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ERAS Overview

• ERAS (Enhanced Recovery After Surgery) is a system based on evidence-based interventions, assessed by measuring outcomes and improving compliance through feedback loops.
• It involves a team approach including surgeons, anaesthetists, nurses, hospital administrators, and funders.

ERAS Guidelines for Perioperative Care

Preoperative

• Preoperative preparation and counselling
• Curtailed fasting
• Preoperative supply of carbohydrate drinks
• No bowel preparation
• Prophylaxis of thromboembolic complications
• Antibiotic prophylaxis

Intraoperative

• Preferences for laparoscopy or short transverse incisions
• Avoidance of post-operative drains
• Short-acting anaesthetics and analgesics
• Prevention of hypothermia
• Epidural anaesthesia
• Restricted sodium and fluids
• Prevention of postoperative nausea and vomiting

Postoperative

• Early removal of urinary catheter
• Non-opioid analgesics
• Stimulation of bowel motor activity
• No nasogastric tubes
• Early enteral nutrition
• Evaluation of treatment outcomes
• Surrogate markers for outcome:
  • Early recovery = Discharge from Recovery Room
  • Intermediate outcome = Days in hospital
  • Late outcome = Return to baseline function

Role of Anaesthesiologist

Anaesthetist’s Role in an ERAS Programme

Preoperative

• Pre-operative assessment clinics
• Cardio-pulmonary exercise testing
• Pre-habilitation
• Starvation

Intraoperative

• Goal-directed fluid therapy
  • Monitors
  • Fluids
• Analgesia
• Avoid hypothermia
• Anti-emesis
• DVT prophylaxis

Postoperative

• Managing:
  • Pain
  • Nausea and vomiting
  • DVT/early mobilization

Preoperative Interventions

Pre-operative Assessment Clinics

• Established in many countries to risk stratify patients.
• Address co-morbidities through timely multidisciplinary discussion.

Cardio-pulmonary Exercise Testing

• Determine anaerobic threshold to risk stratify patients.
  • Consider alternatives (e.g., neoadjuvant radio/chemo therapy) if risks are high.
• Assess the effects of pre-habilitation and neoadjuvant therapy on cardiopulmonary reserve.

Starvation

• Avoid long starvation periods (not more than 8 hours).
• Provide clear fluids up to 2 hours pre-surgery.
• Offer carbohydrate-rich fluids to reduce insulin resistance.

Intraoperative Interventions

Antibiotic Prophylaxis

• Single dose administration.

Avoid Hypothermia

• Decrease surgical site infection, coagulopathy, stress response, and cardiac morbidity.
• Maintain body temperature above 36°C using oesophageal temperature measurement and forced-air warmers.

Goal-Directed Fluid Therapy (GDFT)

• Context-sensitive fluid administration for optimal balance.
• Avoid too much or too little fluid to prevent gut ischaemia or delayed function and complications.
• Utilize noninvasive cardiac output monitors for targeting fluid administration.

Evidence:

• GDFT has shown benefits over standard treatment, especially in higher-risk patients or major surgeries.

Analgesia

Epidural

• Consider risks vs benefits for individual patients and surgery type.
  • Alternatives: paravertebral blocks, abdominal wall blocks (TAP, rectus sheath), wound infiltration catheters.

Advantages:

• Attenuates stress response, improves pulmonary and gut function, reduces thromboembolic events, and minimizes blood loss.

Disadvantages:

• Significant failure rate, hypotension, neurological injury, and resource intensiveness.

Systemic Drugs

• Paracetamol: IV preferred over oral; rectal is unpredictable.
• NSAIDs: Short-term use to reduce opiate requirements; cautious use in elderly and those with renal impairment.
• NMDA-R antagonists: Ketamine and magnesium for pain reduction.
• GABA analogues: Gabapentin or pregabalin preoperatively.
• Intravenous lignocaine: Reduces opioid requirement and postoperative complications.

Procedure-specific Analgesia:

• Colorectal: Thoracic epidural, TAP blocks, paracetamol, NSAIDs, ketamine.
• Hepatobiliary (liver resection): Pregabalin/gabapentin, thoracic epidural, spinal morphine, subcostal TAP blocks.
• Oesophagectomy: Thoracic epidural or paravertebral block with catheter.
• Major Gynaecological: Epidural anaesthesia, spinal morphine, TAP blocks, LA infiltration with wound catheters.
• Major Urological: Pregabalin, thoracic epidural, intrathecal morphine, paracetamol, NSAIDs, ketamine.
• Orthopaedics (Total Hip Replacement): Gabapentin, dexamethasone, ketamine, spinal morphine, paracetamol, oxycodone, tramadol, COX-2 inhibitors, fascia-iliaca block.
• Total Knee Replacement: Pregabalin, intrathecal morphine, NSAIDs, paracetamol, ketamine, periarticular injection, peripheral nerve blocks.

ERAS for Colorectal Surgery

Detailed Flow Diagram for ERAS

Role of Primary Care

• Shared decision making clarifying treatment options
• Optimising pre-operative haemoglobin levels
• Managing pre-existing comorbidities
• Discharge planning and liaising with social care

Patient Preparation

• Shared decision making
• Optimised health/medical condition
• Informed and shared decision making
• Pre-operative health and risk assessment
• PT information and expectation management
• Discharge planning (expected date of discharge)
• Pre-operative therapy instruction as appropriate

Admission

• Admission on the day of surgery
• Optimising fluid hydration
• CHO loading
• Reduced starvation
• No/reduced oral bowel preparation (bowel surgery)

Intraoperative

• Minimally invasive surgery
• Use of transverse incisions (abdominal)
• No NG tube (bowel surgery)
• Use of regional/LA with sedation
• Epidural management (including thoracic)
• Optimise fluid management technologies to deliver individualised goal-directed fluid therapy

Postoperative

• Planned mobilisation
• Rapid hydration and nourishment
• Appropriate IV therapy
• No wound drains
• No NG tube (bowel surgery)
• Catheters removed early
• Regular oral analgesia
• Paracetamol and NSAIDs
• Avoidance of systemic opiate-based analgesia where possible or administered topically

Post Discharge Care

• Discharge when criteria met
• Therapy support (stoma, physio)
• 24-hour telephone follow-up

Head and Neck ERAS

Item	Recommendation	Evidence	Recommendation
Preadmission education	All patients undergoing major head and neck cancer surgery with free flap reconstruction should receive structured teaching from a qualified health practitioner.	Low	Strong
Perioperative nutritional care	Patients undergoing major surgery for head and neck cancer should undergo preoperative comprehensive nutritional assessment, with a special focus on dysphagia and risk for refeeding syndrome. Preoperative nutrition intervention is recommended for those at risk.	High	Strong
	A standard polymeric enteral nutrition formula should be considered suitable for use in patients requiring perioperative nutrition support.	Low	Weak
	A standard polymeric enteral nutrition formula should be used for oral intake and/or tube feeding in patients requiring perioperative nutrition support. There is insufficient evidence to support the use of other specialized formulas.	Moderate	Conditional
	Preoperative screening and management for the risk of refeeding syndrome should be conducted for appropriate candidates. Fluids should be preferred for up to 2 hours prior to induction of anesthesia, and clear fluids up to 3 hours prior.	High (fluids), Low (solids), Moderate (CHO)	Strong (fluids), Strong (solids), Strong (CHO)
	Oral diet is the first choice for all patients tolerating it. In patients for whom oral feeding cannot be established postoperatively tube feeding should be initiated within 24 hours. Nutrition interventions should be developed in consultation with the multidisciplinary team and individualized according to nutritional status and surgical procedure.	Moderate	Strong
Prophylaxis against thromboembolism	All patients undergoing head and neck surgery with free flap reconstruction, are at increased risk of thromboembolism, and prophylaxis is recommended. The risk of bleeding must be weighed against the benefits on an individualized basis.	High	Strong
Antibiotic prophylaxis	Antibiotic prophylaxis should be administered for patients undergoing head and neck cancer surgery with free flap reconstruction and should begin 1 hour prior to the procedure and continued for 24 hours.	High	Strong
Postoperative nausea and vomiting prophylaxis	Patients undergoing major head and neck cancer surgery should receive preoperative and intraoperative prophylaxis against postoperative nausea and vomiting. A combination of agents targeting different pathways should be used.	High	Strong
Standard anesthetic protocol	Local anesthetics should act synergistically, given intravenously and titrated to required effect. Postoperative and adjuvant analgesia should be used.	Low	Strong
	The anesthetic protocol should not only prevent awareness but also minimize adverse effects on the cardiovascular system, maintain metabolic and electrolyte balance, and prevent complications such as hypothermia.	Low	Strong
Preventing hypothermia	Normothermia should be maintained intraoperatively. Temperature monitoring is necessary.	High	Strong
Perioperative fluid management	Intravenous fluids should be managed in a goal-directed manner, avoiding over and under hydration.	Moderate	Strong
Routine postoperative ICU admission	Routine intensive care unit admission to facilitate an immediate postoperative period of deep monitoring and the initiation of early physiotherapy is advised. For high-risk patients, ICU admission should be individualized according to the extent of surgery. A subset of patients may be monitored in an extended recovery unit or specialist ward providing adequate skilled nursing and medical coverage.	Low	Weak
Pain management	Multimodal analgesia, including NSAIDs, COX inhibitors, and paracetamol, are preferred for patients undergoing head and neck cancer surgery. Patient-controlled analgesia (PCA) should be used for immediate analgesia and as a bridge to oral analgesia.	High	Strong
Postoperative flap monitoring	Free flap monitoring should be performed at least hourly for the first 24 hours postoperatively. Monitoring should continue beyond this period as clinically indicated. Early signs of impending flap compromise should prompt immediate surgical intervention. Adjunct monitoring techniques should be considered.	Moderate	Strong
Postoperative physiotherapy	Physiotherapy should commence within the first 24 hours if surgery is recommended for patients undergoing major head and neck cancer surgery.	Moderate	Strong
Postoperative wound care	Vacuum-assisted closure may be considered for complex cervical wounds.	Low	Weak
Postoperative wound care	Patients with hydrocolloid dressings should be used for skin graft donor site treatment.	Low	Weak
Urinary catheterization	Urinary catheters should be removed as soon as the patient is able to void, ideally less than 24 hours after the completion of surgery.	Low	Weak
Tracheostomy care	Cuff deflation after tracheostomy and stoma is closure is recommended.	High	Strong
Postoperative pulmonary physical therapy	Pulmonary physical therapy should be initiated as early as possible after head and neck reconstruction to avoid pulmonary complications.	High	Strong

Links

• Lower GIT surgery
• Liver resection
• Joint replacement
• Stress response

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References:

1. Horosz B, Nawrocka K, Malec-Milewska M. Anaesthetic perioperative management according to the ERAS protocol. Anaesthesiology Intensive Therapy. 2016;48(1).
2. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
3. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/
4. Enhanced recovery after surgery.] Anaesthesia Refresher Course – 2015 University of Cape Town Dr Martin Nejthardt
5. Dunkman, W. J. and Manning, M. W. (2018). Enhanced recovery after surgery and multimodal strategies for analgesia. Surgical Clinics of North America, 98(6), 1171-1184. https://doi.org/10.1016/j.suc.2018.07.005

Summaries:
Fast-track anaesthesia

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