ERAS Protocols

ERAS Protocols
1. Introduction
2. Rationale
3. Components of ERAS
4. Challenges & Future
Introduction
• Multiple, evidence based, perioperative interventions
• Decisions taken early
• Multi-professional, multi-disciplinary approach
 Introduction
• History
• Bardram et al1
• Reduction of length of stay after laparoscopic colonic resection
• Prof Henrik Kehlet2,3
• ‘Fast-track’ surgery
• Multi modal surgical care
• PROSPECT
• PROcedure-SPECific pain managemenT

1. Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet.
1995;345:763-764.
2. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86:227-230.
Introduction
• History
• ERAS study group (2001)
• Ken Fearon & Olle Ljungqvist
• Consensus protocol for Colonic surgery (2005)
• ERAS society registered in Stockholm (2010)

• American Society for Enhanced Recovery (ASER)

• Perioperative Quality Initiative (POQI)

Rationale
• Attenuation of surgical trauma & stress response
• Maintenance of physiologic homoeostasis
• Facilitating prompt recovery
• Reduction in post-operative complications
• Reduction in length of hospital stay
• Transparency in provision of healthcare
• Optimal surgical experience
Components of ERAS

Pre- Intra- Post-

operative operative operative
ERAS – General Guidelines
Components
• Pre-operative
• Patient counselling
• Optimisation of co-morbidities
• Prehabilitation
• Alcohol & smoking cessation
• Risk assessment
 Components
• Pre-operative
• Fasting guidelines
• Faster recovery with carbohydrate loading1,2
• Type of surgery
• Minimally invasive surgery reduces length of stay3

1. Awad S, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr 2013; 32: 34–44.
2. Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014; 8:
CD009161.
3. Haverkamp MP, de Roos MA, Ong KH. The ERAS protocol reduces the length of stay after laparoscopic colectomies. Surg Endosc 2012; 26:361–7.
 Components
• Intra-operative
• Pre-anaesthetic medications
• Benzodiazepines & long acting narcotics1,2
• Avoid mechanical bowel preparation
• Minimise impact of anaesthetic agents
• Depth of anaesthesia monitoring

1. Walker KJ, Smith AF. Premedication for anxiety in adult day surgery. Cochrane Database Syst Rev 2009; 9: CD002192.
2. Lepouse C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the postanaesthesia care unit. Br J Anaesth 2006; 96: 747–53.
 Components
• PONV prophylaxis
• Based on risk factors

1. Walker KJ, Smith AF. Premedication for anxiety in adult day surgery. Cochrane Database Syst Rev 2009; 9: CD002192.
2. Lepouse C, Lautner CA, Liu L, Gomis P, Leon A. Emergence delirium in adults in the postanaesthesia care unit. Br J Anaesth 2006; 96: 747–53.
 Components
• Intra-operative
• Neuromuscular blockade
• Avoid long acting drugs
• Monitoring (qualitative and/or quantitative)
• Normothermia
• Preventing hypothermia reduces complications1,2

1. Esnaola NF, Cole DJ. Perioperative normothermia during major surgery: is it important? Adv Surg 2011; 45: 249–63.
2. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, Beattie C. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical
trial. JAMA 1997; 277: 1127–34.
 Components
• Intra-operative
• Inspired oxygen concentration
• PROXI trial1
• Titrated to maintain normoxia
• Nasogastric intubation
• Oropharyngeal & pulmonary complications2
• Recommended only for patients with delayed gastric emptying

1. Meyhoff CS et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA 2009;
302: 1543–50.
2. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; 3:CD004929.
 Components
• Intra-operative
• Glycaemic control
• Even moderate increase associated with increased mortality1,2
• No conclusive superiority of strict v/s liberal control
• As close to normal as possible

1. Umpierrez GE et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002; 87: 978–82.
2. Eshuis WJ et al. Early postoperative hyperglycemia is associated with postoperative complications after pancreatoduodenectomy. Ann Surg 2011; 253: 739–44.
 Components
• Intra-operative
• Haemodynamic management
• GDFT with isotonic balanced solutions1
• Maintain near-zero fluid balance2
• Vasopressors & Inotropes for hypotension

1. Feldheiser A et al. Anaesthesia Working Group of the Enhanced Recovery After Surgery S, Enhanced Recovery After Surgery S. Development and feasibility study of an algorithm for
intraoperative goal directed haemodynamic management in noncardiac surgery. J Int Med Res 2012; 40: 1227–41.
2. Brandstrup B et al. Which goal for fluid therapy during colorectal surgery is followed by the best outcome: near-maximal stroke volume or zero fluid balance? Br J Anaesth 2012; 109: 191–9.
Components
• Post-operative
• Pain management
• Multimodal
• Oral & parenteral
• TEA
• Abdominal wall blocks
• Continuous wound infusion
• Intraperitoneal Local Anaesthetic (IPLA)
 Components
• Post-operative
• Post-operative Delirium
• Avoidance of prolonged fasting
• Avoidance of deep anaesthesia
• Maintaining sleep-wake cycle
• Avoidance of Benzodiazepines1

1. Lonergan E, Luxenberg J, Areosa Sastre A, Wyller TB. Benzodiazepines for delirium. Cochrane Database Syst Rev 2009; 1: CD006379.
ERAS for Gastrointestinal (GI)
Surgery
 Components – GI Surgery
• Attenuation of post-operative ileus (POI)
• TEA1
• Opioid-sparing strategies2
• Early feeding2
• Mobilisation2
• Judicious use of IV fluids2

1. Popping DM et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259: 1056–67.
2. Kehlet H. Postoperative ileus–an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol 2008; 5: 552–8.
ERAS for Obstetric Surgery
 Components – Obstetric surgery
• Pre-operative
• Patient counselling
• Optimisation of co-morbidities
• Fasting guidelines
• Avoid carbohydrate loading in diabetics
• Pre-anaesthetic medication
• Antacids & H2-receptor antagonists1
• Avoid pre-operative sedation2,3

1. Paranjothy S, Griffiths JD, Broughton HK, Gyte GML, Brown HC, Thomas J. Interventions at caesarean section for reducing the risk of aspiration pneumonitis. Cochrane Database of Syst Rev
2014:CD004943.
2. Cree JE, Meyer J, Hailey DM. Diazepam in labour: its metabolism and effect on the clinical condition and thermogenesis of the newborn. BMJ 1973;4:251–5.
3. Bavaro JB, Mendoza JL, McCarthy RJ, Toledo P, Bauchat JR. Maternal sedation during scheduled versus unscheduled cesarean delivery: implications for skin-to-skin contact. Int J Obstet Anesth
2016;27:17–24.
Components – Obstetric surgery
• Intra-operative
• Antibiotic prophylaxis
• First generation cephalosporin
• within 60 minutes before incision
• + Azithromycin in suspected contamination
• Skin preparation
• Chlorhexidine based solution (CDC)
• Vaginal preparation with Povidone may be considered
 Components – Obstetric surgery
• Intra-operative
• Regional anaesthesia preferred1,2,3
• Active prevention of hypothermia
• Surgical technique
• Blunt expansion of hysterotomy
• Closure in two layers
• Skin closure with subcuticular sutures

1. Rollins M, Lucero J. Overview of anesthetic considerations for cesarean delivery. Br Med Bull 2012;101:105–25.
2. Afolabi BB, Lesi FE. Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev 2012;10:CD004350.
3. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2012;5:CD003519.
 Components – Obstetric surgery
• Intra-operative
• Neonate management
• Facility for neonatal resuscitation
• Delayed cord clamping1
• Normothermia
• Avoid routine suctioning2
• Room air breathing

1. Delayed umbilical cord clamping after birth. Pediatrics 2017;139:e20170957.

2. Perlman JM, Wyllie J, Kattwinkel J, et al. Part 7: neonatal resuscitation: 2015 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with
treatment recommendations. Circulation 2015;132(suppl1):S204–41.
Components – Obstetric surgery
• Post-operative
• Thromboprophylaxis
• Mechanical preferred over pharmacological
• Early mobilisation
• Removal of indwelling catheters
• Discharge counselling
ERAS for Paediatric Surgery
 Components – Paediatric surgery
• Relatively fewer studies
• Review of fast-track protocols in paediatric surgery1
• Systematic review of 5 studies2
• ERAS programs promising in children
• ERAS protocols in colorectal surgery3

1. Reismann M, von Kampen M, Laupichler B, Suempelmann R, Schmidt AI, Ure BM. Fast-track surgery in infants and children. J Pediatr Surg. 2007;42:234-238.
2. Shinnick JK, Short HL, Heiss KF, Santore MT, Blakely ML, Raval MV. Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res. 2016;202:165-176.
3. Short HL, Heiss KF, Burch K, et al. Implementation of an enhanced recovery protocol in pediatric colorectal surgery. J Pediatr Surg. 2017;118:1131-1136.
Components – Paediatric surgery
• Unique characteristics
• Autonomy
• Consent
• Anxiety
• Altered anatomy & physiology
• Pharmacokinetics & Pharmacodynamics
Components – Paediatric surgery
• Pre-operative
• Information, counselling
• Fasting guidelines
• Carbohydrate loading (10 ml/kg)
Components – Paediatric surgery
• Intra-operative
• Standardised anaesthetic protocol
• GA + RA
• Opioid sparing
• Avoid too deep anaesthesia
• Minimally invasive surgery
• Temperature monitoring
• 36-38ᵒC
Components – Paediatric surgery
• Post-operative
• Avoidance of routine nasogastric intubation
• Avoidance of peritoneal drains
• Remove within 96h if required
• Early removal of indwelling catheters
• Post-operative ileus prevention
Components – Paediatric surgery
• Post-operative
• Nausea & vomiting
• Multimodal prophylaxis regardless of risk factors
Challenges & Future
Challenges & Future
• Translating research to clinical practice
• Fasting guidelines
• Minimally invasive techniques
• Avoidance of sedation
• Nasogastric intubation

• Lack of collaboration among specialties

Challenges & Future
• Resource intensive
• Multidisciplinary collaboration
• Ultimately cost-effective

• Data in paediatric surgery lacking

• Lack of equipoise to perform RCTs
• No specific measures of recovery
Challenges & Future
• Most studies exclude patients with co-morbidities

• Institutional strategies for assessing success

Challenges & Future
• Inclusion of blood transfusion protocols
• Role of post-operative anaemia in recovery

• Role of high dose corticosteroids

• From opioid-sparing to opioid-free

• Procedure-specific protocols
Challenges & Future
• Revisiting end-points
• More focus on post-discharge problems
• Ex: Thromboembolism, delirium, rehabilitation
Challenges & Future
• Perioperative Surgical Home (PSH)
• Care beyond operating room
• Upto 30 days post-operatively
• Additional focus on care processes around surgery
• Institution specific
Summary • Patient/family counselling
• Optimisation & prehabilitation
Pre- • Bowel preparation
• Fasting & carbohydrate loading
oper
ative

• Pre-anaesthetic medication
• Standardised anaesthetic protocol
Intra • Multimodal analgesia & PONV prophylaxis
- • Glycaemic control
• Indwelling tubes
oper
ative

• Early feeding & mobilization

• Multimodal analgesia
Post- • Judicious IV fluid management
• Defined discharge criteria
oper
ative
“Why is the surgical patient in
hospital today?”

-Prof Henrik Kehlet