What is ERAS?
The Enhanced Recovery After Surgery (ERAS) program is a paradigm shift from traditional
perioperative management initiated by Kehlet in 1997[1] as a multidisciplinary approach to the care of the surgical patient.[1]
[2]
[3] The program is based on perioperative medical optimization, including preoperative
counseling, pain relief, carbohydrate loading, thromboembolism prophylaxis, standard
anesthetic protocol and intraoperative fluid, recovery of normal gastrointestinal
function, and early mobilization ([Table 1]). The primary goal of the protocol is to minimize the response to the stress of
the operation by maintaining homeostasis, avoiding catabolism with consequent loss
of protein and muscle strength, and cellular dysfunction.[3]
Table 1
Enhanced Recovery After Surgery (ERAS) program principles
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Enhanced Recovery After Surgery (ERAS) program
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What does it promote?
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Why should it be implemented?
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What is necessary for the implementation?
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– Minimization of the stress response to the operation by controlling the perioperative
physiology
– Operative medical optimization: pre-operative counseling, pain relief, carbohydrate
loading, thromboembolism prophylaxis, standard anesthetic protocol and intraoperative
fluid, recovery of normal gastrointestinal function, and early mobilization
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– Shorter length of hospital stay
– No increase in readmissions and/or reoperations and/or complications rates
– Faster and safer patient recovery
– Improved quality of life and patient satisfaction
– Reduction in overall healthcare costs
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– Program coordinator (doctor/nurse)
– Involvement of all units dealing with the surgical patient
– Multidisciplinary team working together around the patient
– Multimodal approach to resolving issues that delay recovery and cause complications
– Scientific, evidence-based approach to care protocols
– Change in management through interactive and continuous audits
– Whenever possible, minimally invasive surgery
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Source: Adapted from Kehlet (1997)[1] and Carey and Molder (2018).[2]
The main objectives of the ERAS program are to accelerate functional recovery, improve
postoperative outcomes, shorten the length of stay (LOS) in the hospital, reduce the
overall health care costs, and improve the satisfaction of the patients without increasing
complications and/or hospital readmission rates.[4] The ERAS protocols resulted in a 30% to 50% reduction in the LOS and similar reductions
in complications, as well as lower costs and readmission rates.[3] The protocols were developed for colorectal surgery, and variations are being adopted
for surgical procedures of various specialties, including Gynecology.[5]
[6]
The ERAS Society is an international nonprofit professional society that promotes,
develops, and implements ERAS programs, publishes updated guidelines for many operations,
and was officially registered in 2010 in Sweden (http://erassociety.org). Its mission is to develop perioperative care and to improve recovery through research,
education, auditing and implementation of evidence-based practices. Throughout its
history, the ERAS Society has developed and published numerous evidence-based protocols
and implementation programs worldwide to enhance recovery after surgery. This society
conducts structured implementation programs that are currently in use in more than
20 countries. The ERAS Society group published in 2016 the guidelines for pre- and
intraoperative care in gynecologic oncology surgery.[7]
[8] In 2005, the Department of Surgery of The Faculty of Medical Sciences of Universidade
Federal do Mato Grosso, Brazil, adapted the ERAS program to our reality and created
the Accelerating the Total Postoperative Recovery (ACERTO, in the Portuguese acronym)
project. The application of the ACERTO multimodal protocol determined a significant
improvement in morbidity and mortality in general surgery.[9]
Why should an ERAS pathway be adopted in gynecologic surgeries?
Why should an ERAS pathway be adopted in gynecologic surgeries?
Most of the data on the ERAS program that is available in the literature refers to
colorectal surgeries. Variations of the protocol are being adopted for gynecologic
procedures despite the limited population and procedure-specific outcome data.[5] Studies comparing the ERAS program to conventional practices in gynecologic surgery
have shown a faster patient recovery, as well as a significant reduction in the LOS
without an increase in readmission rates and complications in patients submitted to
the practices recommended by the program.[2]
[3]
[4]
[10] In addition, the incidences of urgent clinic and emergency room visits, readmissions,
and reoperations within 90 days of the surgery were similar for patients who were
discharged on the day of the surgery compared with those admitted for more than 24
hours.[11]
Introducing the ERAS protocol for abdominal hysterectomy reduced the LOS without increasing
complications or readmissions.[10] For benign vaginal hysterectomies, ERAS has been associated with a reduction in
the LOS of 51.6%, and it enables more women to be discharged within 24 hours, with
no increase in patient readmissions rates.[12] Establishing the program for vaginal hysterectomy also resulted in a reduction in
costs, coupled with increased patient satisfaction and no rise in morbidity.[13]
In Urogynecology, ERAS implementation has been associated with a greater proportion
of same-day discharges and high patient satisfaction, but with slightly increased
hospital readmissions within 30 days.[5] The implementation of ERAS protocols in gynecologic surgeries has been associated
with a substantial reduction in the administration of intravenous fluids and morphine,
as well as a reduction in the LOS in open procedures associated with improved patient
satisfaction and decreased hospital costs.[14]
Regarding minimally invasive surgeries (MISs), increased American Society of Anesthesiologists
(ASA) physical status, being African American, and increased length of procedure were
significantly associated with readmissions after laparoscopic hysterectomies for benign
and malignant conditions performed following an ERAS pathway.[15] Even in gynecologic oncology MISs in, ERAS is associated with a decreased LOS without
increases in morbidity or readmission rates.[11]
The implementation of ERAS protocols for women undergoing major gynecologic surgery
has been associated with a substantial decrease in intravenous fluid and morphine
administration combined with a reduction in the LOS, improved patient satisfaction,
and decreased hospital costs.[14] Despite the lack of high quality studies evaluating the benefits of enhanced recovery
programs in comparison to conventional care for gynecologic cancer patients, this
approach is considered a safe perioperative management strategy. The LOS is reduced,
without affecting the rates of complications or readmission.[6]
[16]
[17]
[18]
The ERAS principles are applied across all surgical specialties, and ongoing innovation
must continue to enable the processes to improve.[3] A successful ERAS program can lead to a reduction in overall healthcare costs, faster
and safer recovery, and improved quality of life and patient satisfaction. In addition,
for patients with gynecologic cancer, returning to or getting close to the baseline
physiological level enables the accomplishment of the planned adjuvant therapies without
delay, resulting in better oncologic outcomes.[4]
How should an ERAS program be implemented?
How should an ERAS program be implemented?
The essential aspect in changing the practice and implementing an ERAS pathway is
forming a team composed of key individuals from each involved unit.[3] As illustrated in [Table 1], the ERAS program has several principles.[2]
[3] The approach to the care of the surgical patient through the various parts of the
hospital must be multimodal and multidisciplinary.[3] The process of implementation of an ERAS program involves a team consisting of surgeons,
anesthetists, an ERAS coordinator (often a nurse or a physician assistant), nurses,
dieticians, and physiotherapists from units that care for the surgical patient.[3] No single element by itself will improve the outcomes of surgery. Adherence to the
program is crucial, and continuous auditing of the care process enables the team to
have a comprehensive view of the patient outcomes.[3] Minimally invasive surgery is a vital component of an ERAS program, and should be
the preferred surgical approach whenever possible.[2]
The program brings together best practices, organization of care and clinical management.[6] The care protocol is based on published evidence, and it is important to implement
additional changes in light of new evidence. An important goal for the ERAS Society
is to build a network of hospitals around the world. Successful implementation of
an ERAS program requires a multidisciplinary team effort and active participation
of the patient in the goal-oriented functional recovery program.[4] The ERAS program focuses on patients who actively participate in their own recovery
process, and ensures they receive adequate postoperative care.
The implementation ERAS in gynecologic surgery involves four essential stages: the
preadmission, preoperative, intraoperative, and postoperative stages.[2] The strategies include preadmission counseling, avoidance of preoperative bowel
preparation, use of opioid-sparing multimodal perioperative analgesia (including locoregional
analgesia), intraoperative goal-directed fluid therapy, and avoidance of routine use
of nasogastric tubes, drains and/or catheters.[4] Postoperatively, it is important to encourage early feeding, early mobilization,
timely removal of tubes and drains, if present, and opioid-sparing analgesia regimens.
The recommendations of the perioperative enhanced recovery pathway for gynecologic
surgeries are shown in [Table 2].[2]
[4]
[7]
[8]
[17] Smoking and alcohol consumption (alcohol abusers) should cease four weeks before
surgery. Anemia should be actively identified, investigated, and corrected preoperatively.
Mechanical bowel preparation should not be used routinely even when bowel resection
is planned. The intraoperative prevention of intraoperative hypothermia with suitable
active warming devices should be used routinely. Very restrictive or liberal fluid
regimes should be avoided in favor of euvolemia. The intraoperative stage recommendations
include the standard anesthetic protocol, avoidance of nasogastric tubes or removal
at the end of surgery, and infusion of local anesthetic (bupivacaine) in the wound
(deep and superficial injections) prior to closure.[4]
[7]
Table 2
Main recommendations of the perioperative enhanced recovery pathway for gynecologic
surgeries
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Enhanced Recovery After Surgery (ERAS) program recommendations for gynecologic surgeries
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Preadmission stage
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Prevention of complications
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Appropriate preoperative risk stratification, timely risk modification, and medical
optimization have to be performed.
Screen and treat anemia
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Counseling
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Preoperative counseling of patients and caregivers
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Preoperative stage
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Bowel preparation
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Elimination of mechanical bowel preparation and rectal enema for most procedures
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Diet
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No solids after midnight; clear liquid diet 2–4 hours before surgery;
100-g carbohydrate-loaded drink the night before surgery; and a 50-g carbohydrate-loaded
drink 2–4 hours before surgery
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Premedication
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Avoid long- or short-term sedative agents
(Tramadol ER, Pregabalin, Celecoxib, Acetaminophen IV)
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IVF therapy
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Saline lock until going to the OR
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Intraoperative stage
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Analgesia immediately before going to the OR
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Acetaminophen 1,000 mg PO; Gabapentin 600–1,200 mg PO once or Pregabalin 100–300 mg
PO once; Celecoxib 200–400 mg PO once
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Nausea and vomiting prophylaxis
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Scopolamine transdermal patch 2 hours preoperatively; Dexamethasone 4 mg IV once at
induction
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Analgesia
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Total intravenous anesthesia; regional anesthesia if appropriate; Acetaminophen 1,000 mg
IV once (if not oral); local wound infiltration: preincisional or postincisional bupivacaine
hydrochloride or postincision liposomal bupivacaine
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Fluid balance
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Goal-directed fluid therapy with a net zero balance at the end of the surgical case;
Lactated Ringer's over normal saline for electrolyte balance
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Postoperative stage
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IVF therapy
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IVF 40 ml/h; saline lock when tolerating 500 ml oral
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Analgesia
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Opioid-sparing analgesia; Acetaminophen or Ibuprofen; Pregabalin, 75 mg every 12 hours
(for 48 hours)
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Nausea and vomiting management
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Ondansetron 4 mg PO every 6 hours prn nausea and vomiting,
or Prochlorperazine 10 mg IV every 6 hour prn nausea and vomiting
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Diet
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Regular diet on POD0; oral hydration; gum chewing
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Foley catheter
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Remove on POD1
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Activity
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Ambulate 8 times a day; eat all meals sitting in a chair; stay out of bed 8 hours
a day
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Transfusion
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Restrictive; only for hemoglobin level > 7
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Abbreviations: ER, endorectal; IV, intravenous; IVF, intravenous fluids; OR, operating
room; PO, postoperative; POD, postoperative day; PRN, pro re nata (when necessary).
Source: Adapted from Miralpeix et al. (2015);[4] Nelson et al. (2016);[7]
[8] Ljungqvist et al. (2017);[3] and Carey and Molder (2018).[2]
The prophylaxis against thromboembolism includes well-fitting compression stockings
and intermittent pneumatic compression. Extended prophylaxis (28 days) should be given
to patients after laparotomy for abdominal or pelvic malignancies. The key postoperative
protocol elements are early feeding (limiting the administration of intravenous fluids
when the patient tolerates oral intake greater than 500 ml), early mobilization and
opioid-sparing analgesia. A multimodal approach to postoperative nausea and vomiting
with antiemetic agents should be used for patients undergoing gynecologic procedures.
The patient should ambulate 8 times per day, have all meals sitting in a chair, and
stay out of bed at least 8 hours per day.[4]
[7]
Final considerations
The implementation of the ERAS program represents a paradigm change in the perioperative
management of the surgical patient, and is a multidisciplinary approach based on scientific
evidence management.[3] The program is clinically effective and has impacts on the outcomes of the patients,
offering a safe, high-quality and cost-effective/cost-saving perioperative care. Therefore,
the ERAS program should become the standard practice for all women undergoing elective
gynecologic surgeries.[16] Implementation challenges have been attributed to a variety of contextual factors,
such as perceived lack of resources and resistance to change among providers. The
number and combination of ERAS elements varied considerably across the studies. In
Brazil, the challenge is to define strategies to adopt perioperative enhanced recovery
programs in different scenarios. Compliance by the staff and the patients to the protocol
elements of the ERAS is crucial to ensure a well-established and successful program.
