Explaining the ERAS Guidelines
The Enhanced Recovery After Surgery (ERAS) Guidelines
An evidence-based multi-disciplinary approach to perioperative care. The goal of the guidelines is to decrease recovery time and post-operative complications, while saving money and reducing hospital length of stay. Resulting in an overall better quality of life for patients.
Primary Principles of ERAS
The initial ERAS protocol is based on 20 primary principles divided between the pre-, intra-, and post-operative periods. One of the overarching guidelines is that these all of these steps require the involvement of the entire multi-disciplinary team.
The group that received the combination of ERAS with laparoscopy experienced a 40-50% reduction in post operative side effects and shortened length of hospital stay by 2-3 days5.
Vlug MS, Wind J, Hollmann MW, et al. (2011)
Post-operative
- Early diet advancement
- Early ambulation
- Early catheter removal
- Pain and nausea management
- Goal-directed fluid management
- Use of chewing gum
- Well-defined discharge criteria
These are the general principles of ERAS for each operative period2:
Pre-operative
- Pre-admission education
- Early discharge planning
- Reduced fasting duration
- Carbohydrate loading
- No bowel prep or only selective bowel prep
- Venus thromboembolism and antibiotic prophylaxis
- Pre-warming
INTRA-operative
- Active warming
- Opioid-sparing techniques
- Specialized surgical techniques
- Avoidance of unnecessary drains or NG tubes
- Fluid management
- Pain and nausea management
Post-operative
- Early diet advancement
- Early ambulation
- Early catheter removal
- Pain and nausea management
- Goal-directed fluid management
- Use of chewing gum
- Well-defined discharge criteria
The ERAS Society started with a focus on gastrointestinal surgery, but has since then developed surgery-specific protocols as well, which expand on these main principles.
The ERAS protocol was inspired by a Danish Professor of surgery named Henrik Kehlet. Kehlet questioned the benefit of traditional surgical practices such as extended fasting, mobility restrictions, and others. This questioning led to further evaluation of surgical procedures and the impact on patient outcomes.
These innovative guidelines were further developed in 2001 with the initiation of the ERAS study group by professors Olle Ljungqvist and Kenneth Fearon. The ERAS Society was founded in 2010 to support research, education, and collaboration for healthcare professionals involved in optimizing surgical outcomes.1
ERAS was developed to help better manage the body’s natural post-surgical stress reaction. Previous post-surgical protocols, like prolonged fasting, didn’t do much to improve overall outcomes, but significantly increased physical and mental stress for the patient.
The goal of the ERAS protocol is to help reduce stress and to manage physical side effects such as inflammation and insulin resistance that tend to develop during this time. The principles help reduce the risk of malnutrition, dehydration, and infection. Pain, nausea, and other uncomfortable surgical side effects are also addressed.
A main component of ERAS is to help reduce the risk of malnutrition after surgery, a common occurrence due to muscle catabolism and extended periods of inadequate intake due to required fasting. The ERAS protocol emphasizes decreased periods of fasting and encourages protein intake through the use of dietary supplements. The goal is to prevent complications associated with malnutrition. Research on the benefits of ERAS have found that the use of oral nutrition protein supplements significantly increases patient protein intakes, reduces hospital stay, and lowers the risk of infection.3
In addition to nutrition and surgical practices, ERAS doesn’t just tackle the physical experience of the patient, it also addresses psychological stressors through pre-and post-operative education and well-developed plans of care.4
The ERAS has been extensively evaluated for different types of surgery. A multi-center study compared the outcomes of patients undergoing colorectal surgery utilizing ERAS and laparoscopic surgical techniques or traditional methods. The group that received the combination of ERAS with laparoscopy experienced a 40-50% reduction in post-operative side effects and shortened length of hospital stay by 2-3 days.5
Other evaluations of the ERAS guidelines have found that it can help reduce hospital stay, costs, decrease pain, and result in an overall better quality of life for patients.5
Even with these positive perioperative results, successful implementation of ERAS does require institutional support and collaboration between interdisciplinary team members. There may be some financial and staffing barriers to overcome in attempting to implement these guidelines.
With the increasing costs of healthcare and patient demands for quality care, ERAS is a beneficial methodology for improving outcomes for both patients and providers. It is a safe methodology that does require some buy-in the healthcare team, but has the power to reduce complications and have economic benefits.
References
- [1] Ljungqvist O. ERAS--enhanced recovery after surgery: moving evidence-based perioperative care to practice. JPEN J Parenter Enteral Nutr. 2014;38(5):559-566.
- [2] Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292-298.
- [3] Yeung SE, Hilkewich L, Gillis C, Heine JA, Fenton TR. Protein intakes are associated with reduced length of stay: a comparison between Enhanced Recovery After Surgery (ERAS) and conventional care after elective colorectal surgery. Am J Clin Nutr. 2017;106(1):44-51.
- [4] Pędziwiatr M, Mavrikis J, Witowski J, et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol. 2018;35(6):95.
- [5] Vlug MS, Wind J, Hollmann MW, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg. 2011;254(6):868-875.
- [6] Chen S, Zou Z, Chen F, Huang Z, Li G. A meta-analysis of fast track surgery for patients with gastric cancer undergoing gastrectomy. Ann R Coll Surg Engl. 2015;97(1):3-10.
