Enhanced Recovery After

Surgery

By Lauren Magnusson
 History of ERAS

Started with a doctor from Denmark named Henrik

Kehlet in the 1990s

He began to research why surgical complications

were occurring

This hypothesis lead to programs being developed to

enhance patient care and improve recovery
 Goals of ERAS

 Enhanced recovery after surgery combines evidence

based interventions to improve surgical outcomes by
changing the way care is provided pre operatively,
post operatively and intra operatively

 The goal is to reduce the bodies stress response to

surgery and support organ function therefore
improving post operative outcomes
What do we mean by Surgical Stress??

 This is the bodies metabolic response to injury

 The stress response is represented by hormonal and
metabolic changes that result in hematological,
immunological and endocrine responses
 Insulin resistance is associated with post operative
complications and mortality
 This leads to a combination of catecholamine release
and hyper inflammation followed by
immunosuppression
 Who is Involved?

 Multi disciplinary approach is required

 Patient is one of the main players

Preoperative Stage
 Patient Teaching

 This begins prior to the patients surgical experience

 Patients need to understand what to expect
throughout the surgical phases
 Teaching needs to involve what will happen in the pre
and post operative phases
 Discharge teaching should also begin prior to surgery
 No Extensive Pre Op Fasting

 Patients need to stop eating food 6 hours prior to

surgery
 Patients can however drink clear fluids up to two
hours before surgery
 Why the change?!
 Reduces preoperative thirst and hunger
 Also reduces preoperative stress
 Carb Loading

 What does this mean?!?

 At ARH patients are advised to drink 375ml of CLEAR

juice prior to surgery

 Why?!
 Limited to NO bowel Prep

 Previously colorectal patients had mechanical bowel

prep to “clean” the colon

 It was shown that the use of mechanical bowel preps lead

to dehydration and electrolyte imbalances

 Also this prep was associated with post operative ileus

 Warming the Patient

 Goal is to maintain normothermia

 This starts while the patient is waiting to enter the

operating room
Intraoperative Stage
 Maintaining Normothermia

 Active warming blankets and warming mattresses

 Ambient room temperature

 Warming of IV fluids

 Why?!
Adapting and Limiting IV Fluids

 IV fluid rates should be individualized to the patients

needs

 Goal
 Want to prevent fluid and sodium overload
 Maintain homeostasis
Thoracic Epidurals, Spinal Anesthesia
and Laparoscopic Approaches

 Regional Anesthetics such as epidurals are used to

minimize opioid use post operatively

 Regional blocks can reduce the bodies response to surgical

stress

 Laparoscopic approaches are recommended if available

because they improve recovery by decreasing pain and
complications
Limiting the use of Nasogastric Tubes

 Nasogastric tubes after colorectal surgeries were

used after surgery to prevent abdominal distension
and vomiting

 Risks of the nasogastric tube after surgery?!

 If used during a surgery the NG tube should be

removed as soon as possible in the PACU
Other Intraoperative Interventions

 Prophylaxis antibiotics

 Prophylaxis chemical and mechanical venous

thromboembolism

 Pre-emptive antiemetic’s
Post operative Stage
 Goals in the Post Operative
Period

 Post op day 0: Pain control, Push oral fluids, Reduce IV

fluids, do not bolus just for low urine output, mobilize the
patient, provide gum for chewing, prevent nausea and
vomiting
 Post op day 1: Mobilization!, gum chewing, providing solid
food diets, removing foleys and saline locking patients
 Post op day 2: Continued mobilization and Gum chewing
 Post op day 3-5: Discharge home
 Limiting Opioids

 This is done by using multimodal pain management

 Using opioids along side NSAIDs and acetaminophen

helps manage postoperative pain and decrease
complications
 Preventing Fluid Overload

 Limiting the use of IV fluids

 Saline locking patients once they are drinking

adequately
 Early Mobilization

 THIS IS KEY!!

 Patients need to be mobilized post op day 0

 Patients should be up in chair for all meals

 Gum Chewing

 Why?!

 Simple intervention to improve gastrointestinal

functioning and promote bowel activity

 Patients postoperative flatus and defecation times

are shortened
Prevention of Nausea and Vomiting

 One of the main ways to promote comfort after

surgery

 Need to treat nausea and vomiting as quickly as

possible to allow patients to resume oral intake and
mobilize