Enhanced Recovery After Surgery (ERAS)

Updated: Feb 23

If you’re contemplating surgery or have scheduled a surgical procedure it’s likely that you having been searching the intranet looking for the latest and greatest pearls about surgery and anesthesia. It’s also likely that you have seen the buzz-phrase “Enhanced Recovery After Surgery (ERAS)” and may wonder what’s this all about?

Enhanced Recovery After Surgery@ is a set of guidelines that use evidence-based practices to improve your recovery time after surgery.

We refer the interested reader to these 2 official sites:

www.ERASsociety.org

www.Erasusa.org

For anesthesiologists, ERAS has several pillars that include: a) allowing patients to drink carbohydrate solutions up to 2 hours prior to surgery (a safe time window), b) pre-operative pain medications, c) multi-modal pain therapy during the intra-operative period to minimize opiate usage and, finally, d) specific guidelines for fluid management.

A basic over-view of ERAS from an anesthesiologist’s perspective, relative to best patient care includes:

Drinking Carbohydrate-Containing fluids prior to surgery: historical dogma has been that patients should not eat or drink anything or 10-12 hours before their surgery. Many patients arrive for surgery feeling weak, nauseous, hungry, anxious and even angry. It’s not uncommon for patients to reports having headaches from lack of food and caffeine.

Studies have suggested that it is safe to consume clear liquids up to 2 hours prior to anesthesia.

Our experience is that when patients are allowed to consume carbohydrate (CHO) containing clear liquids, (sports drinks, black coffee, tea, clear juices) they arrive for surgery feeling much better. Some anecdotal data suggest that the incidence of nausea and vomiting is less among patients that are allowed to drink CHO-fluids.

Pre-operative Analgesia: Animal models have shown that if pain pathways are inhibited before a painful stimulus is applied, (e.g. before surgical incision), post-operative pain maybe reduced, thereby requiring less pain medicine.

Replicating these findings in human surgical patients has been difficult but, in general, we believe that there is a benefit to administering analgesic medication pre-operatively. Most commonly, this include acetomenophen (Tylenol), gabapentin and a COX2 inhibitor.

Regional Anesthesia/Nerve Blocks: The widespread availability of ultrasound technology allows anesthesiologists to precisely block major nerves to the arms, legs and abdominal wall using long-acting anesthetics and thereby block manor pain transmission pathways. Many orthopedic procedures can be done with a nerve block without the need for general anesthesia. In many cases, nerve blocks can be and adjunct to general anesthesia and greatly reduce post-operative pain and opiate usage.

Multi-Modal Intraoperative Analgesia: There is a world-wide movement to reduce opiate usage both intra-operatively and post-operatively. This is accomplished by substituting other categories of pain medications in place of opiates. These include: ketamine, dexmedotomidine, ketorolac and lidocaine.

Improved Fluid Management. During surgery, the body loses fluid due to blood loss, evaporation, edema and urine production. These fluids are typically replaced lactated ringers solution that is an simple electrolyte solution. There is no formal consensus on the amount of fluid to administer during surgery. It is known, however, that too much or too little fluid resuscitation can lead to worse outcomes. New classes of hemodynamic monitors are available to guide fluid management and their use is associated with more precise fluid administration and improved outcomes.

Surgical ERAS practices:

Early Ambulation: Almost all surgeons want patients up and walking on the day of their surgery. Prolonged bed rest increases the risk of blood clots (deep vein thrombosis, DVT) in the leg which can dislodge and travel to the lung where they can cause life threatening complications. DVTs are one fo the major cause of post-operative complications. Similarly, lack of activity can redispose patients to pneumonia and muscle wasting.

Early Oral Intake: It was common for patients to be told not to eat for days after surgery. This lack of nutrition delayed wound healing and contributed generalized weakness following surgery. Current thinking is to promote early food intake (within reason) to maintain gut function and provide nutrient to support would healing. You may be given a small nutrition shake the evening of your surgery. The sooner your

Infection Control: Post-operative wound infections and bladder infections are the #1 post-operative complications. Judicious use of anti-biotics during surgery along with reduced use or early removal of drains and urinary bladder catheters has greatly reduced the risk of infections.

Hope this was helpful. Ask your anesthesiologist what ERAS components he/she endorses.

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