Eras PP

Enhanced Recovery After
Surgery
By Lauren Magnusson
History of ERAS
Started with a doctor from Denmark named Henrik

Kehlet in the 1990s
He began to research why surgical complications

were occurring
This hypothesis lead to programs being developed to

enhance patient care and improve recovery
Goals of ERAS
 Enhanced recovery after surgery combines evidence

based interventions to improve surgical outcomes by
changing the way care is provided pre operatively,
post operatively and intra operatively
 The goal is to reduce the bodies stress response to

surgery and support organ function therefore
improving post operative outcomes
What do we mean by Surgical Stress??
 This is the bodies metabolic response to injury

 The stress response is represented by hormonal and
metabolic changes that result in hematological,
immunological and endocrine responses
 Insulin resistance is associated with post operative
complications and mortality
 This leads to a combination of catecholamine release
and hyper inflammation followed by
immunosuppression
Who is Involved?
 Multi disciplinary approach is required
 Patient is one of the main players

Preoperative Stage
Patient Teaching
 This begins prior to the patients surgical experience

 Patients need to understand what to expect
throughout the surgical phases
 Teaching needs to involve what will happen in the pre
and post operative phases
 Discharge teaching should also begin prior to surgery
No Extensive Pre Op Fasting
 Patients need to stop eating food 6 hours prior to

surgery
 Patients can however drink clear fluids up to two
hours before surgery
 Why the change?!
 Reduces preoperative thirst and hunger
 Also reduces preoperative stress
Carb Loading
 What does this mean?!?
 At ARH patients are advised to drink 375ml of CLEAR

juice prior to surgery
 Why?!
Limited to NO bowel Prep
 Previously colorectal patients had mechanical bowel

prep to “clean” the colon
 It was shown that the use of mechanical bowel preps lead

to dehydration and electrolyte imbalances
 Also this prep was associated with post operative ileus

Warming the Patient
 Goal is to maintain normothermia
 This starts while the patient is waiting to enter the

operating room
Intraoperative Stage
Maintaining Normothermia
 Active warming blankets and warming mattresses
 Ambient room temperature
 Warming of IV fluids
 Why?!
Adapting and Limiting IV Fluids
 IV fluid rates should be individualized to the patients

needs
 Goal
 Want to prevent fluid and sodium overload
 Maintain homeostasis
Thoracic Epidurals, Spinal Anesthesia
and Laparoscopic Approaches
 Regional Anesthetics such as epidurals are used to

minimize opioid use post operatively
 Regional blocks can reduce the bodies response to surgical

stress
 Laparoscopic approaches are recommended if available

because they improve recovery by decreasing pain and
complications
Limiting the use of Nasogastric Tubes
 Nasogastric tubes after colorectal surgeries were

used after surgery to prevent abdominal distension
and vomiting
 Risks of the nasogastric tube after surgery?!
 If used during a surgery the NG tube should be

removed as soon as possible in the PACU
Other Intraoperative Interventions
 Prophylaxis antibiotics
 Prophylaxis chemical and mechanical venous

thromboembolism
 Pre-emptive antiemetic’s
Post operative Stage
Goals in the Post Operative
Period
 Post op day 0: Pain control, Push oral fluids, Reduce IV

fluids, do not bolus just for low urine output, mobilize the
patient, provide gum for chewing, prevent nausea and
vomiting
 Post op day 1: Mobilization!, gum chewing, providing solid
food diets, removing foleys and saline locking patients
 Post op day 2: Continued mobilization and Gum chewing
 Post op day 3-5: Discharge home
Limiting Opioids
 This is done by using multimodal pain management
 Using opioids along side NSAIDs and acetaminophen

helps manage postoperative pain and decrease
complications
Preventing Fluid Overload
 Limiting the use of IV fluids
 Saline locking patients once they are drinking

adequately
Early Mobilization
 THIS IS KEY!!
 Patients need to be mobilized post op day 0
 Patients should be up in chair for all meals

Gum Chewing
 Why?!
 Simple intervention to improve gastrointestinal

functioning and promote bowel activity
 Patients postoperative flatus and defecation times

are shortened
Prevention of Nausea and Vomiting
 One of the main ways to promote comfort after

surgery
 Need to treat nausea and vomiting as quickly as

possible to allow patients to resume oral intake and
mobilize

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Enhanced Recovery After

Started with a doctor from Denmark named Henrik

He began to research why surgical complications

This hypothesis lead to programs being developed to

 Enhanced recovery after surgery combines evidence

 The goal is to reduce the bodies stress response to

 This is the bodies metabolic response to injury

 Multi disciplinary approach is required

 Patient is one of the main players

 This begins prior to the patients surgical experience

 Patients need to stop eating food 6 hours prior to

 What does this mean?!?

 At ARH patients are advised to drink 375ml of CLEAR

 Previously colorectal patients had mechanical bowel

 It was shown that the use of mechanical bowel preps lead

 Also this prep was associated with post operative ileus

 Goal is to maintain normothermia

 This starts while the patient is waiting to enter the

 Active warming blankets and warming mattresses

 Ambient room temperature

 IV fluid rates should be individualized to the patients

 Regional Anesthetics such as epidurals are used to

 Regional blocks can reduce the bodies response to surgical

 Laparoscopic approaches are recommended if available

 Nasogastric tubes after colorectal surgeries were

 Risks of the nasogastric tube after surgery?!

 If used during a surgery the NG tube should be

 Prophylaxis chemical and mechanical venous

 Post op day 0: Pain control, Push oral fluids, Reduce IV

 This is done by using multimodal pain management

 Using opioids along side NSAIDs and acetaminophen

 Limiting the use of IV fluids

 Saline locking patients once they are drinking

 Patients need to be mobilized post op day 0

 Patients should be up in chair for all meals

 Simple intervention to improve gastrointestinal

 Patients postoperative flatus and defecation times

 One of the main ways to promote comfort after

 Need to treat nausea and vomiting as quickly as

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