Applying principles of enhanced recovery after surgery

Enhanced recovery after surgery (ERAS) is an international, multidisciplinary initiative dedicated to the advancement of perioperative surgical care. ERAS is comprised of intervention bundles targeting each of the preoperative, intraoperative, and postoperative phases of care1. Collectively, these interventions have been shown to significantly decrease perioperative morbidity and improve overall patient outcomes2. Successive ERAS iterations have been applied to individual disciplines and surgical procedures. However, the underlying tenets are applicable across disciplines. Recognizing and understanding the evidence behind each step in the perioperative pathway facilitates the delivery of thoughtful, effective care of the surgical patient. Surgical practice historically is deeply rooted in the culture of the individual surgical centre and long-established practice patterns often taught as dogma3. Surgeons must understand each facet of perioperative decision-making and remain curious as to why certain facets of patient care are structured the way they are. Examples of this include standardized patient instructions outlining preoperative mechanical bowel preparation (or lack thereof), admission criteria for the inpatient ward, and use of pre-established orders outlining postoperative oral intake. The ERAS pathway can serve as a scaffold to understand cultural surgical norms, as well as the evidence base for perioperative management. The following sections outline the core elements of ERAS (Fig. 1), highlighting the evidence on which they were built, and provide tangible strategies to incorporate these initiatives into practice. ERAS Intervention Bundles for Preoperative, Intraoperative and Postoperative Phases of Care ERAS, enhanced recovery after surgery; NSAIDs, non-steroidal anti-inflammatory drugs; TAP, transversus abdominis plane. Starting before the patient reaches the hospital doors, preoperative interventions are crucial in setting the foundation for successful surgery. Shifting practice and rethinking preoperative management was a significant challenge to the implementation of ERAS. This is largely a consequence of long-held beliefs around optimal patient preparation. Preoperative instructions for abdominopelvic surgery, for example, have traditionally outlined aggressive mechanical bowel preparation coupled with extended fasting. It has since been established, however, that such a regimen does not improve surgical outcomes and in fact may increase morbidity through impaired bowel motility (ileus), dysregulation of blood glucose, worse overall postoperative nausea/emesis, and adversely impacting volume status4. Adoption of this change in practice around bowel preparation and fasting continues to be met with some resistance, particularly by those who trained in an era where strict adherence to mechanical bowel preparation and fasting was felt to be imperative to safe surgical practice. Yet the ongoing accrual of evidence supporting preoperative recommendations for gastrointestinal management makes this a critical evolution in preoperative care. As most preoperative care is performed outside of the surgical centre, standardized instructions are provided to patients to guide them through this phase. Therefore, it is important that such instructions are regularly and rigorously evaluated to ensure they align with best evidence. ERAS can effectively be used in this setting as a validated source of current evidence and recommendations for care. Table 1 outlines preoperative ERAS recommendations, including key studies and sample orders. Example preoperative ERAS recommendations Prolonged preoperative fasting should be avoided. Solids may be permitted until 6 h before surgery and clear liquids should be continued until 2 h before surgery. Carbohydrate loading with an isotonic complex carbohydrate solution (classically 50 g of malodextrin) is recommended 2–3 h before surgery. ✓ Diet order. Final snack 8 h before scheduled surgery. Clear fluids permitted until 2 h before scheduled surgery. Nil by mouth 2 h before scheduled surgery. ✓ Diet order. Preoperative carbohydrate load with clear apple juice or cranberry cocktail 500 ml orally 3 h before scheduled surgery; must be consumed by 2 h before scheduled surgery. Mechanical bowel preparation should not be administered routinely. In circumstances where mechanical bowel preparation is desired, oral antibiotics are now recommended to be given in conjunction. ✓ Take (a macrolide - check your hospital antibiogram for site specific selection) + Metronidazole 2 g 12 h before surgery. NSAIDs and paracetamol can be administered before surgery, ✓ Paracetamol 1000 mg pre-procedure; please provide to patient 1 h before surgery. ✓ (NSAID of choice) for one dose pre-procedure; please provide to patient 1 h before surgery. Cefazolin is the antibiotic of choice for preoperative prophylaxis when indicated. Cefazolin should be given to most patients with reported penicillin allergy and only withheld in cases of penicillin-induced severe cutaneous reactions or verified cefazolin allergy. ✓ Cefazolin 1 g intravenously to be given within 60 min of incision time. ✓ If confirmed cefazolin allergy or prior severe non-IgE-mediated reaction to any β-lactam then an alternative antimicrobial may be selected (according to site-specific antibiogram). Prolonged preoperative fasting should be avoided. Solids may be permitted until 6 h before surgery and clear liquids should be continued until 2 h before surgery. Carbohydrate loading with an isotonic complex carbohydrate solution (classically 50 g of malodextrin) is recommended 2–3 h before surgery. ✓ Diet order. Final snack 8 h before scheduled surgery. Clear fluids permitted until 2 h before scheduled surgery. Nil by mouth 2 h before scheduled surgery. ✓ Diet order. Preoperative carbohydrate load with clear apple juice or cranberry cocktail 500 ml orally 3 h before scheduled surgery; must be consumed by 2 h before scheduled surgery. Mechanical bowel preparation should not be administered routinely. In circumstances where mechanical bowel preparation is desired, oral antibiotics are now recommended to be given in conjunction. ✓ Take (a macrolide - check your hospital antibiogram for site specific selection) + Metronidazole 2 g 12 h before surgery. NSAIDs and paracetamol can be administered before surgery, ✓ Paracetamol 1000 mg pre-procedure; please provide to patient 1 h before surgery. ✓ (NSAID of choice) for one dose pre-procedure; please provide to patient 1 h before surgery. Cefazolin is the antibiotic of choice for preoperative prophylaxis when indicated. Cefazolin should be given to most patients with reported penicillin allergy and only withheld in cases of penicillin-induced severe cutaneous reactions or verified cefazolin allergy. ✓ Cefazolin 1 g intravenously to be given within 60 min of incision time. ✓ If confirmed cefazolin allergy or prior severe non-IgE-mediated reaction to any β-lactam then an alternative antimicrobial may be selected (according to site-specific antibiogram). Clinicians must follow the guidelines (for example antimicrobial prophylaxis) from their own institutions. ERAS, enhanced recovery after surgery; NSAIDs, non-steroidal anti-inflammatory drugs; IgE, immunoglobulin E. Example preoperative ERAS recommendations Prolonged preoperative fasting should be avoided. Solids may be permitted until 6 h before surgery and clear liquids should be continued until 2 h before surgery. Carbohydrate loading with an isotonic complex carbohydrate solution (classically 50 g of malodextrin) is recommended 2–3 h before surgery. ✓ Diet order. Final snack 8 h before scheduled surgery. Clear fluids permitted until 2 h before scheduled surgery. Nil by mouth 2 h before scheduled surgery. ✓ Diet order. Preoperative carbohydrate load with clear apple juice or cranberry cocktail 500 ml orally 3 h before scheduled surgery; must be consumed by 2 h before scheduled surgery. Mechanical bowel preparation should not be administered routinely. In circumstances where mechanical bowel preparation is desired, oral antibiotics are now recommended to be given in conjunction. ✓ Take (a macrolide - check your hospital antibiogram for site specific selection) + Metronidazole 2 g 12 h before surgery. NSAIDs and paracetamol can be administered before surgery, ✓ Paracetamol 1000 mg pre-procedure; please provide to patient 1 h before surgery. ✓ (NSAID of choice) for one dose pre-procedure; please provide to patient 1 h before surgery. Cefazolin is the antibiotic of choice for preoperative prophylaxis when indicated. Cefazolin should be given to most patients with reported penicillin allergy and only withheld in cases of penicillin-induced severe cutaneous reactions or verified cefazolin allergy. ✓ Cefazolin 1 g intravenously to be given within 60 min of incision time. ✓ If confirmed cefazolin allergy or prior severe non-IgE-mediated reaction to any β-lactam then an alternative antimicrobial may be selected (according to site-specific antibiogram). Prolonged preoperative fasting should be avoided. Solids may be permitted until 6 h before surgery and clear liquids should be continued until 2 h before surgery. Carbohydrate loading with an isotonic complex carbohydrate solution (classically 50 g of malodextrin) is recommended 2–3 h before surgery. ✓ Diet order. Final snack 8 h before scheduled surgery. Clear fluids permitted until 2 h before scheduled surgery. Nil by mouth 2 h before scheduled surgery. ✓ Diet order. Preoperative carbohydrate load with clear apple juice or cranberry cocktail 500 ml orally 3 h before scheduled surgery; must be consumed by 2 h before scheduled surgery. Mechanical bowel preparation should not be administered routinely. In circumstances where mechanical bowel preparation is desired, oral antibiotics are now recommended to be given in conjunction. ✓ Take (a macrolide - check your hospital antibiogram for site specific selection) + Metronidazole 2 g 12 h before surgery. NSAIDs and paracetamol can be administered before surgery, ✓ Paracetamol 1000 mg pre-procedure; please provide to patient 1 h before surgery. ✓ (NSAID of choice) for one dose pre-procedure; please provide to patient 1 h before surgery. Cefazolin is the antibiotic of choice for preoperative prophylaxis when indicated. Cefazolin should be given to most patients with reported penicillin allergy and only withheld in cases of penicillin-induced severe cutaneous reactions or verified cefazolin allergy. ✓ Cefazolin 1 g intravenously to be given within 60 min of incision time. ✓ If confirmed cefazolin allergy or prior severe non-IgE-mediated reaction to any β-lactam then an alternative antimicrobial may be selected (according to site-specific antibiogram). Clinicians must follow the guidelines (for example antimicrobial prophylaxis) from their own institutions. ERAS, enhanced recovery after surgery; NSAIDs, non-steroidal anti-inflammatory drugs; IgE, immunoglobulin E. ERAS identifies several key moments after the induction of anesthesia that warrant special attention. The theatre team must work together to achieve optimal outcomes through open communication on temperature, volume status, operative approach, and preparation for the postoperative phase of care. The surgical safety checklist provides structure to the conversation around these metrics. There are many surgical safety checklists available, including those designed by the WHO, as well as specific institution and even procedure-based lists. The ERAS-Surgical Safety Checklist has effectively consolidated and bolstered these lists to create a user-friendly checklist that optimizes engagement, streamlines communication, and facilitates safer surgical practice8. The checklist is implemented at three time points: before induction of anaesthesia, before skin incision, and before the patient leaves the operating theatre. Table 2 provides examples of key aspects of intraoperative care as highlighted by ERAS. While analgesia is outlined in the ‘postoperative’ section, it should be noted that the best strategy to optimize postoperative analgesia starts intraoperatively. Opioid-sparing strategies such as incorporation of surgeon-placed transversus abdominis plane (TAP) blocks in the ERAS pathway have been shown to significantly decrease postoperative pain and length of stay12. Example intraoperative ERAS recommendations A minimally invasive surgical approach should be strongly considered where appropriate based on patient factors and surgery-specific data. Active body-warming systems should be employed to maintain normothermia in order to lower rates of surgical-site infection and complications. ✓ Apply active body-warming system 1 h before scheduled procedure, to remain in place until arrival in the operating theatre. Target a zero-balance approach. Note: concerns in the literature regarding a zero-balance approach contributing to acute kidney injury have not been well validated. ✓ Intraoperative discussion with anaesthetic colleagues. Routine placement of postoperative drains (including abdominal, pelvic, and thoracic) should be discouraged or of minimized duration. Routine use of nasogastric tubes should be avoided; if placed during surgery, should be removed at the end of the case. A minimally invasive surgical approach should be strongly considered where appropriate based on patient factors and surgery-specific data. Active body-warming systems should be employed to maintain normothermia in order to lower rates of surgical-site infection and complications. ✓ Apply active body-warming system 1 h before scheduled procedure, to remain in place until arrival in the operating theatre. Target a zero-balance approach. Note: concerns in the literature regarding a zero-balance approach contributing to acute kidney injury have not been well validated. ✓ Intraoperative discussion with anaesthetic colleagues. Routine placement of postoperative drains (including abdominal, pelvic, and thoracic) should be discouraged or of minimized duration. Routine use of nasogastric tubes should be avoided; if placed during surgery, should be removed at the end of the case. ERAS, enhanced recovery after surgery; NA, not applicable. Example intraoperative ERAS recommendations A minimally invasive surgical approach should be strongly considered where appropriate based on patient factors and surgery-specific data. Active body-warming systems should be employed to maintain normothermia in order to lower rates of surgical-site infection and complications. ✓ Apply active body-warming system 1 h before scheduled procedure, to remain in place until arrival in the operating theatre. Target a zero-balance approach. Note: concerns in the literature regarding a zero-balance approach contributing to acute kidney injury have not been well validated. ✓ Intraoperative discussion with anaesthetic colleagues. Routine placement of postoperative drains (including abdominal, pelvic, and thoracic) should be discouraged or of minimized duration. Routine use of nasogastric tubes should be avoided; if placed during surgery, should be removed at the end of the case. A minimally invasive surgical approach should be strongly considered where appropriate based on patient factors and surgery-specific data. Active body-warming systems should be employed to maintain normothermia in order to lower rates of surgical-site infection and complications. ✓ Apply active body-warming system 1 h before scheduled procedure, to remain in place until arrival in the operating theatre. Target a zero-balance approach. Note: concerns in the literature regarding a zero-balance approach contributing to acute kidney injury have not been well validated. ✓ Intraoperative discussion with anaesthetic colleagues. Routine placement of postoperative drains (including abdominal, pelvic, and thoracic) should be discouraged or of minimized duration. Routine use of nasogastric tubes should be avoided; if placed during surgery, should be removed at the end of the case. ERAS, enhanced recovery after surgery; NA, not applicable. The postoperative phase involves multiple ERAS target points that collectively seek to dismantle the historical belief of postoperative ‘convalescence’ during which the patient was thought to slowly regain their vital functions and capacity13. Though there are some variations according to surgical procedure and specialty, the core tenets of ERAS interventions in the postoperative phase seek to decrease postoperative in-hospital morbidity through active mobilization, early feeding, avoidance of hospital-acquired infection, decreased reliance on opioid analgesia, and facilitation of early discharge. Four central components of this postoperative phase, namely early resumption of diet, focus on analgesia, urinary catheter removal, and deep-vein thrombosis prophylaxis, are outlined in Table 3. Example postoperative ERAS recommendations Early introduction of diet should be encouraged, even after bowel surgery. Intravenous fluids should generally be discontinued on resumption of diet. ✓ Diet order. Please implement surgical transition diet when patient arrives on the unit. ✓ Please discontinue intravenous fluid once patient tolerating oral fluids (typically 500 ml). Incorporation of a comprehensive multimodal analgesia strategy, beginning before surgery (see preoperative recommendations above) is essential to optimizing postoperative pain. Opioid-sparing analgesia should be prioritized with judicious use of opioids if needed (no patient-controlled analgesia!). ✓ Paracetamol 1 g orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Ibuprofen 400 mg orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Hydromorphone 1–2 mg orally every 4 h as needed for severe breakthrough pain only. Urinary catheters should be removed as soon as possible after surgery (consider immediately after surgery for minimally invasive surgery and within 24 h for laparotomy). ✓ For laparotomy patients, please remove urinary catheter at 06.00 hours on postoperative day 1, no later than 24 h after surgery. Dual prevention with mechanical prophylaxis and chemoprophylaxis should be strongly considered for patients at elevated risk of venous thromboembolism. ✓ Tinzaparin 4500 units subcutaneously daily to begin at 21.00 hours on postoperative day 0. ✓ Please apply bilateral sequential compression device on arrival to unit. To remain in place when patient is not mobilizing. Early introduction of diet should be encouraged, even after bowel surgery. Intravenous fluids should generally be discontinued on resumption of diet. ✓ Diet order. Please implement surgical transition diet when patient arrives on the unit. ✓ Please discontinue intravenous fluid once patient tolerating oral fluids (typically 500 ml). Incorporation of a comprehensive multimodal analgesia strategy, beginning before surgery (see preoperative recommendations above) is essential to optimizing postoperative pain. Opioid-sparing analgesia should be prioritized with judicious use of opioids if needed (no patient-controlled analgesia!). ✓ Paracetamol 1 g orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Ibuprofen 400 mg orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Hydromorphone 1–2 mg orally every 4 h as needed for severe breakthrough pain only. Urinary catheters should be removed as soon as possible after surgery (consider immediately after surgery for minimally invasive surgery and within 24 h for laparotomy). ✓ For laparotomy patients, please remove urinary catheter at 06.00 hours on postoperative day 1, no later than 24 h after surgery. Dual prevention with mechanical prophylaxis and chemoprophylaxis should be strongly considered for patients at elevated risk of venous thromboembolism. ✓ Tinzaparin 4500 units subcutaneously daily to begin at 21.00 hours on postoperative day 0. ✓ Please apply bilateral sequential compression device on arrival to unit. To remain in place when patient is not mobilizing. ERAS, enhanced recovery after surgery; NICE; National Institute for Health and Care Excellence. Example postoperative ERAS recommendations Early introduction of diet should be encouraged, even after bowel surgery. Intravenous fluids should generally be discontinued on resumption of diet. ✓ Diet order. Please implement surgical transition diet when patient arrives on the unit. ✓ Please discontinue intravenous fluid once patient tolerating oral fluids (typically 500 ml). Incorporation of a comprehensive multimodal analgesia strategy, beginning before surgery (see preoperative recommendations above) is essential to optimizing postoperative pain. Opioid-sparing analgesia should be prioritized with judicious use of opioids if needed (no patient-controlled analgesia!). ✓ Paracetamol 1 g orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Ibuprofen 400 mg orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Hydromorphone 1–2 mg orally every 4 h as needed for severe breakthrough pain only. Urinary catheters should be removed as soon as possible after surgery (consider immediately after surgery for minimally invasive surgery and within 24 h for laparotomy). ✓ For laparotomy patients, please remove urinary catheter at 06.00 hours on postoperative day 1, no later than 24 h after surgery. Dual prevention with mechanical prophylaxis and chemoprophylaxis should be strongly considered for patients at elevated risk of venous thromboembolism. ✓ Tinzaparin 4500 units subcutaneously daily to begin at 21.00 hours on postoperative day 0. ✓ Please apply bilateral sequential compression device on arrival to unit. To remain in place when patient is not mobilizing. Early introduction of diet should be encouraged, even after bowel surgery. Intravenous fluids should generally be discontinued on resumption of diet. ✓ Diet order. Please implement surgical transition diet when patient arrives on the unit. ✓ Please discontinue intravenous fluid once patient tolerating oral fluids (typically 500 ml). Incorporation of a comprehensive multimodal analgesia strategy, beginning before surgery (see preoperative recommendations above) is essential to optimizing postoperative pain. Opioid-sparing analgesia should be prioritized with judicious use of opioids if needed (no patient-controlled analgesia!). ✓ Paracetamol 1 g orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Ibuprofen 400 mg orally scheduled every 6 h for 72 h then every 6 h as needed. ✓ Hydromorphone 1–2 mg orally every 4 h as needed for severe breakthrough pain only. Urinary catheters should be removed as soon as possible after surgery (consider immediately after surgery for minimally invasive surgery and within 24 h for laparotomy). ✓ For laparotomy patients, please remove urinary catheter at 06.00 hours on postoperative day 1, no later than 24 h after surgery. Dual prevention with mechanical prophylaxis and chemoprophylaxis should be strongly considered for patients at elevated risk of venous thromboembolism. ✓ Tinzaparin 4500 units subcutaneously daily to begin at 21.00 hours on postoperative day 0. ✓ Please apply bilateral sequential compression device on arrival to unit. To remain in place when patient is not mobilizing. ERAS, enhanced recovery after surgery; NICE; National Institute for Health and Care Excellence. Surgical training extends far beyond the operating room and must involve dedicated exposure to the perioperative pathway in its entirety. By learning to critically appraise each prescribed intervention in perioperative care, surgeons can effectively shape their future practice. ERAS is an expansive, multinational initiative that effectively functions to gather and disseminate best practice recommendations across surgical disciplines. The above sections showcase only a small fraction of how ERAS can be used to optimize patient care, but may serve as a guide to understanding how certain parts of the care pathway came to be and highlight where local surgical practice may differ from global recommendations. This is a fast-moving discipline and, while it is important to be familiar with the evidence guiding perioperative care today, it is equally important to understand how this will inevitably continue to evolve (for example the widespread use of glucagon-like peptide 1 (GLP-1) agonists will require special consideration with regard to preoperative fasting). The authors would encourage all surgeons and surgical trainees to further explore the breadth of ERAS, as well as the nuances of care delivery within their specialty. The authors have no funding to declare. Dr Nelson is Co-Chair of the Scientific Committee for the ERAS® Society. The authors declare no other conflict of interest. Not applicable.

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