The Enhanced Recovery After Surgery (ERAS) protocol was initiated in the 1990s and describes a multimodal, interdisciplinary, and evidence-based approach to perioperative management for major surgeries. The protocol aims to reduce post-operative complications and hospital stay duration, earlier return of bowel function, earlier return of normal activities, and improvement in cardiopulmonary function.
The body undergoes profound stress during and after surgery, and ERAS attempts to disrupt medical stressors by addressing preoperative counseling, optimizing nutrition, standardizing analgesic and anesthetic regimens, and early mobilization. Many of these goals are achieved through management by the anesthesiologist or CRNA. Preoperatively, the patient remains hydrated with minimized fasting periods and carbohydrate loading to maintain euglycemia. Intraoperatively, the anesthesiologist maintains normothermia with warmed fluids and warming blanket, utilizes goal-directed fluid therapy, closely controls blood glucose levels within a specific range, and utilizes lung protective ventilation. Opioids are minimized or avoided completely. Postoperatively, nausea is avoided with prophylactic medications like dexamethasone and ondansetron. Oral intake and nutrition is encouraged, and ambulation and gut motility are supported by adhering to an opioid free pain regimen.
Multimodal analgesia is an important component of ERAS, as recovery can be delayed by inadequate analgesia. First-line analgesia often relies on large doses of opioids, which can contribute to sedation, nausea, constipation, and delaying return to normal activity and resumption of bowel function. By using two or more analgesic agents or techniques simultaneously, better pain relief can be achieved. Minimizing opioids can be accomplished with regional anesthesia such as peripheral nerve blocks or epidurals, non-opioid analgesics like COX-2 inhibitors or NSAIDs, intravenous or oral acetaminophen, anticonvulsants, and infusions of ketamine or lidocaine.
There are many benefits of the ERAS protocol. There are a multitude of reports in literature describing improvement in surgical outcomes including reduction in postoperative complication rates and opioid prescribing rates. There has been a decrease in hospital mortality among colorectal surgery patients as well as reduction in delirium, blood clots, muscle atrophy, infection, and nausea. In addition, patient satisfaction is increased, and cost effectiveness has been demonstrated in numerous studies around the world. The considerable costs of implementing an ERAS program is easily offset by the potential savings of thousands of dollars per surgery. As the benefits of ERAS become better known and accepted, healthcare providers should expect ERAS and multimodal analgesia to become more prevalent in the perioperative setting.
