Have you heard of ERAS protocols, but never quite understood what they entail? ERAS means Enhanced Recovery After Surgery, and in this blog post, we will not only explain the key elements of ERAS in general surgery, but also discuss the obstacles for success, and offer potential solutions to help increase compliance with ERAS programs.
When you need surgery the hospital stay significantly disrupts your independence.
This is due to tubes, catheters, intravenous fluid administrations and other restrictions that are needed for many types of interventions. All are inhibitors for what you can do. The goal of Enhanced Recovery After Surgery (ERAS) protocols is to help patients regain their independence as quickly as possible by reducing complication rates, and promoting early recovery, which ultimately also shorten hospital stay and reduce the economic burdens.
ERAS is more than a protocol - it is a multimodal postoperative recovery program based on the latest medical science and it is performed by a multidisciplinary team, including the patient.
How it started:
The ERAS concept was developed in 1997 by Prof. Henrik Kehlet, a Danish colorectal surgeon. Prof. Kehlet proposed that evidence-based, standardized multimodal care can lessen the body’s reaction to surgery, thereby reducing postoperative morbidity. The concept was first referred to as “Fast track” surgery, and became later known as an “Enhanced Recovery After Surgery” protocol. Subsequently the ERAS Society was initiated and registered in Sweden in 2010 as an international non-profit organization with members from different professions involved in surgical care. The mission of the ERAS Society is to provide guidance, to organize educational meetings, and to help hospitals in developing protocols to improve the quality of patient care to reduce postoperative complications after surgeries.
ERAS programs have now been developed for most surgical specialties, however, the implementation of the programs have been relatively slow. It has been suggested this may be due to the need for multidisciplinary collaboration as well as psychological and organizational factors that could obstruct the transition from traditional care. The success of the programs depends on that everyone involved in the healthcare team, including the patient, work together and carry out all planned interventions throughout the entire process from the first assessment of the patient to the end of the follow-up period after discharge.
ERAS protocols generally have led to better patient outcomes, specially
in reducing hospital stay. Reduction in the rates of complications
and readmissions have till now primarily been shown for colorectal surgery.
Let’s review the key elements of an ERAS protocol for general surgery.
ERAS protocols provide guidelines on optimal nutrition, and include recommendations of foods and drinks with increased amounts of carbohydrates. They may also advise the use of nutritional supplements, or specialized diet before surgery in order to ensure that patients get the nutrients they need to promote healing and recovery.
Fasting for many hours has traditionally been routine before surgery, but it has been shown to increase insulin resistance, and not to reduce the risk of accidentally inhaling food or fluid into the lungs after anesthesia. Therefore, ERAS protocols recommend to keep fasting before surgery as short as possible, and to consume carbohydrate-rich drinks to decrease insulin resistance after surgery. This can be a glucose-rich drink 2-3 hours before surgery, and some also recommend a carbohydrate drink the night before. Common choices for many ERAS programs include Powerade, or Gatorade, however, if patients have conditions where the stomach doesn't empty properly, or have other problems that affect how the stomach moves, this may not be advised.
Smoking and alcohol cessation.
It is well known that smoking and alcohol increase the risk of complications after surgery and delay healing. Patients who smoke will be advised to quit smoking at least four weeks before surgery, as well as abstain from consumption of alcohol in order to enhance organ functions, and to condition the body to better withstand the stress of surgery.
Increased information to the patient. The traditional consent forms that typically are presented to patients focus primarily on possible complications. Since most patients are anxious about what lies ahead and what to expect after surgery, educating them well about the intervention and recovery process can help reduce such anxiety and prepare them better mentally for surgery.
ERAS guidelines recommend that comprehensive information should be provided about the surgical procedure, the expected hospital stay, and how the patient can take an active role in the recovery process. Patient education should be an ongoing process that continues in the recovery period until the surgical wound has healed. It should include information about wound care, pain management, and rehabilitation to ensure a successful recovery.
Regional anesthesia techniques.
ERAS protocols increasingly focus on reducing the use of opioids (narcotics) during surgery and using shorter-acting anesthetics, which allows for earlier extubation to the benefit of most patients. Regional anesthesia techniques, such as epidural anesthesia, can both reduce the need for general anesthesia and for opioids, which can decrease the risk of complications and improve recovery.
Minimally invasive surgery.
Combining ERAS protocols with minimally invasive surgery has been shown
to reduce the inflammatory stress response leading to fewer complications and shorter hospital stays. Smaller incisions may also result in less pain and reduce the need for pain medication.
Minimizing use of tubes.
ERAS protocols recommends to carefully consider whether surgical drains, nasogastric tubes, urinary catheters and other invasive tubes are needed, since such devices restricts the patients possibility for early movement.
Early extubation has been shown to be associated with shorter ICU and hospital stays. Patients who start eating normally and move sooner also results in overall higher patient satisfaction. Some centers have achieved success with extubation already in the operating room, and evidence suggests it does not increase morbidity or mortality.
Pain control with minimized opioid use.
ERAS guidelines recommend combining various groups of medications for pain relief to reduce the need for opioids, which can have significant side effects such as nausea, vomiting, constipation and risk of addiction. The technique, called multimodal analgesia may include the use of non-opioid painkillers, local anesthetics, and nerve blocks. Sufficient pain management is crucial for promoting patient collaboration in activities such as mobilization, physiotherapy and rehabilitation earlier in their recovery process, which can help reducing the risk of postoperative complications, and lead to shorter hospital stays.
Prevention of low body temperature and low oxygen concentration.
The use of anesthetics affects the body’s thermoregulation, and low body temperature is linked to an increased risk of postoperative complications, like arrhythmias, surgical site infections, blood clotting, and mortality. Therefore it is essential to keep patients warm in the ICU which can be done through simple methods such as warming blankets.
Fluid control and anti-nausea medications.
Balancing how much fluid patients get after surgery is important to maintain normal heart rate, blood pressure, and other hemodynamic values. ERAS protocols recommend a restrictive fluid strategy for both intravenous fluid administration and the need for blood transfusions to prevent complications such as too much fluid in the lungs.
Medications to prevent or treat nausea and vomiting is also recommended to avoid patient discomfort that could hinder mobilization and delay discharge.
Early removal of drains, tubes, catheters.
The sooner intravenous fluid administration can be discontinued, and drains, tubes, catheters, and other devices can be removed from the patient, the sooner he/she can start mobilization which helps to decrease complications.
Early oral feeding.
Early feeding can help prevent gastrointestinal complications and reduce the length of hospital stay. ERAS protocols recommend feeding patients as soon as possible after surgery and start with clear fluids followed by a soft diet. This may include a specialized diet or nutritional supplements, as well as monitoring of fluid intake to prevent dehydration.
Early mobilization is a key component of ERAS protocols. Starting mobilization within 24 hours of surgery has been shown to reduce the risk of complications, including clotting of blood in the legs or lungs, and infections in the lungs. It has also been shown to decrease pain, fatigue, cognitive dysfunction, and anxiety. Patients are generally advised to spend 2 hours outside the bed on the day of surgery and 6 hours per day thereafter until discharge.
Physical therapy and rehabilitation are also essential components of ERAS protocols, and are typically started immediately after surgery in order to help patients regain strength and mobility.
Compliance with ERAS protocols:
Although ERAS has its strongest evidence base in colorectal surgery, many of these interventions are general and are being applied in most other surgical specialties too. By introducing ERAS programs the length of hospital stay for surgical patients have been shown to be reduced by up to 30%, leading to significant cost savings. In addition, by improving the patient's overall recovery process by reducing pain, improving mobility, and reducing the risk of complications, patient satisfaction is improved and they can return to their normal activities sooner.
Several obstacles to successful ERAS programs have been reported, such as preoperative risk factors, early surgical complications, lack of awareness and education about the benefits of early mobilization, insufficient staff or time to mobilize patient, a culture that does not prioritize physical activity during hospitalization, technical difficulties due to drains, catheters etc., and direct patient-related factors such as pain, inactivity, and insecurity. Other obstacles may include resistance to change and financial resources.
Compliance and outcomes of ERAS programs can be understood by collecting and analyzing relevant data. Real-time data collection enables the ERAS team to quickly act if compliance and/ or outcomes are not meeting the goals, and it reveals the impact of their work on patient outcomes. Positive outcomes can help secure additional resources, while negative results can be used to modify ERAS protocols based on new compelling evidence.
ERAS elements such as cessation of smoking and alcohol consumption, diet adjustments and early mobilization after surgery need active involvement and cooperation of the patient. Most other items of an ERAS protocol are passive with regards to the patient’s involvement.
Compliance has been reported to be high in the preoperative and intraoperative stages for passive items which does not rely on patient involvement, but decreased significantly after surgery particularly with regards to mobilization which was 48% on the 1st postoperative day but just 28% on the 2nd postoperative day. Poor active compliance has been associated with increased morbidity and longer hospital stay.
Several randomized controlled trials have shown the benefits of early mobilization, including faster gastrointestinal recovery, improved sleeping time, shorter hospital stays, and improved functional exercise capacity. Patient-reported outcomes are also improved with early mobilization, including reduced pain, improved quality of life, and reduced fatigue.
It is important that patients are educated and understands the importance of an early mobilization as soon as the day of surgery. Often the programs specify targets for the total amount of time that should be spent out of bed, the total distance to walk, or the frequency of periods of walking.
The multidisciplinary ERAS team usually consist of 4 to 8 people including at least a surgeon, an anaesthesiologist, a nurse and an administrative employee.
The primary burden is often on the nurse, and it has been shown that at least 50% of the working time needs to be dedicated to the ERAS protocol for a successful implementation. This may not always be feasible and it is tempting to speculate whether the availability of staff and tools to help the patient in the first days after surgery could be part of the reason for low compliance with mobilization in the ERAS protocols.
Relatively simple interventions have the potential to improve adherence to the ERAS mobilization recommendations. Patients may be reluctant to get out of bed because they are afraid of pain when moving and feel insecure. A practical item such as an ergonomic, comfortable abdominal binder that effectively supports the wound and the sore abdominal muscles can decrease pain and make it easier for the patient to move, which may improve compliance with mobilization goals.
Abdominal binders have been shown to decrease pain, make patients walk longer and speed up gastrointestinal function. An effective abdominal binder may also help to make patients less dependent on the availability of staff to help them. (https://www.qualiteam.com/pages/qualibelly-advanced-triband-abdominal-support). Since no negative effects have been shown from wearing an abdominal binder, it should be evaluated whether such binders should be part of ERAS recommendations to improve compliance with mobilization.
Wearable devices that count steps and monitor movement can provide continuous data on physical activity of patients without burdening the staff, and such control of mobilization have been linked to improved clinical outcomes.
Educational tools such as applications for downloading on mobile devices for promoting postoperative mobilization developed in cooperation with exercise physiologists and physical therapists may also provide an opportunity to improve compliance.
Enhanced Recovery After Surgery (ERAS) protocols are designed to help patients recover from surgery quickly, reducing complication rates and shortening hospital stay. A key element of successful ERAS programs is active participation from patients, including following protocols for preoperative preparation, pain relief, and early mobilization. However, compliance can be difficult, which can lead to increased morbidity and longer hospital stays. To address this, patients need to be informed about the importance of complying with activities in the protocol that depends on them, and they need to be given the tools to do so.
For example, abdominal binders may help patients comply with ERAS protocols for mobilization by reducing pain and improving mobility.
Ultimately, the success of ERAS protocols depends highly on involving patients actively in their recovery. Providing them with practical tools could significantly improve compliance and should be considered as an adjunct to ERAS recommendations to promote postoperative recovery.
Kehlet, H. Enhanced Recovery After Surgery (ERAS): Good for now, but what about the future?. Can J Anesth/J Can Anesth 62, 99–104 (2015). https://doi.org/10.1007/ s12630-014-0261-3
Taurchini M, Del Naja C, Tancredi A. Enhanced Recovery After Surgery: A patient centered process. J Vis Surg. 2018 Feb 27;4:40. doi: 10.21037/jovs.2018.01.20. PMID: 29552522; PMCID: PMC5847857.
Gillis C, Gill M, Marlett N, MacKean G, GermAnn K, Gilmour L, Nelson G, Wasylak T, Nguyen S, Araujo E, Zelinsky S, Gramlich L. Patients as partners in Enhanced Recovery After Surgery: A qualitative patient-led study. BMJ Open. 2017 Jun 24;7(6):e017002. doi: 10.1136/ bmjopen-2017-017002. PMID: 28647727; PMCID: PMC5726093.
Reeana Tazreean1, Gregg Nelson2,3 & Rosie Twomey. Early mobilization in enhanced recovery after surgery pathways: current evidence and recent advancementsJ. Comp. Eff. Res. (2022) 11(2), 121–129
Tanya Castelino, Julio F. Fiore, Petru Niculiseanu, Tara Landry, Berson Augustin, Liane S. Feldman. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review.
Surgery, Volume 159, Issue 4, 2016, Pages 991-1003, https://doi.org/10.1016/j.surg.2015.11.029.
Jiang N, Hao B, Huang R, Rao F, Wu P, Li Z, Song C, Liu Z, Guo T. The Clinical Effects of Abdominal Binder on Abdominal Surgery: A Meta-analysis. Surg Innov. 2021 Feb;28(1):94-102. doi: 10.1177/1553350620974825. Epub 2020 Nov 25. PMID: 33236689.