ERAS PROTOCOL

1. ENHANCED RECOVERY
AFTER SURGERY
Presentor : Dr. Vinayshankar, PG
Morderator: Dr. Susruth Maralihalli, Professor
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2. CONTENTS
 HISTORY AND OVERVIEW OF ERAS
 METABOLIC RESPONSES TO SURGERY
 PHASES AND COMPONENTS OF ERAS
 PRE-OPREATIVE CONSIDERATIONS
 INTRA OPERATIVE CONSIDERATIONS
 POST OPERATIVE CONSIDERATIONS
 ERAS IN SPECIFIC SURGERIES
 SETTING UP AN ERAS PROGRAM 2

3. HISTORY AND OVERVIEW
 Professor Henrik Kehlet from Copenhagen, Denmark - founder ERAS
 The ERAS Study Group  founded in 2001 by Professor Ken Fearon and Professor
Olle Ljungqvist.
Primary goal - treat the surgical patient in a multidisciplinary team.
 Multimodal enhanced recovery pathway (ERP) - beneficial effects become synergistic.
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5. METABOLIC RESPONSES TO
INJURY
 Neuroendocrine responses,
stress hormones cascades,
activation of cytokine, and
immune reactions occur.
 Catabolic state in the body.
 Development of insulin
resistance - disrupts many
metabolic pathways.
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6.  Hyperglycemia  Insulin resistance  Glucose production and a decrease in glucose
uptake by the periphery.
Even when insulin levels increase to three times basal levels  no increase in
peripheral glucose uptake.
Hence, in the postoperative fasting state, without the assistance of exogenous insulin,
peripheral glucose uptake is reduced.
 Increased Protein catabolism
 Less Muscle function  Decreased capacity to mobilize
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7. Elective surgery results in a state of insulin resistance.
 Insulin resistance has been shown to be an independent predictor of length of stay.
 Increased postoperative complications - free radical formation.
Leads to alterations in gene expression  propagates a cycle of increased inflammation
causing even more insulin resistance.
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8. GRADED NATURE OF THE INJURY
RESPONSE
 The more severe the injury, the greater the response.
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9.  Applies to immunological changes/sequelae:
 Following elective surgery of intermediate severity, there may be a
transient and modest rise in temperature, heart rate, respiratory rate, energy
expenditure and peripheral white cell count.
 Following major trauma/sepsis, these changes are accentuated, resulting in
a systemic inflammatory response syndrome (SIRS), hypermetabolism,
marked catabolism, shock and even multiple organ dysfunction (MODS).
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10.  Metabolic response - graded, evolves with time.
 Immunological sequelae of major injury evolve from a proinflammatory state
Driven primarily by the innate immune system into a compensatory anti-inflammatory
response syndrome (CARS).
 In patients who develop infective complications  Acute phase response and
continued catabolism.
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11. PHASES AND COMPONENTS
OF ERAS
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14. PREOPERATIVE CONSIDERATIONS
1. Preoperative Optimization
 Preanesthetic and presurgical evaluation by an anesthesiologist associated with improved
outcomes for the efficiency
o Identifying patients at elevated respiratory risk
o 55% decrease in preoperative testing
o 88% reduction in case cancellations
o Reduction in day of surgery delays
o Reduced total length of stay
o A positive impact on hospital finances with cost reduction
o Lower in-hospital mortality. 14

15. 2. Setting Expectations and Patient Education
 Information on the procedure and typical recovery should be clear.
 Clear expectations of goals.
 Expected length of stay and disposition
 The patient must understand that his or her active participation throughout the perioperative
experience will facilitate the recovery.
Patient information material to be at no higher than a sixth grade reading level, friendly,
clear, concise, and simply designed.
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16. 3. Nutrition
 Ensuring preoperative adequate nutrition.
 Enteral or parenteral nutritional supplementation can be considered for the most
nutritionally compromised patient, the enteral route is always preferred.
 Two main approaches to preoperative enteral nutrition include
 Standard oral nutrition supplements - high in protein, contain vitamins and
minerals
 Immunonutrition supplements - addition of arginine and omega 3 fatty acids.
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17. 4.Exercise and Prehabilitation
 Prehabilitation is defined as “the process of enhancing the functional capacity of the individual
to enable him or her to withstand a stressful event.”
 Perioperative cardiopulmonary exercise testing and prehabilitation.
Active exercise  even when suffering from documented coronary artery disease, heart failure,
hypertension, diabetes, chronic obstructive pulmonary disease, depression, dementia, cancer,
and stroke  better outcomes.
 Addition of physical fitness  significantly improved mortality, discharge to home versus a
care facility, and length of stay.
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19. 5.Preoperative Anemia Management
Anemia is one of the commonest modifiable risk factors for patients undergoing major
surgery.
Anemia is a risk factor for all complications and mortality for patients undergoing major surgery
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20. The administration of blood products both pre- and perioperatively to correct anemia is also
a causative factor for complications and impacts long-term survival in patients with cancer.
There is an association between preoperative anemia and:
o In-hospital mortality
o 30-day mortality
o Acute myocardial infarction
o Acute ischemic stroke or central nervous system complications
o Acute kidney injury, renal failure/dysfunction, or urinary complications
Preoperative Interventions to Increase Hemoglobin
 Oral Iron Therapy
 Intravenous Iron Infusions
 Use of Erythropoietin-Stimulating Agents (ESA)
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21. 6.Smoking Cessation
 Tobacco use, especially smoking  increase postoperative mortality.
 Increases postoperative complications including prolonged ventilation, pneumonia,
deep venous thrombosis, wound infection, delayed wound healing, and reduced bone
fusion.
 Carbon monoxide and nicotine  increase heart rate and blood pressure and the
body’s demand for oxygen.
 Nicotine also causes vasoconstriction  Reduced perfusion to many tissue beds.
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22. DURATION OF NICOTINE FREE
DAYS REQUIRED
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23. 7. Preoperative Fasting and Preoperative Carbohydrate Loading
 Pre-operative fasting for 6 to 12 hours was considered previously to reduce the risk of aspiration
of gastric contents during the induction of anesthesia.
 Fasting state  insulin resistance  hyperglycemia  failure to achieve a postsurgical
anabolic state Need for exogenous Insulin
 Recent guidelines - fasting from clear liquids for 2 hours and solid food for 6 hours.
 Preoperative carbohydrate:
oImproves patient nausea and discomfort
oAchieves post operative anabolic state faster
 The most commonly studied carbohydrate loading drink includes 100 g of carbohydrate the
evening prior and 50 g of carbohydrate 2 to 3 hours prior to surgery.
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24. 8.Preoperative Bowel Preparation
 As human feces can have as much as 1012 bacteria/gram, colon surgeries has been
associated with a higher rate of SSI than small bowel and upper GI surgery.
 Mechanical bowel preparation alone is not beneficial prior to colon resection.
 Fluid and electrolyte abnormalities  large volumes of fluid administration during surgery
 subsequent bowel edema and ileus.
 The combination of a mechanical and an oral antibiotic bowel preparation.
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25. INTRAOPERATIVE
CONSIDERATIONS
1. Surgical Considerations
 Prevention of surgical site infection consists of the use of mechanical, chemical, and/or
antimicrobial modalities.
 Mechanical and chemical methods: patient bathing preoperatively and skin preparation.
 Antimicrobial prophylaxis as per guidelines
 Minimally invasive surgical approaches should be considered.
 The use of catheters or drains should be limited unless necessary.
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26. 2. Hypothermia Prevention
 Common perioperative problem.
 90% of all patients undergoing elective surgery suffer from inadvertent postoperative
hypothermia.
 High risk –
oPatients over the age of 60 years
oPatients that have malnourishment
oPreexisting medical comorbidities
oGeneral anesthesia
oMajor long surgery.
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27.  The reasons for hypothermia are multifactorial.
 Radiation accounts for 50% to 70% of heat loss.
 Convection accounts for 15% to 25% of heat loss.
 Evaporation accounts for 5% to 20%
conduction accounts for 3% to 5%.
 Temperature reduction accelerated by:
Cold intravenous fluids
Low operating room temperatures
Decreased thermoregulatory threshold
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28. PREVENTION OF HYPOTHERMIA
 Steps to take to prevent this hypothermia including
 Active, convective heating using clean, filtered, forced-air warming blankets in patients
in the preoperative area (prewarming) and also during anesthesia.
 Thermal insulation.
 Warmer ambient operating room temperatures.
 Warmed irrigation solutions during surgery.
 Warmed infusions and blood products.
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29. 3. Venous Thromboembolism Prophylaxis
 Venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and
pulmonary embolism (PE), is the number one cause of potentially preventable death in common
but preventable causes of morbidity and mortality in the perioperative patient.
 Specific risk factors include:
o Major general, vascular, or orthopedic surgery
o Lower extremity paralysis due to spinal cord injury
o Fracture of the pelvis, hip, or long bones
o Cancer
o Prior VTE
o Age 40 years and higher
o Obesity
o Oral contraceptive use
o Hyper-viscosity syndromes
o Severe cardiopulmonary disease 29

30.  Appropriate VTE prophylaxis
 Nonpharmacologic methods include
oEarly ambulation,
oGraduated compression stockings, and
oIntermittent pneumatic compression devices.
 Pharmacologic methods include the use of
oLow dose unfractionated heparin
oLow molecular weight heparin
oFactor xa inhibitors.
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31. 4. Perioperative Fluid Management.
 More modern goal-directed therapy (GDT) intravenous fluid approaches rely on the use of
advanced medical devices, including esophageal Doppler monitors and other noninvasive
cardiac output or bioimpedence models to determine whether or not patients are “fluid
responsive” during surgery.
Patients randomized to restricted and liberal fluid resuscitation strategies found a clear linear
relationship between total fluids administered (and weight gain) and complications following
colorectal surgery including pulmonary edema and tissue healing complications.
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32.  Goal Directed Fluid therapy, in no way, means reduction in fluid administration.
 Goal directed therapy  maintain zero fluid balance coupled with minimal weight
gain or loss.
Once the patient is able to maintain adequate hydration, supplemental fluids should be
used judiciously
 Based on evidence from several studies, it is better to use a balanced crystalloid such
as Plasma-Lyte, rather than Normal Saline to reduce complications.
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34. 5. Perioperative Pain Management
 According to the International Association for the Study of Pain (IASP) Taxonomy, the
definition of pain is described as “an unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in terms of such damage.”
Elevations in heart rate and blood pressure were treated with opioid medications.
Opioids, reduce pain immediately after administration.
However
oWorsen pain scores after they wear off,
oIncrease nausea and vomiting
oRespiratory depression,
oReduce gastrointestinal motility
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35. ERAS protocols- multimodal analgesia
 Preoperative and postoperative administration of acetaminophen and celecoxib or other
nonsteroidal anti-inflammatory drugs, as well as gabapentin.
Intraoperatively, the utilization of ketamine, lidocaine, and magnesium.
Neuraxial opioid analgesia, can be accomplished by either a single shot (both spinal and epidural)
or catheter-based therapy (epidural).
Also include regional analgesic techniques such as peripheral nerve blocks, paravertebral blocks,
plexus blocks, and local infiltration
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36. POST OPERATIVE
CONSIDERATIONS
1. Postoperative Nausea and Vomiting Prevention
 Postoperative nausea and vomiting (PONV) is very common and can cause significant
distress to patients, with the incidence of vomiting at approximately 30%, nausea at 50%,
and the combination of PONV as high as 80%.
 This could further increase the time to first feeding, which in turn may prolong ileus and/
or hospital stay.
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38. 2. Early Nutrition and Postoperative Ileus Prevention
 Postoperative ileus is the most common cause of prolonged hospital stay and readmissions
following surgery on the digestive tract, occurring in up to 19% of cases.
 Risk factors contribute to postoperative ileus and include:
 Open surgery
 Increased surgery length of time
 Blood transfusion
 Fasting
 Fluid overload
 Opioids
 Postoperative nausea and vomiting
 Other pharmacological agents 38

39.  Nasogastric tubes (NGTs) were previously used prophylactically to prevent ileus, limit distension on the
gastrointestinal anastomosis, as well as to prevent pulmonary complications.
NGT  delays return of gastrointestinal activity and increases pulmonary complications.
 Anesthetic technique can also aid in prevention of postoperative nausea and vomiting.
 Maintenance of normovolemia in the perioperative setting should be achieved as fluid overload and
dehydration both negatively affect return of bowel function, length of stay, and complications.
Chewing gum – sham feeding
Alvimopan – reduction in NGT use, faster return of bowel function & earlier discharge
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40. 3. Mobilization
 Prolonged postoperative bedrest leads to deconditioning, increased deep venous thrombosis risk, and loss
of muscle mass.
 Deterioration of mobility and activities of daily living can be seen in older patients after only 2 days of
hospitalization.
 Patients that begin a preoperative exercise program are more active postoperatively and have a faster
return to baseline exercise capacity when compared to patients undergoing a postoperative exercise
program.
However, compliance with this is highly variable.
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41. ERAS IN SPECIFIC SURGERIES
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42. ERAS IN COLORECTAL SURGERY
 First ERAS guidelines developed in 2012
 In 1997, Henrik Kehlet published the initial series of patients, applying novel perioperative care
strategies to colon resection patients.
 Demonstrated that the principles
Elucidated reduction in complications
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43.  Attenuation of TNF-α, IL-1β, IL-6, and IFG-γ and no increase in cortisol levels.
Meta-analyses and systematic reviews demonstrate less opioid use, shorter length of stay,
decreased morbidity, and no increase in readmission rates for laparoscopic or open colon or
rectal resections
ERAS is inversely related to length of stay postoperatively in colorectal surgery.
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44. ERAS IN
HEPATOPANCREATICOBILIARY
SURGERY
 ERAS protocol in 61 consecutive patients undergoing liver resection
 92% of patients tolerating a diet on postoperative day 1
 Reduction in length of stay from 8 to 6 days
 No increased readmissions or morbidity.
 ERAS patients also reported improved quality of life over controls.
 Patients undergoing pancreaticoduodenectomy often have high rates of delayed gastric
emptying; the use of ERAS has reduced the incidence of delayed gastric emptying by nearly
half, thus allowing earlier feeding in this complex patient population.
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45. ERAS IN GASTRECTOMY AND
ESOPHAGECTOMY
 Patients undergoing foregut surgery have notoriously been subjected to prolonged periods of
nasogastric tube decompression and resultant starvation.
Randomized controlled trials demonstrate that removal of the nasogastric tube in the operating
room and early feeding, as components in an ERAS program, result in
 Shorter length of stay
 Fewer grade III or higher postoperative complications
 Faster return to baseline weight and functional status
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46.  In 2014, consensus guidelines for ERAS after gastrectomy were published,
 No routine use of nasogastric decompression
 Early feeding within the first postoperative day
 Early consideration for nutritional support if the patient is malnourished or unable to maintain at least
60% of caloric requirement
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47. ERAS IN OTHER SURGICAL
SPECIALTIES
 Open large ventral hernia repair with varying techniques of abdominal wall
reconstruction including myofascial release
 Complex urological procedures such as radical cystectomy
 Minimally invasive and open complex cytoreductive gynecological oncology surgery
 Total joint replacement surgery in orthopedics
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48. SETTING UP AN ERAS
PROGRAM
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50. REFERENCES
BAILEY AND LOVE’S SHORT PRACTICE OF SURGERY 27TH EDITION
SABISTON TEXTBOOK OF SURGERY 21ST EDITION
SCHWARTZ TEXTBOOK OF SURGERY 11TH EDITION
A COMPLETE GUIDE TO ERAS FOR OPTIMIZING OUTCOMES 1ST
EDITION 2020
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51. THANK YOU
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