment of anaemia. Patients are also allowed clear fluids up to two hours prior to surgery. Components in the intraoperative phase include minimally invasive surgery and avoidance of routine nasogastric intubation. Postoperatively, patients are provided multimodal analgesia and are mobilised early.

Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced Recovery After Surgery (ERAS) protocols: Time to change practice?
Can Urol Assoc. 2011 Oct. 5 (5): 342-348

Fig 2: Conventional Surgery compared to Enhanced Recovery After Surgery for Bowel Resection

The differences between conventional surgery for a bowel resection and Enhanced Recovery After Surgery are outlined in the figure below.

Conventional Surgery

Pre-admissions
  • Pre-admission assessment and patient information provided
  • Mechanical bowel preparation
Day Zero
  • Nil by mouth
  • Drain
  • Nasogastric (NG) Tube
  • Intravenous Therapy (IVT)
  • Patient Controlled Analgesia (PCA)
  • Indwelling catheter (IDC)
  • Bed rest
Day One
  • NG Tube
  • Nil by mouth
  • Deep breathing
  • IVT
  • PCA
  • Bed rest
  • Drains
Day Two
  • NG Tube removed
  • Sit out of bed
Day Three
  • Clear liquids if bowel sounds present
  • Catheter removed
  • Sit out of bed
Day Four
  • Clear liquids if bowel sounds present
  • Walk with assistance of physiotherapist
Day Five
  • Full liquids
  • IV removed – commence oral analgesics
  • Walk with the assistance of physiotherapist
Day Six
  • Soft diet
  • Walk independently
Day Seven to Eleven
– Discharge Criteria
  • Appropriate pain control with oral analgesia
  • Taking solid foods, no IV fluids
  • Independently mobilise or same level as prior to admission
  • Return of gut functions

Enhanced Recovery After Surgery

Pre-admissions
  • Pre-admission assessment
  • Avoid bowel preparation
  • Patient information provided
  • ERAS specific education
  • Prehabilitation
  • Oral Supplements
Day Zero
  • Sit out of bed
  • Eating and drinking as tolerated
  • IVT
  • PCA
  • IDC
  • Chewing gum
Day One
  • Mobilisation – sit out of bed for at least 6hrs/day and walk
  • Catheter removed
  • Drains removed
  • Eating and drinking as tolerated
  • Transition to oral analgesics
  • Cease PCA
  • Cease IVT
Day Two/Three
  • Mobilisation – sit out of bed for at least 6hrs/day and walk
  • Normal diet

Day Four -
Discharge Criteria

  • Appropriate pain control with oral analgesia
  • Independently mobilise or same level as prior to admission
  • Return of gut functions
Follow Up
  • Follow-up phone call post discharge