Overview

Definition: Enhanced Recovery After Surgery (ERAS) is an evidence-based, multidisciplinary approach to perioperative care that aims to optimize patient recovery, reduce complications, and shorten hospital stays by standardizing care pathways and minimizing surgical stress response.
Epidemiology:
-ERAS protocols are increasingly adopted across various surgical specialties globally
-Studies show significant reductions in length of stay, complication rates, and healthcare costs
-Adoption varies by institution and country, but represents a paradigm shift in surgical practice for improving patient outcomes.
Clinical Significance:
-ERAS significantly improves patient experience and outcomes by reducing postoperative morbidity and mortality, expediting return to normal function, and lowering healthcare expenditures
-It is crucial for residents to understand and implement these protocols for optimal patient care and successful surgical practice, directly impacting DNB and NEET SS examination preparation.

Key Principles

Multimodal Approach: ERAS is built on a combination of evidence-based practices spanning preoperative, intraoperative, and postoperative phases.
Patient Centered Care: Emphasis on patient education, involvement, and shared decision-making throughout the perioperative journey.
Team Collaboration: Requires close cooperation between surgeons, anesthesiologists, nurses, dietitians, physiotherapists, and pharmacists.
Evidence Based Practice: Relies on a foundation of scientific evidence to guide every component of the protocol.
Continuous Audit Improvement: Regular monitoring and auditing of protocol adherence and outcomes to drive ongoing improvements.

Protocol Components

Preoperative Optimization:
-Preoperative counseling and education about the surgical process and recovery expectations
-carbohydrate loading to improve insulin sensitivity
-avoidance of prolonged fasting
-optimization of comorbidities like diabetes and anemia
-prophylactic antibiotics
-bowel preparation (often minimized or omitted in certain procedures).
Intraoperative Management:
-Minimally invasive surgical techniques where appropriate
-careful fluid management to avoid overload or deficit
-maintenance of normothermia
-avoidance of routine nasogastric tubes
-judicious use of drains
-multimodal analgesia to minimize opioid use
-avoidance of prolonged mechanical ventilation and excessive intraoperative opioids.
Postoperative Care:
-Early mobilization and ambulation
-early oral nutrition and hydration
-multimodal analgesia with a focus on non-opioid adjuvants (e.g., NSAIDs, paracetamol, regional blocks)
-avoidance of routine intravenous fluid resuscitation
-early removal of urinary catheters and drains
-management of nausea and vomiting
-regular nursing assessment and support.

Specialty Applications

Colorectal Surgery: One of the first and most studied areas for ERAS, showing significant reductions in ileus, pain, and hospital stay.
Gynecologic Surgery: Applied to procedures like hysterectomy and ovarian surgery, improving pain control and faster recovery.
Urologic Surgery: Used in procedures such as radical prostatectomy and cystectomy, enhancing postoperative mobility and reducing urinary complications.
Thoracic Surgery: ERAS protocols for lung resection have shown reduced pulmonary complications, shorter chest tube duration, and earlier discharge.
Orthopedic Surgery: Increasingly used for joint replacement and spine surgery to improve pain management and functional recovery.

Benefits And Outcomes

Reduced Length Of Stay: Typically leads to a 1-3 day reduction in hospital stay across various procedures.
Decreased Morbidity: Significant reduction in surgical site infections, pneumonia, ileus, and other postoperative complications.
Improved Patient Satisfaction: Patients report better pain control, faster return to normal activities, and a more positive surgical experience.
Cost Effectiveness: Reduced hospital stay and complication rates translate into significant cost savings for healthcare systems.
Faster Return To Function: Enables patients to resume daily activities, return to work, and regain independence sooner.

Challenges And Considerations

Protocol Adherence: Variability in adherence among healthcare providers can impact outcomes.
Patient Factors: Patient education, motivation, and existing comorbidities can influence ERAS success.
Institutional Buy In: Requires strong leadership and interdepartmental collaboration for successful implementation.
Audit And Feedback: Continuous auditing and providing feedback to teams are essential for maintaining standards.
Resource Allocation: May require investment in nursing staff, physiotherapists, and specialized equipment.

Key Points

Exam Focus:
-ERAS is a fundamental concept in modern surgical practice
-Understand its core principles, components, and benefits
-Be prepared to discuss specific ERAS protocols for common surgical procedures (e.g., colorectal, gynecologic).
Clinical Pearls:
-Emphasize early mobilization and multimodal analgesia
-Prioritize patient education and engagement for better adherence and outcomes
-Always consider patient-specific factors when tailoring ERAS protocols.
Common Mistakes:
-Over-reliance on opioid analgesia
-delayed mobilization
-inadequate preoperative counseling
-inconsistent protocol implementation across the care team
-failure to audit and refine protocols.