ERAS-Enhanced Recovery After Surgery-Pathways To Expedite & Enhance Recovery

American College of Osteopathic Obstetricians and Gynecologists
The 87th Annual Conference
The Right Care for Every Woman

March 29-April 3, 2020 l Hilton Torrey Pines l La Jolla, CA
ERAS-Enhanced Recovery After

Surgery-Pathways to Expedite
& Enhance Recovery
Eric J. Carlson, DO, MPH, FACOOG
Axia Women’s Health Care
Clinical Associate Professor
Departments of Obstetrics & Gynecology
Philadelphia College of Osteopathic Medicine, and
Sidney Kimmel College of Medicine-
Thomas Jefferson University
carlsone@mlhs.org
ERAS-What is it?
• ERAS is a multimodal, multidisciplinary approach to the care of the
surgical patient to accelerate postoperative convalescence and reduce
general morbidity;
• ERAS process implementation involves a team consisting of surgeons,
anesthestists, an ERAS coordinator and staff from units that care for the
surgical patient;
• The care protocol is based upon evidence;
Enhanced Recovery After Surgery-A Review. Ljunqvist O, Scott M, Fearon KC. JAMA Surg. 2017;152(3):292-298.
Dtsch Med Wochenschr. 2005 Mar 11;130(10):536-40. {article in German}
American College of Osteopathic Obstetricians and Gynecologists l The 87th Annual Conference l March 29-April 3, 2020 l La Jolla, CA
Dr. Henrik Kehlet
University of Copenhagen
Copenhagen, Denmark
Research Interests include the surgical

stress response and nutrition in the
surgical patient
Developed the concept of

“Fast Track Surgery”
and “Multimodal Surgical Care”
Dr. Kehlet hypothesized…
• Undergoing surgery was akin to running a marathon, and starving a person prior
to surgery (NPO) increased the stress response of surgery, dehydration and
prolonged the postoperative recovery;
• Increased administration of intraoperative crystalloids adversely affects GI
glycocalyx and inhibits post op GI function;
• Increased intraoperative crystalloids results in interstitial edema, decreased
oxygen delivery to tissues, and hemodilution, which weakens the patient postop,
inhibiting movement, further impairing postoperative “GI recovery”;
• “Opiate-heavy” anesthesia increases postoperative constipation, nausea,
sedation…resulting in impaired GI function, less postoperative movement and
cognitive impairment;
• Larger surgical incisions increase postoperative pain and the “medical culture”
responds by increasing opiates, prolonging inactivity and thereby impairing GI
recovery and increasing risk for thromboembolic event;
Dr. Kehlet hypothesized the following will improve/hasten recovery
and decrease LOS:
• Optimize intraoperative fluid management

• Smaller surgical incisions and improved surgical technique
• Optimize hemodynamics
• Prevent postoperative nausea/vomiting
• Regional and/or local anesthesia if possible
• Opiate-sparing postoperative pain management
• Avoid NPO prior to surgery and initiate diet soon after surgery
• Ambulate postoperatively “soon and often”
• Team-based approach with constant team-member communication
British Journal of Anaesthesia
1997; 78:606-617
66
British Journal of Anaesthesia

1997; 78:606-617American College of Osteopathic Obstetricians and Gynecologists l The 87th Annual Conference l March 29-April 3, 2020 l La Jolla, CA
Members of the Original Enhanced Recovery
After Surgery Study Group-Formed 2001
The surgery process is inherently vulnerable to “silo management”-one care provider in the process is unaware of what
other care providers are doing.
Enhanced Recovery After Surgery-A Review. Ljunqvist O, Scott M, Fearon KC. JAMA Surg. 2017;152(3):292-298.
EnhancedAmerican College of Osteopathic Obstetricians and Gynecologists
Recovery After Surgery-A Review. Ljunqvist O, Scott M,th Fearon
l The 87 KC. JAMA
Annual Conference Surg. 2017;152(3):292-298.
l March 29-April 3, 2020 l La Jolla, CA
Enhanced Recovery After Surgery-A Review. Ljunqvist O,l Scott
American College of Osteopathic Obstetricians and Gynecologists The 87thM, Fearon KC. JAMA
Enhanced Recovery After Surgery-A Review. Ljunqvist O,l The 87
American College of Osteopathic Obstetricians and Gynecologists ScottthM, Fearon KC. JAMA
ERAS
Improving Perioperative Care Worldwide
Sankt Eriksgatan 117
SE-113 43 Stockholm
Sweden
ERAS SOCIETY Guidelines/Best Practices:
• Pancreatoduodenectomy • Breast Reconstruction
• Cesarean Section • Head and Neck Cancer Surgery
• Total Hip/Knee Replacement • Liver Surgery
• Cardiac Surgery • Bariatric Surgery
• Gynecologic Surgery • Elective Rectal/Pelvic Surgery
• Elective Colorectal Surgery • Elective Colonic Surgery
• Lung Surgery • Radical Cystectomy-bladder CA
• Esophagectomy • Gastrectomy
• Gastrointestinal Surgery
• The ERAS Study Group determined that perioperative care, rather than
the actual operation, dictated the patient’s outcome.
NygrenJ,HauselJ,KehletH,etal. A comparison in five EuropeanCentres of case mix, clinical management and outcomes
following either conventional or fast-track perioperative care in colorectal surgery. ClinNutr.2005;24(3):455-461.
Fearon KC, Ljungqvist O, Von Meyenfeldt M, Et al. Enhanced recovery after surgery: a consensus review of clinical care for
patients undergoing colonic resection. Clin Nutr 2005; 24: 466-477.
Enhanced Recovery After Surgery
• Discussing Cesarean Section as a model to explain ERAS
Checklist for Focused ERAS-Cesarean
Informed Knowledge- The patient should have a clear understanding of:
• 1- reason/indication for the cesarean section;

• 2- the location and type of abdominal laparotomy incision;
• 3- abdominal skin incision closure type to be used by attending;
• 4- preventative efforts to be used to minimize infection;
• 5- patient’s individualized post-op risk for thromboembolism;
• 6- plans for oral intake for pre- & post time periods;
• 7- anticipated postoperative activities and locations of mother & baby
Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society
Recommendations (Part 1). Wilson RD, Caughey AB, Wood
American College of Osteopathic Obstetricians and Gynecologists SL,
l The 87 th et al. AJOG; December 2018:523-530
Annual Conference l March 29-April 3, 2020 l La Jolla, CA
ERAS Cesarean Delivery Elements-
Preoperative
• Anesthetic medications
• Fasting
• Carbohydrate supplementation
• Antimicrobial prophylaxis
• Skin wash/vaginal preparation to minimize infectious risk
• Procedures for prevention of intraoperative hypothermia
Intraoperative
• Pre- and intraoperative anesthetic management;
• Abdominal/vaginal antimicrobial cleansing;
• Cesarean delivery surgical techniques (opening-delivery-closure);
• Perioperative fluid management;
• Neonatal immediate care/delayed cord clamping
Postoperative
• ERAS sham feeding/chewing gum
• Nausea and vomiting management
• Analgesia
• Perioperative nutritional care/early feeding
• Glucose control
• Thromboembolism prevention
• Early mobilization
• Urinary drainage management
ERAS Cesarean Delivery Elements
• Maternal and neonate discharge
• instructions
Antenatal Pathway
Cesarean Section
Preadmission Information/Education/Counseling
• What happens before, during and after cesarean delivery?
Elective Cesarean-detailed discussion of risks/benefits:

• Mom
• Baby
• What are we getting ourselves into?
Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society
Recommendations (Part 1). Wilson RD, Caughey AB, Woodl SL,
American College of Osteopathic Obstetricians and Gynecologists etthal.
The 87 AJOG; December
Annual Conference 2018:523-530
Antenatal Pathway
Cesarean Section
Preoperative Maternal Comorbidity Optimization
• Maternal Obesity (BMI > 40 Kg/m2)

• Increases the risk for maternal/fetal complications
• Optimal gestational weight gain management
• Surgical complexity requires multidisciplinary planning
• Optimal Goal: Implement preconceptional weight loss strategy

• Behavioral Changes (diet, portion-control, exercise)
• Bariatric Surgery
Antenatal Pathway
Cesarean Section
• Control Maternal Hypertension
• uncontrolled maternal hypertension significantly increases

maternal and fetal morbidity
• uncontrolled maternal hypertension significantly increases

cesarean section
Antenatal Pathway
Cesarean Section
• Maternal Gestational Diabetes significantly increases the risk for

maternal and fetal morbidity
• Maternal Diabetes should receive timely and effective

management during preconception and pregnancy
Antenatal Pathway
Cesarean Section
• Maternal anemia
• Low Birthweight
• Preterm Birth
• Increased perioperative morbidity and mortality
{the etiology of the anemia should be identified and corrected}
Antenatal Pathway
Cesarean Section
• Maternal cigarette smoking

• low birthweight
• stillbirth
• impaired wound healing
{Smoking Cessation implemented before or in early pregnancy}
Antenatal Pathway
Cesarean Section
Preadmission Information/Education/Counseling
• What happens before, during and after cesarean delivery?
Elective Cesarean-detailed discussion of risks/benefits:

• Mom
• Baby
• What are we getting ourselves into?
Preoperative Pathway
Cesarean Section
Preanesthetic Medications
• 1- Antacids
• 2- Histamine H2 Receptor Antagonist
• {to reduce the risk for aspiration pneumonitis}
• [Avoid preoperative sedation for scheduled cesareans]
Cesarean Section
Preoperative Bowel Preparation
• Oral or Mechanical Bowel Preparation should NOT be used before

Cesarean Delivery
Cesarean Section
Preoperative Fasting
• Women should be encouraged to drink clears (pulp-free juice,

coffee, or tea without mild) until 2 hours before surgery
• A light meal may be eaten up to 6 hours before surgery
Cesarean Section
Preoperative Carbohydrate Supplementation
• Oral carbohydrate fluid supplementation, 2 hours before cesarean

section, may be offered to diabetic women
Intraoperative Pathway
Cesarean Section
Preoperative Antimicrobial Prophylaxis
• IV cephalosporin (1st gen) within 60 minutes of the skin incision
• Add Azithromycin (labor; ruptured membranes) to reduce risk for
post op infection
Preoperative Skin Preparation

• Chlorhexidine-alcohol >> Povidone-Iodine soln for skin cleansing
Vaginal prep with Povidine-Iodine soln to reduce post-op infection

Guidelines for Intraoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society
Recommendations (Part 2). Caughey AB, Wood SL, Macones,
American College of Osteopathic Obstetricians and Gynecologists G et thal.
l The 87 AJOG; December
Annual Conference 2018:523-530
Cesarean Section
Pre- and Intraoperative Anesthetic Management
• Regional Anesthesia is preferred for C/S for ERAS protocol
Prevent Hypothermia
• Monitor patient, apply warming device
• Forced air warming
• Intravenous fluid warming
• Increasing OR temperature
Intraoperative Care
Cesarean Section
Surgical Techniques/Considerations
• Blunt expansion of transverse hysterotomy to reduce EBL

• Closure of the hysterotomy in 2 layers may lower rate of rupture
• Peritoneum closure increases operative time without benefit
• In women with > 2 cm of subcutaneous tissue, close the space
• Opt for suture over staples for skin closure
Cesarean Section
Perioperative Fluid Management
• Perioperative and intraoperative euvolemia are important

factors in patient perioperative care and appear to lead to
improved maternal and neonatal outcomes after cesarean
section
Cesarean Section
Neonate Pathway
• Delayed cord clamping for at least 1 minute for term delivery
• Delayed cord clamping for at least 30 seconds for preterm birth
• Body temp should be measured and maintained between
36.5oC and 37.5oC after birth until stabilization
• Avoid routine suctioning of airway and gastric aspiration
• The capacity for immediate neonatal resuscitation is mandatory
• Routine neonatal supplementation with room air over inspired
air with O2
Postoperative Pathway
Cesarean Section
Chewing gum after cesarean section
Nausea and vomiting prevention
• Fluid preloading, IV ephedrine/phenylephrine, and lower limb
compression reduce hypotension & intraop and postop N/V
• Antiemetic agents
Postoperative Analgesia
• multimodal agents include NSAIDs and paracetamol
Guidelines for Postoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations
(Part 3). Macones G, Caughey AB, Wood SL, et al. AJOG; December
American College of Osteopathic Obstetricians and Gynecologists 2018:523-530.
l The 87th Annual Conference l March 29-April 3, 2020 l La Jolla, CA
Cesarean Section
• Perioperative Nutritional Care
• a regular diet within 2 hours after cesarean section is suggested
• Perioperative Glucose Control

• tight control of capillary blood glucose is recommended
• Prophylaxis against VTE

• Pneumatic compression stockings
• Heparin VTE prophylaxis should not be routinely used
Cesarean Section
Early Post-Cesarean Delivery Mobilization
• Early mobilization after cesarean is recommended
Post-Cesarean Delivery Urinary Drainage

• Urinary catheter should be removed immediately post-op
Cesarean Section
Postoperative/Postpartum Mother Pathway
• Discharge Counseling
THE END
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American College of Osteopathic Obstetricians and Gynecologists

The 87th Annual Conference

The Right Care for Every Woman

ERAS-Enhanced Recovery After

Research Interests include the surgical

Developed the concept of

• Optimize intraoperative fluid management

British Journal of Anaesthesia

• 1- reason/indication for the cesarean section;

Elective Cesarean-detailed discussion of risks/benefits:

• Maternal Obesity (BMI > 40 Kg/m2)

• Optimal Goal: Implement preconceptional weight loss strategy

• Control Maternal Hypertension

• uncontrolled maternal hypertension significantly increases

• uncontrolled maternal hypertension significantly increases

• Maternal Gestational Diabetes significantly increases the risk for

• Maternal Diabetes should receive timely and effective

{the etiology of the anemia should be identified and corrected}

• Maternal cigarette smoking

{Smoking Cessation implemented before or in early pregnancy}

Elective Cesarean-detailed discussion of risks/benefits:

• [Avoid preoperative sedation for scheduled cesareans]

• Oral or Mechanical Bowel Preparation should NOT be used before

• Women should be encouraged to drink clears (pulp-free juice,

• A light meal may be eaten up to 6 hours before surgery

• Oral carbohydrate fluid supplementation, 2 hours before cesarean

Preoperative Skin Preparation

Vaginal prep with Povidine-Iodine soln to reduce post-op infection

• Blunt expansion of transverse hysterotomy to reduce EBL

• Perioperative and intraoperative euvolemia are important

• Perioperative Glucose Control

• Prophylaxis against VTE

Post-Cesarean Delivery Urinary Drainage

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