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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 7
| Issue : 2 | Page : 50-60 |
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Emerging concepts in enhanced recovery after surgery: Potential functional adaptations to existing principles
Balakrishnan Gurushankari1, Kanchan Bilgi2, Raja Kalayarasan3, Sathasivam Sureshkumar1, Pankaj Kundra4, Vikram Kate1, Ananthakrishnan Nilakantan5
1 Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Neuroanesthesiology, Neurosciences, Vikram Hospital, Bengaluru, Karnataka, India
3 Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
4 Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
5 Department of Surgery, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India
| Date of Submission | 29-Oct-2020 |
| Date of Decision | 17-Nov-2020 |
| Date of Acceptance | 27-Nov-2020 |
| Date of Web Publication | 30-Dec-2020 |
Correspondence Address:
Dr. Sathasivam Sureshkumar
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijamr.ijamr_251_20
The revolutionary concept of enhanced recovery after surgery (ERAS), recognized and proven in colonic surgery, soon caught on as an attractive proposition that translated into better and faster patient recovery after various types of surgery. As an evolving concept, it is being widely accepted, with various surgical specialties suitably adapting the guidelines for use in the perioperative setting. Identification and mitigation of risk factors in special groups of patients such as patients presenting for emergency surgery, those in the extremes of age and weight, and those with various comorbidities require additional care and investigations. The use of ERAS in emergency setting has been remarkably difficult to implement, owing to a short preoperative period, altered physiology, and unexpected postoperative outcomes. There is reluctance in the application of ERAS in emergency due to difficulty in implementing all its components, especially the preoperative components. The rapid advancements in technology and increased availability of point of care diagnostics, such as ultrasound and intraoperative electroencephalogram, and the increasing number of anesthesiologists getting trained in their usage are important factors that are positively influencing perioperative patient care in the last decade. This has led to significant developments in noninvasive and rapid methods of monitoring hemodynamics and postoperative care. This review aims to highlight the influence of newer perioperative practices that are already included or are likely to have positive impact when included in an ERAS program and provide comprehensive review on the application of ERAS in emergency setting and in various surgical specialties. Keywords: Emergency enhanced recovery after surgery, fast-track surgery, goal-directed fluid therapy, multimodal analgesia, multimodal prehabilitation
How to cite this article:
Gurushankari B, Bilgi K, Kalayarasan R, Sureshkumar S, Kundra P, Kate V, Nilakantan A. Emerging concepts in enhanced recovery after surgery: Potential functional adaptations to existing principles. Int J Adv Med Health Res 2020;7:50-60 |
How to cite this URL:
Gurushankari B, Bilgi K, Kalayarasan R, Sureshkumar S, Kundra P, Kate V, Nilakantan A. Emerging concepts in enhanced recovery after surgery: Potential functional adaptations to existing principles. Int J Adv Med Health Res [serial online] 2020 [cited 2023 Apr 2];7:50-60. Available from: https://www.ijamhrjournal.org/text.asp?2020/7/2/50/305451 |
| Introduction | |  |
The revolutionary concept of enhanced recovery after surgery (ERAS), recognized and proven in the 1990s in colonic surgery, soon caught on as an attractive proposition that translated into better and faster patient recovery after various types of surgery. Popularized by Kehlet and Mogensen, the idea encouraged clinicians to understand the postoperative pathophysiology in surgical cases and highlighted the importance of rehabilitation.[1] From 2001, Fearon and Ljungqvist have been at the helm of the movement that led to the establishment of the ERAS society (Registered) that guided physicians and surgeons on perioperative care elements which became the principles of ERAS, a practice also sometimes nicknamed fast-track surgery.
As an evolving concept, it is being widely accepted with various surgical specialties suitably adapting the guidelines for use in the perioperative setting. Identification and mitigation of risk factors in special groups of patients such as patients presenting for emergency surgery, those in the extremes of age and weight, and those with various comorbidities require additional care and investigations. The rapid advancements in technology and increased availability of point-of-care diagnostics, such as ultrasound and intraoperative electroencephalogram, and the increasing number of anesthesiologists getting trained in their usage are important factors that are positively influencing perioperative patient care in the last decade. This has led to significant developments in noninvasive and rapid methods of monitoring hemodynamics, respiration, depth of anesthesia, and postoperative care. This review aims to highlight the influence of newer perioperative medical and surgical practices that are already included or are likely to have positive impact when included in an ERAS program.
| Universal Aspects of Enhanced Recovery after Surgery | | |
The core principles of ERAS are centered on the prevention of catabolism in the perioperative period and reduction of any intervention that may be deemed avoidable or may impede patient mobilization in any way. Minimization of preoperative fasting and ingestion of a carbohydrate-rich clear liquid 2 h before surgery, judicious use of intravenous fluids, minimally invasive surgical techniques, multimodal analgesia with reduction or avoidance of opioid analgesics, early removal of or doing away with indwelling catheters and invasive lines, and early initiation of oral or enteral feeds even in abdominal surgical procedures are a few of the several interventions that have been recommended in the ERAS society guidelines.[2]
In the unprecedented times of the COVID-19 pandemic, it is estimated that more than 40 million surgeries have been postponed world over. Meticulous implementation of ERAS is the obvious answer to the stress on healthcare systems and patients alike.[3],[4] It is possible that the often-encountered anxious patient may become wary when the term fast-track surgery is used, which may imply rapid turnover of cases and hint at a profit motive in healthcare. Thus, the role of preoperative counseling and patient education about ERAS, with emphasis on quality of perioperative care rather than mere explanation of the process, is essential to ensure compliance and follow-up.[5] Li and Jensen described that the safe implementation of ERAS protocols in patients undergoing colon surgery and reported satisfaction in areas such as early intake and readiness for discharge. Effective implementation of ERAS calls for investment of additional time and effort from the side of the patient as well as the clinical team, adding to positive clinician–patient interaction.[6]
| Multimodal Prehabilitation | | |
Prehabilitation in ERAS is a multimodal program consisting of physical, nutritional, and psychological interventions. Optimization of the physical status by medications and cessation of smoking and alcohol consumption in the weeks before the surgery are well-established components of ERAS. Cavallaro et al. studied the impact of using a scripted preoperative patient education module that was reinforced with telephonic calls in the days before surgery. This enabled compliance as well as allowed the patient to report a couple of hours before surgery and resulted in better implementation of all the points of the bundle, thus contributing to further reduction in length of hospital stay.[7]
Physical prehabilitation, consisting of assessment of exercise tolerance by history and the use of easy to administer tests, such as the 6-min walk test and exercise interventions, has been shown to identify high-risk patients.[8] Inspiratory muscle training by using volume-oriented incentive spirometry has been shown to result in a lesser reduction in the peak expiratory flow rate compared to the preoperative values in patients undergoing elective gastrectomy, while reducing the length of hospital stay significantly with no increase in surgical complications compared to the conventional management group.[9],[10]
The integration of immunonutrition in the ERAS protocols has been recommended in view of recovery benefits that were observed in certain groups, such as gastrointestinal and gynecological cancer patients.[11] Preoperative assessment of nutritional status using validated tools such as the Nutritional Risk Screening Tool-2002, subjective global assessment, or the Malnutrition Universal Screening Tool and identification and correction of specific nutritional deficiencies using the “food first” approach have been found to improve surgical outcomes in terms of reduced length of stay.[12],[13],[14] However, robust data are still awaited as studies show heterogeneity in the difference between the outcomes in patients receiving immunonutrition and regular dietary supplementation, with no difference in the length of hospital stay but reduction in complications such as infection.[15]
Psychological prehabilitation has been shown to not only reduce stress and anxiety in patients but also ensure better compliance with other methods of prehabilitation, resulting in better pain control and recovery postoperatively. Quantified using the hospital anxiety and depression scale, the psychological states of patients have a mixed response in studies and further research may throw more light on the extent of benefit of formal psychological counseling as a part of a prehabilitation program in ERAS.[16] Multimodal prehabilitation must work in tandem for optimal preoperative preparation of the patient [Figure 1]. | Figure 1: Components of multimodal prehabilitation that must work in tandem for optimal preoperative preparation of the patient
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| Preoperative Fasting | | |
Patients presenting for emergency surgery with comorbidities such as obesity and diabetes and history of trauma are known to have prolonged gastric emptying time.[17] Identification of at-risk patients is crucial to prevention of pulmonary aspiration, a major cause of airway-related anesthetic interventions.[18] Gastric ultrasound has emerged as a useful tool to assess the volume of gastric contents in the preoperative period. An estimated gastric volume of >1.5 ml/kg is considered a risk factor for pulmonary aspiration of the contents. The empty antrum is visualized as the “target sign” whereas recent ingestion of liquid gives a hypoechoic appearance. The presence of solid food in the stomach gives a characteristic hyperechoic nonhomogenous image of the antrum, while a “starry night” appearance indicates recently ingested gastric contents mixed with air.[19] This practice of perioperative gastric ultrasound assessment has been found to yield useful information even in special conditions, such as obesity and trauma where additional airway challenges can lead to increased chances of pulmonary aspiration.[20]
Early initiation of feeding postoperatively has been possible due to implementation of the various components of ERAS, such as reduced opioid consumption, increased use of minimally invasive techniques, early mobilization, reduced catabolism, and improved physiological state due to minimal fasting times, practice of preoperative carbohydrate loading, and early removal of nasogastric tube (NGT) postoperatively. Some patients may need placement of an NGT. With a relatively short course of training, the use of the 4-point ultrasound technique to confirm the correct placement of the NGT can be a routine practice, precluding the need for an X-ray, thus avoiding delay in initiating enteral feeding due to doubtful placement, complications due to incorrect placement, and unnecessary exposure to radiation.[21] The sensitivity of ultrasound for confirmation of the NGT can reach 97% when, along with auscultation, ultrasound check is performed in at least two points (neck and subxiphoid views) and visualization of the antrum with injection of air–water mixture is ensured.[22]
Postoperative ileus is a known complication of surgery, especially abdominal surgery, and is exacerbated by the use of opioids for analgesia. Drugs used to increase gastric and intestinal motility include metoclopramide, erythromycin, stool softeners, or laxatives and the peripherally acting quaternary mu-opioid receptor antagonist alvimopan. The short-term use of alvimopan in doses of 12 mg twice a day (not exceeding 15 doses) has been found to reduce the incidence of postoperative ileus and thus reduce the length of hospital stay in patients undergoing abdominal surgeries.[23] Huang et al. in their recent study in patients who underwent radical cystectomy observed that patients who received alvimopan had shorter duration of postoperative ileus that resulted in significantly shorter hospital stay leading to lesser costs.[24] Introduction of alvimopan to a pre-existing enhanced recovery program for radical cystectomy led to a further significant reduction in the delay of initiation of normal feeds and the total length of stay in hospital.[25] An audit from a large multicenter database of 5299 patients who underwent various segmental colonic resection surgeries also showed significant reduction in length of hospital stay, costs, and rate of admission to the intensive care unit (1.83% vs. 7.20%, P < 0.05) in the 438 patients who received alvimopan, with no significant difference in the rate of complications or mortality.[26]
| Analgesia in Enhanced Recovery after Surgery | | |
Opioid-free analgesia is strongly recommended in ERAS, and regional or local anesthesia, paracetamol, and nonsteroidal anti-inflammatory drugs (NSAIDs) are the popularly used analgesics that are effective. However, the American College of Chest Physicians offer a word of caution regarding the thrombotic and arrhythmogenic cardiac complications that occur with selective cyclooxygenase 2 (COX-2) inhibitors due to the inhibition of prostacyclin that has led to limited prescription of these drugs in patients with pre-existing cardiac disease.[27] Earlier studies in experimental models as well as clinical studies have noted an increase in the incidence of anastomotic leakage in patients undergoing colorectal surgery who received COX-2 inhibitors, due to the role of COX-2–induced prostaglandin E that is essential for anastomotic healing. This highlights the role of regional analgesia such as epidural analgesia as the primary modality and systemic analgesics mainly serve as adjuncts.[28],[29]
| Goal-Directed Management of Hemodynamics | | |
Preoperative assessment of inferior vena cava (IVC) can predict hypovolemia and fall in blood pressure after induction of anesthesia.[30] A cause of delay in certain types of surgical procedures is due to time taken to get certain investigations such as transthoracic two-dimensional echocardiography due to risk factors noted in the preoperative assessment. Cardiac ultrasound (focused cardiac ultrasound [FoCUS]) employed in the preoperative assessment of the patient can help detect the left ventricular systolic function and presence of significant valvular stenosis. With many anesthesiologists gaining training in FoCUS, qualitative assessment of the heart can help achieve goal-directed hemodynamic management, rule out, or identify gross pathologies which may warrant detailed echocardiography when necessary.[31] Identification of hypervolemia due to aggressive fluid resuscitation or cardiac failure using lung ultrasound and venous congestion in well-perfused organs such as the liver and kidney can be done in the perioperative period. Venous congestion results in interstitial edema that can be particularly harmful for encapsulated organs such as the liver and the kidneys.[32]
The VExUS score has been designed to assess the degree of venous congestion using point-of-care ultrasound (POCUS), imaging the IVC diameter (>2 cm indicates increased preload and right atrial pressure), the portal, hepatic, and intrarenal veins.[33] A fluid restrictive strategy is an important tenet of ERAS. Pleth variability index has been shown to perform equally well as the pulse pressure variation in low-to-moderate risk abdominal surgeries in predicting the length of hospital stay. Thus, invasive arterial blood pressure monitoring can be avoided.[34],[35]
The use of passive leg raising (PLR) test can probably avoid fluid overload. The effect of the PLR test is assessed best by measuring the change in cardiac output. However, noninvasive surrogates such as change in the end-tidal carbon dioxide (CO2) and change in the velocity–time integral (VTI) measured by cardiac ultrasound are found to be reliable.[36],[37] Biais et al. found that the stroke volume changes measured by transthoracic echocardiography after passive leg raise maneuver were found to be in agreement with that measured by using the Flotrac Vigileo monitor using an invasive arterial catheter.[38] Muller et al. found that a change in VTI of 10% or more with infusion of 100 ml hydroxyethyl starch over 1 min was predictive of fluid responsiveness (area under receiver operating characteristics curve 0.92, 95% confidence interval [CI]: 0.78-0.98) with a sensitivity of 95% and specificity of 78% (mini-fluid challenge).[39] Biais et al. studied the predictability of the stroke volume index (SVI) variability with the 50 and 100 ml mini-fluid challenges with normal saline and found a 6% or greater increase in SVI to predict fluid responsiveness with 93% sensitivity and 85% specificity (area under receiver operating characteristic curve [ROC] 0.95 [95% CI, 0.90–0.99]) with 100 ml.[40] In summary, maintenance of zero fluid balance can be achieved using noninvasive techniques, albeit in selected patients.
| Emergency Enhanced Recovery after Surgery | | |
Emergency surgeries, in general, have a high morbidity and mortality. Patients in emergencies have a varied presentation and altered physiology. The use of ERAS in the emergency setting has been remarkably difficult to implement owing to a short preoperative period, altered physiology, and unexpected postoperative outcomes. There is reluctance in the application of ERAS in emergency due to the difficulty in implementing all its components, especially preoperative components. Huddart et al. and Møller et al. reported reduction in mortality in patients undergoing emergency laparotomy using the principles of the fast-track protocol.[41],[42] There are several other studies on ERAS in emergency surgeries that have shown the feasibility of implementing most of the components of ERAS, thus leading to a better outcome.[43] Mohsina et al. in their randomized controlled trial (RCT) established the safety and feasibility of ERAS in patients undergoing laparotomy for peptic ulcer perforation closure in emergency and have shown significant reduction in the length of hospitalization in the adapted ERAS group.[44] A recent RCT by our center, compared the adapted ERAS versus standard care in patients undergoing emergency small bowel surgeries and reported a reduction in the length of hospital stay the ERAS group and no difference in postoperative complications between the groups.[45]
Adaption of the care elements in the conventional ERAS as per the emergency care and use of additional resources to assess the patient's suitability for ERAS may help clinicians to safely implement the maximum care elements without any added morbidity. The regular use of the ASA physical status classification, cardiac risk indices, and biomarkers such as troponins and natriuretic peptides can aid in identification of high-risk patients and tailoring of therapeutic approaches.[46] The use of noninvasive POCUS to identify cardiac and lung pathologies is a useful and lifesaving tool for the evaluation of emergency surgical patients [Figure 2].[47] This is particularly true in low-resource settings to avoid inevitable delay of diagnosis of life-threatening but curable emergencies. | Figure 2: Comprehensive point-of-care ultrasound assessment in emergencies
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Preoperative care elements in emergency enhanced recovery after surgery
In an emergency setup, adhering to all the preoperative care elements of ERAS is difficult as only limited preoperative time duration is available when compared to an elective setting. However, care should be taken to implement as many elements as possible to counter the stress. Giving a detailed preoperative counseling may not be feasible but information regarding surgical procedure to be performed, its complications, need for stoma, and duration of hospital stay can reduce anxiety and enhance recovery and compliance of the patients and the caregivers.[48] Aiming for a complete optimization of the medical illness preoperatively in emergent surgery is not realistic, however, wherever feasible, maximum optimization should be achieved. A concept of prewarming, i.e., preservation of normal body temperature, has proven to reduce the postoperative complications such as infections.[49] This can be achieved by using a warmer and prewarmed intravenous fluid 2 h before and after surgery. Carbohydrate loading, fasting, and selective bowel preparation might not be feasible in an emergency setting as patients may present differently; some may have prolonged fasting due to delayed presentation or a shorter fasting time.
Preoperative assessment of the condition of the lungs can be performed at the bedside to recognize pulmonary edema, pleural effusion, hemothorax, pneumothorax, lung collapse, and consolidation, which can expedite the diagnosis and treatment of these life-threatening emergencies.[50] Under the Bedside Lung Ultrasound in Emergency (BLUE protocol), patients can be categorized into five profiles based on the presence or absence of normal lung sliding sign and further evaluated for the correctible lung pathologies preoperatively and guide the need for further investigation.[51] Ultrasound is useful in the safe performance of procedures, such as placement of intercostal drainage tubes and therapeutic tapping of pleural effusions. The evaluation of hypotension or shock using ultrasound has been described lucidly by Lichtenstein in what has been called the Fluid Administration Limited by Lung Sonography (FALLS protocol).[51]
Thromboprophylaxis is not routinely recommended in all patients.[48] Low-molecular weight heparin is preferred over unfractionated heparin as it is equally effective with once a day dosing and decreased risk of heparin-induced thrombocytopenia. Most of the patients in emergency present with acute pain and using a routine opioid medication such as tramadol, can adversely affect the postoperative outcome. Opioid analgesics are known to cause prolonged ileus. Thus, the ERAS protocol suggests the use of nonopioid analgesics along with an epidural anesthesia for pain management.[52] Placing an epidural catheter may be challenging, sometimes. However, it is recommended in emergency ERAS. A study on emergency ERAS from our center for perforated duodenal ulcer used nonopioid multimodal analgesia, i.e., intravenous acetaminophen and lumbar epidural, and opioids only for breakthrough pain.[44]
Intraoperative care elements in emergency enhanced recovery after surgery
The intraoperative care elements are the major contributing factors for eliminating perioperative injury and stress. The components include short-acting anesthetic agents, goal-directed fluid therapy (GDFT, avoidance of sodium and water overload), maintenance of normal body temperature, minimally invasive surgery (MIS), and avoidance of drains.[52] The components of multimodal analgesics include thoracic epidurals and NSAIDs. There are several concerns on the adverse effects of NSAIDs in bowel anastomosis, thus leading to a change in focus toward spinal, transversus abdominis plane blocks (TAP), or intravenous lidocaine.[53],[54],[55] There are not many studies that validate their safe use. A study from our center in 99 patients with duodenal perforation used lumbar epidural in patients under ERAS group.[44] The patients were infused with 16 ml of 1% lidocaine with 150 mcg of adrenaline. Short-acting opioids and anesthetic agents such as fentanyl (1 mcg/kg) and sevoflurane (0.5–0.7 minimum alveolar concentration) were used by the authors. Similarly, in another study on ERAS in 70 patients who underwent emergency small bowel surgery, similar technique was used intraoperatively for pain management in the ERAS group.[45]
The hypervolemic state has adverse effects on bowel anastomosis and is known for causing prolonged ileus. Thus, adequate preoperative hydration and intraoperative GDFT is one of the major components in managing surgical stress by maintaining a state of euvolemia.[56] This can be easily achieved in an elective surgery. However, when it comes to an emergency surgery where preoperative optimization is difficult, maintaining a zero balance intraoperatively is a key component.[57] It becomes even more challenging when there is hemorrhage, sepsis and in patients with poor cardiac function. The factors that affect the volume status are preoperative fasting, hemorrhage, volume losses, and absent enteral feeding due to disease pathology. Various factors such as heart rate, blood pressure (especially arterial), end-tidal CO2, central venous pressure, urine output, stroke volume, and cardiac output are used in the monitoring of volume status.[56],[58] Urine output has been used as an indicator of intravascular volume and mirrors adequate renal perfusion.[59],[60] However, using urine output as single marker for volume status is debatable. Some studies suggest that decreased urine output alone should not initiate fluid therapy as it depends on various other factors such as prerenal causes like volume depletion and postrenal causes urinary outflow tract obstruction.[60] GDFT is a continuum of preoperative, intraoperative, and postoperative fluid management. Hydration of the patient and achieving a state of euvolemia before surgery, avoiding retention of sodium, water, and the use of excessive crystalloids form a major component of GDFT. Each patient undergoing surgery needs an individualized fluid therapy for a better outcome.
One of the most important intraoperative care elements of ERAS protocol is MIS, minimal handling of tissues, and avoidance of drains for a better postoperative outcome. Performing a laparoscopic surgery is challenging when it comes to emergency setting. The challenges are that most of the centers might not have a provision for laparoscopic surgery in emergency, might lack trained surgeons, and occupied operation theatre due to prolonged laparoscopic surgeries might not be feasible. Although implementing MIS in emergency is difficult, various studies have reported the use of MIS in emergent surgery. Gonenc et al., a pioneer of ERAS in emergency surgery, studied patients undergoing laparoscopic repair for peptic ulcer perforation.[43] Unnecessary usage of drain impedes early mobilization as it causes additional pain and discomfort to the patient postoperatively, thereby prolonging the recovery. Hence, it should be used judiciously. Intraoperative care elements can be achieved in emergent surgery as well, by the synchronized work of the surgeon and anesthesiologist, thus leading to a smooth postoperative period.
Postoperative care elements in emergency enhanced recovery after surgery
The postoperative care elements primarily focus on early enteral feeding and early mobilization of the patient, thus leading to a speedy recovery. The various components are pain management with epidural, nonopioid oral analgesics; early removal of NGT, catheter, and drains; prevention of postoperative nausea and vomiting (PONV); optimized fluid therapy; early enteral feeding and mobilization; enhancing gut motility; and audit on compliance and outcomes.[52] In a study from our center on ERAS in 70 patients undergoing emergency small bowel surgery, the study group had a shorter length of hospital stay (8 vs. 10.83; mean difference of 2.83 days; P = 0.001).[45] The various techniques the authors used for postoperative analgesia were NSAIDS, epidural (bupivacaine infusion for 24 h) in the initial postoperative hours. Injection diclofenac 75 mg twice daily in the immediate post-operative period which was switched to oral paracetamol 500 mg thrice daily on the 3rd postoperative day if required. The authors used intravenous formulations if there was a delay in the resumption of enteral feeding and used opioid whenever required. for the management of breakthrough pain. In a similar study from our center, similar approaches were followed with adjuvant medications such as metoclopramide 10 mg thrice daily intravenously on postoperative day (POD) 0 and 1.[44]
The major factors that impede early recovery are postoperative ileus and immobilization. Postoperative ileus can be prevented by various methods such as GDFT to reduce gut edema and stretch, carbohydrate loading to reduce insulin resistance, and use of NSAIDS and epidural analgesia, instead of opioids which have anti-inflammatory effects and opioid-sparing action, along with decreased sympathetic stimulation with epidural. In a study by Mohsina et al. on perforated duodenal ulcers, the patients were kept nil orally until the resolution of ileus, i.e., appearance of first bowel sounds and was escalated to liquid diet followed by normal diet as tolerated.[44] When the patients developed intolerance to enteral feeding it was managed by keeping patients nil orally and resumption of feed was carried out once the symptoms subsided, thus enhancing fast-track recovery.
The primary aim of ERAS is to eliminate the factors that impede early mobilization and early enteral feeding, which delays the early recovery and discharge of the patients. A meta-analysis in 2020 on ERAS in emergency abdominal surgeries, which included six studies with 1334 patients reported shorter postoperative time to first flatus (P < 0.00001), time to first defecate (P < 0.02), time to first oral liquid diet (P < 0.00001), time to first oral solid diet (P < 0.00001), and length of hospital stay (P < 0.00001) in ERAS group. The authors also reported lowered risk of complications (P < 0.00001) and major complications (P = 0.0008) including pulmonary complications (P = 0.0003), paralytic ileus (P = 0.01), and surgical site infection (P = 0.0001) in the ERAS group.[61] There was no significant difference in the 30-day mortality, need for readmission, and need for re-operation among both the groups. Substantiated by many studies, most of the postoperative care elements ERAS can be incorporated by the treating physician even in an emergency surgery, thus ensuring a fast-track recovery.
Discharge and follow-up in emergency enhanced recovery after surgery
The basis of ERAS protocol is not to discharge the patient as early as possible from the hospital; rather it prepares the patients for early discharge by enhancing their recovery. The criteria for discharge include toleration of solid diet, return of normal bowel sounds, pain responding to oral analgesics, mobilizing adequately, ability to take care of self, and no complications which may require hospital stay.[44],[45] Follow-up of the patient is required so as to evaluate the complications or need for readmission and also to know the effectiveness of ERAS. Any protocol without follow-up might not yield the required feedback necessary for evolution of the protocol based on patient and other factors. Mohsina et al. reported the discharge criteria as patient tolerating solid diet for 24 h, having passed stools, and without any other factors, such as fever, surgical site infection, or anastomotic leak, which will require hospital care.[44] The authors discharged the patients on oral acetaminophen 500 mg on demand and continued oral omeprazole 20 mg twice daily for 3 months. The complications and need for readmission were evaluated on day 10 and 30 of surgery. Studies have shown reduced postoperative complications and readmission rates with the ERAS protocol.[44],[45],[61] The readmission rates and repeated visit of patients to the hospital can be avoided by proper “patient education.” The length of hospitalization is directly proportional to readmission rates, suggesting that prolonged hospital stay increases morbidity.
Barriers and limitations of enhanced recovery after surgery in emergency
The complex nature of ERAS protocol has led to its poor adherence, especially in emergency, as it requires multistep and multidisciplinary involvement in a short period of time. The need of the hour is also to design a procedure-specific ERAS so as to improve adherence. A good institutional setup with necessary resources (such availability of laparoscope in emergency), updated staffs, and structural, financial, and technical support from the institution are required for breaking the barriers and implementing ERAS in emergency [Figure 3]. | Figure 3: Barriers in implementing enhanced recovery after surgery protocol
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Good communication and a team leader are a necessity along with education sessions for the staff, nurses, and doctors (especially resident doctors). The external factors such as patient point of recovery along with postdischarge functional recovery, pre- and postoperative rehabilitation, cost analysis, language, and patients' comorbidities are important barriers. In general, the outcome measures of ERAS are the objective assessment rather than a patient-reported outcome. The physician's resistance to adapt to new protocols and improper communications among the team members are the individualized problems one can face while implementing ERAS. Involving the multidisciplinary team including the administration, staffs, patients, and their family throughout the process and updating and educating the staff involved enhance the chance of success of ERAS implementation and lead to better outcomes.
It is possible that the implementation of ERAS in elective surgeries and the evident improvement in patient outcomes can influence a paradigm shift among the clinicians involved who might modify their practices in emergency surgeries in suitable patients. However, compliance with various components of ERAS pathways in the preoperative, intraoperative, and postoperative periods has been found to be lower than in an elective setting. In spite of that, Roulin et al. concluded that even partial compliance can produce postsurgical outcomes that are comparable with ERAS implementation in the elective cases.[62] A set of orders and framework with timeline will lead to enhanced adherence to the protocol, rather than just having knowledge of it. It also helps the new staffs or residents, who lack the knowledge about ERAS stick to the guidelines [Figure 4]. | Figure 4: Strategies for implementation of enhanced recovery after surgery protocol
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| Enhanced Recovery after Surgery in Other Specialties | | |
Coronary bypass procedure was the first surgery in which the principles of “fast-track protocol” was described in 1994.[63] Since then, ERAS society and researchers have devised protocols for various procedures including urology, vascular, breast, orthopedics, and gynecology surgery. An institution, patient, and procedure-specific protocol is required to have better compliance and outcomes following the implementation of ERAS in various subspecialties. This enhances patient satisfaction and reducing the financial burden of the hospital, morbidities, and mortalities.
Enhanced recovery after surgery in cardiovascular and thoracic surgery
Studies have shown that application of ERAS protocols has reduced the complication rates in patients undergoing thoracic surgery.[64] The authors also reported reduction in opioid usage along with reduced length of hospital stay and decreased hospital expenses.[65] A study with 234 patients undergoing open lobectomy for cancer reported reduction of complication rates from 50% to 37% in ERAS group with decreased length of hospital stay due to early removal of chest tubes and Foley's catheters.[66] However, some studies have reported that ERAS pathway did not demonstrate a clear benefit in patient undergoing MIS such as video assisted thoracoscopic surgery (VATS), lobectomy, and pulmonary resection.[67] The authors suggested that the components of VATS had most of the ERAS care elements, thus leading to no significant difference between the two groups.
Enhanced recovery after surgery in plastic and breast surgery
Although several studies have reported that the ERAS protocol in plastic surgery is safe and efficacious, with reduced postoperative complications and reduction in the length of hospital stay, it has not become the standard of care.[68],[69],[70] In 2017, the ERAS society has designed a specific protocol for breast reconstruction with 18 preoperative, intraoperative, and postoperative care elements.[71] This promoted the use of ERAS for early recovery following the breast reconstruction. In 2019, a meta-analysis on ERAS in microsurgical breast reconstruction reported decreased length of hospital stay in the ERAS group, with no increase in complication rates.[72] With the recent consensus statements and evidence, ERAS would become the standard of care in plastic surgery in the near future.
Enhanced recovery after surgery in urology
ERAS provides a standardized perioperative care in patients undergoing urological procedures.[73] ERAS was initially implemented in radical prostatectomy which showed a reduction in the hospital stay. This was later extended to radical cystectomy and partial nephrectomy.[74],[75] Most of the procedures in urology are being transformed to minimally invasive procedures such as robot-assisted partial nephrectomy, where the length of hospital stay is reduced significantly. While applying ERAS protocol to such surgeries, it reduced the length of hospital stay further and the cost as well, as many of the procedures were carried out as day care.[73] Further, research is required in formulating protocols specific to urological procedures for an enhanced patient recovery and cost benefits.
Enhanced recovery after surgery in orthopedic surgery
Over the years, the number of joint replacement surgeries has increased leading to a rise in the financial burden of the hospitals.[76] To reduce this financial burden, various institutions have designed procedure-specific ERAS protocols to enhance patient outcomes, thereby limiting the cost and reducing the readmission rates. For this reason, ERAS protocols are particularly tested in elective hip and knee arthroplasty. Studies on ERAS in total hip and knee arthroplasty have reported reduction in length of hospital stay from 4–12 to 1–3 days, with no difference in the readmission and complication rates.[77],[78] Although studies have reported the superiority of ERAS over standard surgical care, there is a reluctance in its adoption as a standard of care in orthopedic surgeries.
Enhanced recovery after surgery in gynecological surgery
The pioneers in ERAS in gynecological surgeries are de Groot et al., who studied principles of ERAS on gynecological surgeries. The authors reported that there was reduction in the length of hospital stay from 7 to 5 days with an enhanced functional recovery from 6 to 3 days in the ERAS group.[79] Similarly, Nelson et al. reported a reduction in length of hospital stay in the ERAS group with no significant difference in the readmission and complication rates.[80] In a study on ERAS in gynecological surgeries, the authors described two different ERAS protocols, one - an extensive protocol for open procedure with regional anesthesia and another - simple protocol for vaginal invasive surgery and MIS without regional anesthesia.[81] In 2016, the ERAS society published recommendations for gynecological oncologic surgery.[82] ERAS has also been attempted in elective cesarean deliveries where it was reported that the number of patients leaving the hospital on POD 1 was substantially high.[83] All these studies suggest that the ERAS protocol can be implemented successfully in obstetrics and gynecology.
Enhanced recovery after surgery in neurosurgery
Enhanced recovery bundles are increasingly being embraced for neurosurgeries, more commonly spine surgeries and elective craniotomies.[84] Smith et al. analyzed the outcomes of a quality improvement program that sought to implement enhanced recovery protocols for spine fusion surgeries that modified most perioperative practices as per the standard ERAS principles, except fluids and hemodynamic management. They produced mixed results, with no change in the length of hospital stay, but significantly reduced opioid consumption and rescue antiemetic use in the ERAS group, probably secondary to poor compliance noted in following the postoperative protocols.[85] The routine use of scalp blocks and paracetamol for postoperative analgesia is a recommended practice.[86] Current literature suggests that total intravenous anesthesia and sevoflurane anesthesia have comparable recovery time and profiles.[87] The level of evidence favoring minimally invasive endoscopic approaches to the skull base and the use of analgesics such as COX-2 inhibitors and flupirtine is currently low. Although the perioperative use of gamma amino butyric acid analogs such as pregabalin and gabapentin has been found to be effective with good patient sleep and comfort in the postoperative period, the overall level of evidence is still insufficient to make a strong recommendation for their routine use. Initiation of artificial feeds in patients who are likely to be in prolonged comatose states is recommended.[88],[89]
Patients on antiplatelet drugs seem to be at a higher risk of developing thromboembolic events in the perioperative period, when the drugs are discontinued and delaying surgery on account of antiplatelets does not seem to reduce the risk of recurrence of the bleed. Platelet function analysis may often help in reducing the duration between stopping the antiplatelet drug and surgery.[90] With an increasing number of patients on dual and newer antiplatelets such as prasugrel and ticagrelor, further studies are needed to establish the reliability of various platelet function analysis methods.[90],[91]
| Checklists and Cognitive Aids in Enhanced Recovery after Surgery | | |
Human errors occurring due to various factors are an unfortunate part of the practice of medicine, leading to avoidable complications that can potentially lead to morbidity or mortality. Checklists have become an integral part of the hospital workflow system, but compliance with all the essential checklists has often found to be lacking.[92],[93] Saxena et al., in a systematic review of the impact of anesthesia-related perioperative checklists on the clinical outcome, reported a positive impact in 92% of the studies analyzed.[94] Cognitive aids are increasingly being promoted for use in anesthetic, neurological, neurosurgical, pediatric, and critical care emergencies.[95],[96] In the absence of ready-to-reference checklists, clinicians were likely to miss nearly a quarter of the life-saving steps needed to tackle an emergency. The use of a checklist for the same emergencies resulted in nearly 100% adherence to all the recommended and necessary steps, translating to better patient outcomes.[97] Literature has begun to emerge regarding the increased need to use cognitive aids for clinicians at various levels of patient management, including expected emergencies. Encouragement to use these if included in perioperative ERAS protocols will ensure optimal patient recovery.
| Impediments to the Implementation of Enhanced Recovery after Surgery | | |
A patient-led study concluded that considering patients as partners in the ERAS program with close interaction and feedback at every step in the perioperative period is likely to improve compliance and consequently the success of the program.[98] There are many personnel involved in an ERAS program that need to work in tandem and follow the same clinical end points.[99] Nevertheless, the clinician must be able to identify any deviations from the protocol and the reasons for the same, giving scope for review and subsequent improvement. The presence of comorbidities or abnormal laboratory tests and the use of opioids may cause significant delays in the perioperative period.[100] As mentioned, the lack of compliance by the hospital staff with checklists, in general, leads to incomplete implementation of the program. Patient cooperation is the key to the whole process.
| Conclusion | | |
ERAS is an evidence-based multidisciplinary approach which is aimed to reduce the surgical stress in patients and maintain normal homeostasis to enhance postoperative outcomes. ERAS which was initially accepted in elective colorectal surgeries now has been extended into emergency procedures and subspecialties. There are several barriers and limitations in implementing ERAS, but these can be overcome by several methods as described above. ERAS not only brings in better outcomes but also increases patient satisfaction and reduces the financial burden. The change in practice comes with the change in the thought process and its time we start implementing ERAS in our day-to-day practice.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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