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Enhanced recovery after surgery: an anesthesiologist’s perspective

Enhanced recovery after surgery (ERAS) is a multimodal and multidisciplinary approach to maintaining physiologic function and improving recovery for surgical patients. The ERAS protocol is based on a range of empirical evidence, and consensus ERAS guidelines for various surgical procedures have been published. The elements of the ERAS protocol include minimal preoperative fasting and carbohydrate treatment instead of overnight fasting; no routine use of preoperative bowel preparation; minimally invasive surgical techniques; standard anesthetic protocol; optimal fluid management rather than generous intravenous fluid administration; prevention and treatment of postoperative nausea and vomiting; active prevention of perioperative hypothermia; multimodal approaches to controlling postoperative pain; and early oral intake and mobilization. Implementation of ERAS shortened hospital stays by 30% to 50% and reduced postoperative complications by 50%. A recent study reported that, when patient compliance with the colorectal ERAS protocol was over 70%, 5-year mortality fell by 42% compared with when compliance was below 70%. Auditing process compliance and patient outcomes are key measures for assisting clinicians implementing the ERAS program. As a perioperativist, an anesthesiologist can play a crucial role in implementing the ERAS program and contribute to protocol establishment, auditing, team education and team leadership. While the ERAS protocol was first implemented for colorectal surgery, as a result of its efficacy, it is now being used in nearly all major surgical specialties.

Enhanced recovery after surgery (ERAS) is a multimodal and multidisciplinary approach to maintaining physiologic function and improving recovery for surgical patients. The ERAS protocol is based on a range of empirical evidence, and consensus ERAS guidelines for various surgical procedures have been published. The elements of the ERAS protocol include minimal preoperative fasting and carbohydrate treatment instead of overnight fasting; no routine use of preoperative bowel preparation; minimally invasive surgical techniques; standard anesthetic protocol; optimal fluid management rather than generous intravenous fluid administration; prevention and treatment of postoperative nausea and vomiting; active prevention of perioperative hypothermia; multimodal approaches to controlling postoperative pain; and early oral intake and mobilization. Implementation of ERAS shortened hospital stays by 30% to 50% and reduced postoperative complications by 50%. A recent study reported that, when patient compliance with the colorectal ERAS protocol was over 70%, 5-year mortality fell by 42% compared with when compliance was below 70%. Auditing process compliance and patient outcomes are key measures for assisting clinicians implementing the ERAS program. As a perioperativist, an anesthesiologist can play a crucial role in implementing the ERAS program and contribute to protocol establishment, auditing, team education and team leadership. While the ERAS protocol was first implemented for colorectal surgery, as a result of its efficacy, it is now being used in nearly all major surgical specialties.
Keywords: Enhanced recovery after surgery; Fast-track surgery. Clear fluids should be allowed up to 2 h and solids up to 6 h prior to induction of anesthesia.
Preoperative oral carbohydrate treatment should be used routinely. In diabetic patients carbohydrate treatment can be given along with the diabetic medication.

Preoperative bowel preparation
Mechanical bowel preparation should not be used routinely in colonic surgery.

Pre-anesthetic medication
Patients should not routinely receive long-or short-acting sedative medication before surgery because it delays immediate postoperative recovery.

Prophylaxis against thromboembolism
Patients should wear well-fitting compression stockings, have intermittent pneumatic compression, and receive pharmacological prophylaxis with LMWH. Extended prophylaxis for 28 days should be given to patients with colorectal cancer. Antimicrobial prophylaxis and skin preparation Routine prophylaxis using intravenous antibiotics should be given 30-60 min before initiating surgery. Additional doses should be given during prolonged operations according to half-life of the drug used.
Preparation with chlorhexidine-alcohol should be used. Intraoperative Laparoscopy and modifications of surgical access Laparoscopic surgery for colonic resections is recommended if the expertise is available.
Standard anesthetic protocol A standard anesthetic protocol allowing rapid awakening should be given.
The anesthetist should control fluid therapy, analgesia and hemodynamic changes to reduce the metabolic stress response. Open surgery: mid-thoracic epidural blocks using local anesthetics and low-dose opioids. Laparoscopic surgery: spinal analgesia or morphine PCA is an alternative to epidural anesthesia.

Perioperative fluid management
Patients should receive intraoperative fluids (colloids and crystalloids) guided by flow measurements to optimize cardiac output. Vasopressors should be considered for intra-and postoperative management of epidural-induced hypotension provided the patient is normovolemic. The enteral route for fluid postoperatively should be used as early as possible and intravenous fluids should be discontinued as soon as is practicable. PONV A multimodal approach to PONV prophylaxis should be adopted in all patients with ≥ 2 risk factors undergoing major colorectal surgery. If PONV is present, treatment should be given using a multimodal approach. Preventing intraoperative hypothermia Intraoperative maintenance of normothermia with a suitable warming device and warmed intravenous fluids should be used routinely to keep body temperature > 36°C.

Drainage of peritoneal cavity after colonic anastomosis
Routine drainage is discouraged because it is an unsupported intervention that is likely to impair mobilization.

Nasogastric intubation
Postoperative nasogastric tubes should not be used routinely. Nasogastric tubes inserted during surgery should be removed before reversal of anesthesia. Postoperative Postoperative analgesia Open surgery: TEA using low-dose local anesthetic and opioids.