Enhanced Recovery After

Surgery (ERAS)
Dr. Sabreen Binta Shaheen
Honorary Medical Officer
General Surgery
Chattagram Maa-Shishu O General Hospital
It is an evidence based multimodal interventions
under a single programme, applied to the care of
the surgical patient in the periopertive period.
• Initially developed for colorectal surgery
• Targeted at impact of surgery on the metabolic & endocrine
response
• Reduces complications without a rise in re-admission
• Nutrition & fluid management plays a central role in ERAS
WHY IMPLEMENT ERAS?
• 35%-40% reduction in length of hospital stay
• Fall in surgical,as well as non-surgical complications in post operative
period
• It has also been associated with an earlier return to work &
productivity
Components Of ERAS
• Pre-operative
• Intra-operative
• Post-operative
Component of ERAS
• Preoperative
1. Pre- admission counselling
2. No prolonged fasting
3. Carbohydrate loading
4. No/selective bowel preparation
5. Antibiotic prophylaxis
6. Thromboprophylaxis
Intraoperative
1. Standardized anaesthetic protocol
2. Intraoperative fluid management
3. Minimaly invasive surgery
4. Avoid Intraperitoneal drain
5. Avoid routine use of NG tubes
6. Prevent hypothermia
Postoperative
1. Early oral nutrition
2. Early mobilization
3. Early urinary catheter removal
4. Stimulate gut motility
5. Use of Non-opioid oral analgesic
Preoperative education
• Patient Counselling
1.Regarding details of surgical & anesthetic procedure
2. Indications and contraindications for surgery
3. Smoking and alcohol cessation:at least 1 month before surgery
4. Supportive pharmacological intervention
• No preoperative fasting :
Solids until 6 h before induction and clear liquids until 2 h before induction for
elective surgery assuming no contraindications (e.g., gastroparesis, bowel
obstruction)
Prolonged Fasting-depleted glycogen storage-insulin resistance -&
hyperglycemia –post operative complications & morbidity
Perioperative fluid management:
The goal of perioperative fluid management is to maintain normovolemia and optimize
tissue perfusion and oxygenation. Individual goal-directed fluid therapy is the most
effective strategy, avoiding both restrictive or liberal strategies
Colloid fluids do not improve intra- and postoperative tissue oxygen tension compared with
crystalloid fluids and do not reduce post operative complications.
• Antibiotics Prophylaxis :
• Use of antibiotics just before surgery is recommended to prevent infectious
complications.

• Use of Anticoagulants :
To minimize thromboembolic events
Intraoperative Management
Standardized anaesthetic protocol:
Opioid-sparing anaesthesia using a multimodal approach, including local
anaesthetics, should be used in order to improve postoperative recovery.
Whenever possible, regional anaesthetic techniques should be performed to
reduce opioid requirements. Thoracic epidural analgesia should be considered
in laparotomy
• Surgical technique:
• Use of short transverse incision
• Laparoscopic approach whenever possible
• Less tissue handling
• Mainitaining proper hemostasis
• Short duration of surgery
• Abdominal drainage :
Abdominal drains should not be routinely used as-
1. Increases intra-abdominal & wound infection
2. Increase anastomotic insufficiency
3. Increase abdominal pain
4. Increase hospital stay
Postoperative management
• Pain Management :
• Decrease total amount of opioids as opioids are associated with impaired
gastrointestinal function & nausea &vomiting,urinary retention
• Use of NSAID &Acetaminophen as adjunct.

• Post operative diet:

• In addition to preoperative carbohydrate loading, early postoperative
nutrition can improve the metabolic response leading to less insulin
resistance, lower nitrogen loss & reduce the loss of muscle strength.
• Patients following ERAS are permitted & encouraged to drink clear liquids
uopn awakening from anesthesia & to eat general diet upon arrival to ward.
• Promote gut motility :
. The mechanism of enhanced recovery from postoperative gastrointestinal
dysfunction with the help of chewing gum is believed to be the cephalic-vagal
stimulation of digestion which increases the promotability of neural and
humoral factors that act on different parts of the gastrointestinal tract.
• Early mobilization :
• Hallmark of ERAS
• Decrease pulmonary complications, decrease insulin resistance, prevention of
loss of muscle mass & shortened interval to return of bowel function.
• Immobilizations associated with increased risk of thromboembolism.
Discharge criteria
• Patients can be discharged when they meet the following criteria :
• Good pain control with oral analgesia
• Taking solid fluid,no intravenous fluids
• Independently mobile or same level as prior to admission
• All the above & willing to go home.
Take Home Message

• ERAS is designed to speed clinical recovery of the patient and reduce both the cost and
length of stay of the patient in the hospital

• It can be achieved by optimizing the health of the patient before surgery through pre-
habilitation ,intra-operative proper management and then delivering evidence based
best care in the peri-operative period.
Thank You