ERAS: IMPROVING PATIENT OUTCOME BY EVIDENCE-BASED MEDICINE

Lack of standardization in perioperative care can negatively impact patient outcome and inflate the cost burden of surgical care. ERAS is an acronym for Enhanced Recovery After Surgery. ERAS protocols are multimodal, multidisciplinary, patient-centric, perioperative care pathways designed to accelerate patient recovery after surgery by standardizing perioperative care. Initially employed for open colorectal surgery, tailormade ERAS protocols for each surgical stream are now available. ERAS Society guidelines (19 in number; available free from http://erassociety.org website) are now available for pancreaticoduodenectomy, rectal/pelvic surgery, hepatic resection, head and neck surgery with free-flap reconstruction, oesophageal, gastric and lung cancer surgery, radical prostatectomy, gynaecooncologic surgery, breast reconstruction and bariatric surgery. Reports of ERAS protocol implementation for neuro-surgical procedures, especially spine surgery have also appeared. The key ERAS elements form a seamless continuum from hospital-arrival to return of baseline function on hospital discharge and are clubbed as preoperative, intraoperative and post-operative bundles.

Preoperative patient counselling, fluid and carbohydrate loading, optimization of nutrition and prehabilitation, avoidance of prolonged fasting, no/selective bowel preparation, antibiotic prophylaxis, thromboprophylaxis, and no premedication comprise the preoperative elements. Emphasis on short acting anaesthetic agents, thoracic epidural catheters wherever applicable, opioid-sparing multimodal analgesia, no drains, goal-directed fluid therapy to avoid fluid and salt overload, maintenance of intraoperative normothermia (convective warming blankets; warm intravenous fluids) and multimodal antiemetics comprise the intraoperative elements. Opioid-sparing post-operative analgesia (thoracic epidural catheters (72h); oral NSAIDS; celecoxib; paracetamol; gabapentin; ketorolac), no nasogastric tubes, early oral nutrition, early removal of catheters, avoiding postoperative nausea and vomiting, stimulation of gut motility (chewing gum), avoiding salt and water overload and early mobilization are the key postoperative elements. Opioids cause immediate adverse effects like nausea, vomiting, pruritus, constipation, sedation and respiratory depression.

An audit of compliance with ERAS-elements and outcomes is essential to complete the loop. A motivated ERAS-team comprising surgeons, anaesthesiologists, pre-admission staff, dieticians, nurses, physiotherapists, social workers, occupational therapists and administrators can reduce length of hospital stay and enhance recovery. Although ERAS embraces evidence-based medicine, it involves fundamental shifts in surgical and anaesthetic practice. Let us bust a few related myths now.

Myth-1: The practice of keeping patients nil per orris (NPO) after midnight is traditionally used to avoid pulmonary aspiration or regurgitation during/after anaesthesia for elective surgery. This, however, lacks supporting scientific evidence, as reported conclusively by a review of 22 RCTs comparing different perioperative fasting regimens and perioperative complications. Preoperative fasting actually increases the metabolic stress, hyperglycemia, insulin resistance, protein loss and reduces muscle function. If patients are allowed to take solids up to 6 hours preoperatively and clear fluids up to 2 hours, there is no increase in complications, (Royal College of Anaesthetists and the American Society of Anesthesiologists guidelines). Carbohydrate loading attenuates postoperative insulin resistance, reduces nitrogen and protein losses, preserves skeletal muscle mass and reduces preoperative thirst, hunger and anxiety, facilitates early return of bowel function and shorter hospital stay and an improved perioperative well-being. Carboload (Hexagon Nutrition) is a clear, complex-carbohydrate drink, exclusively designed to support the ERAS protocol. Chief ingredients include Maltodextrin 47.5g and minerals (zinc, selenium, sodium, potassium). On the evening prior to surgery, at 10PM, 2 sachets (100g) dissolved in 400 ml water each are orally administered to the patients followed by another sachet (50g), dissolved in 400 ml of water, 2h before surgery.

Myth-2: Preoperative mechanical bowel preparation (MBP) has traditionally been the custom in colorectal surgery and other surgery involving bowel segments (radical cystectomy with ileal conduit /neobladder). The aim of MBP is to rid the large bowel of solid faecal contents and to lower the bacterial load, thereby reducing the incidence of postoperative complications. However, MBP liquefies solid faeces, which may increase the risk of intra-operative spillage of contaminant, and it is almost impossible to reduce the bacterial load in the bowel due to the vast number of micro-organisms present in the digestive tract. MBP causes metabolic and electrolyte imbalance, dehydration, abdominal pain/bloating and fatigue, accompanied with an increased incidence of anastomotic leaks, wound infections, intra-abdominal abscesses and extra-digestive complications as evidenced by a (Slim et al) which included 14 randomised controlled trials and nearly 5000 patients.

Myth-3: Traditionally, it has been our constant endeavour to schedule surgery as soon as possible after a patient presents with a resectable pathology. Nutritional deficiency, particularly for oncosurgical patients, is an independent risk factor for complications and prolonged hospital-stay and costs and is a strong predictor of 90-day mortality and poor overall survival.  Overall half the cancer patients and three quarters of oral and GI-cancer patients are malnourished. The prevalence of pre-operative malnutrition is 65.3% for all surgical patients combined and 84.9% for gastrointestinal cancer patients. European Society of Parenteral and Enteral Nutrition defines “severe” nutritional risk as weight loss >10-15% in 6 months, body mass index <18.5 kg/m² or a serum albumin of <30 g/L occurring singly or in combination. Prehabilitation and optimization of the patient prior to surgery cannot be overlooked.

Finally, despite awareness and sufficient evidence to prove the superiority of ERAS versus conventional methods, implementation of ERAS protocols in day-to-day practice faces several barriers and limitations and there exists a huge variation in the pattern of clinical practice followed in the perioperative period in our Indian setups. Adopting ERAS requires unlearning the established practices and adopting new techniques by all the team members. The difficulty in accomplishing necessary compliance to all protocol items calls for new implementation strategies. A good institutional setup that affords access to the necessary resources, a good multidisciplinary team familiar with ERAS components, with a good team leader to coordinate the efforts, and a procedure-specific ERAS design is required for breaking the barriers to implementing ERAS.

To conclude, elements of the ERAS pathways for different surgical subgroups are essentially the same with minor modifications. These seemingly small little changes are doable and weave magic into a patient’s surgical experience.

Dr. Shagun Bhatia Shah
Sr. Consultant
Dept. of Anaesthesiology and Critical Care
(Guest Editor)