ERAS: Roadmap For A Safe Perioperative Journey

Rebecca N. Blumenthal, MD
Summary: 

Enhanced Recovery After Surgery (ERAS) initiatives are important in helping build safety and increase patient satisfaction in hospital systems. ERAS protocols provide transformative plans for minimizing pain, expediting patient recovery, and decreasing perioperative complications and hospital length of stay. In addition to improving patient outcomes, ERAS care maps and standardization have resulted in dramatic declines in opioid usage in surgical patients. This review article illustrates the safety benefits of ERAS protocols by reviewing the recent literature and consensus statements for common ERAS interventions. In addition, the article discusses the benefits afforded to ERAS patients with malignancies and focuses on the significant reduction in opioid usage in ERAS patients.

Introduction

An opioid epidemic has spread across the United States as a result of the misuse, abuse, and diversion of prescribed opioid medications. Chronic opioid usage often begins with a prescription for opioids given for acute pain to a postoperative patient. Alarmingly, up to 10% of opioid naïve post-surgical patients become chronic opioid users.1 Even short courses of opioids can have long term consequences, and patients leaving the hospital with a prescription for opioids have an increased likelihood for long term opioid use.2,3 Research suggests that patients who have a high requirement for opioids as an inpatient typically utilize large quantities of opioids after discharge as well.2,4 This national opioid crisis has left hospitals, clinicians, and health systems across the United States with the responsibility of finding solutions, particularly alternatives to opioid administration for perioperative pain management.

Enhanced Recovery After Surgery (ERAS) protocols provide transformative plans for minimizing pain, reducing opioid administration, expediting patient recovery, and decreasing perioperative complications and hospital length of stay.5 ERAS care maps are evidence-based, multidisciplinary, and collaborative approaches to perioperative care based on scientific principles that optimize preoperative, intraoperative, and postoperative care. ERAS pathways are clinical care bundles that provide consistent approaches to perioperative care. Most importantly, in addition to improving patient outcomes, ERAS care maps and standardization have resulted in dramatic declines in opioid usage in surgical patients.

The concept of ERAS was developed in Denmark in the late 1990s by colorectal surgeon Dr. Henrik Kehlet. Dr. Kehlet suggested that by combining multiple scientifically validated perioperative interventions (thoracic epidurals, early nutrition, and early ambulation) into a synergistic package, ERAS protocols could lead to significant improvements in patient recovery and safety.6 In a recent editorial, Dr. Kehlet and colleagues emphasized the importance of evidence-based support for all ERAS interventions. They stated that the failure to apply rigorous science and pathophysiologic principles in the expansion of ERAS to various surgical subspecialties, might threaten the future success of ERAS.7 With this concept in mind, it is important that each hospital designs institution specific evidence-based ERAS protocols. Creation and rollout of ERAS protocols is a difficult and time-consuming project that presents many challenges for hospital systems. There are a number of limitations and roadblocks that may impede successful ERAS implementation including cost restraints, resource availability, time, administrative support, a lack of enthusiastic ERAS champions, buy-in from all providers, involved quality managers, and reliable ancillary support services. At NorthShore University HealthSystem, the biggest impediments during ERAS development have been resource availability, specifically the need to hire more anesthesia technicians and purchase additional ultrasound equipment to aid in regional blocks, and support from all surgical and anesthesia professionals.

ERAS initiatives are important in providing safe care and increasing patient satisfaction in hospital systems across the United States. ERAS interventions have led to a decrease in perioperative morbidity, a reduction in complications and readmission rates, and an improvement in patient rehabilitation and recovery.5,8 As an added benefit, ERAS protocols have resulted in significant decreases in perioperative opioid usage. To illustrate the safety benefits of ERAS protocols, recent literature and consensus statements for common ERAS interventions will be reviewed (Figure 1). Breakdown of ERAS pathways into individual interventions is for explanation only as ERAS should be thought of as a seamless continuum rather than siloed phases of care. This article will then focus on the associated perceived ERAS benefits to those patients with malignancies. Lastly, this review will describe how ERAS protocols have led to safer perioperative experiences for surgical patients by reducing patient opioid usage.

Components of an Enhanced Recovery Program

PREOPERATIVE

  • Preoperative Education and Optimization
  • Preoperative Fasting Guidelines and Carbohydrate Loading
  • Elimination of Mechanical Bowel Preps
  • Thromboembolism and Antimicrobial Prophylaxis
INTRAOPERATIVE

  • Multimodal Non-Opioid Analgesics and Antiemetics
  • Regional Anesthesia
  • Normothermia and Euvolemia
  • Minimize and Early Removal of Drains/Foleys/NGs
POSTOPERATIVE

  • Early Mobilization/Ambulation
  • Early Nutrition
  • Multimodal Non-Opioid Analgesics
Figure 1: Components of an Enhanced Recovery Program.

Elements of ERAS

A number of preoperative ERAS interventions are responsible for providing patient safety and improving outcomes. The first intervention, preoperative education, targets expectations about surgical and anesthetic experiences and has been shown to decrease fear and anxiety and enhance postoperative recovery by decreasing pain and nausea and improving patients’ overall well-being.9 In addition, preoperative education has been shown to accelerate discharge by encouraging early oral intake and mobilization, improving respiratory physiotherapy, and decreasing multiple complications.10 Preoperative education is accomplished through verbal communication in the surgeon’s office, written pamphlets created for specific ERAS protocols, and multimedia means such as on-line websites. A second preoperative ERAS step includes medical optimization, smoking and alcohol cessation, and prehabilitation. Medical consultation to address issues such as anemia, hypertension, and diabetes has been associated with a decrease in a variety of complications including cardiopulmonary, infectious, bleeding, and other systemic complications.11 Cessation of smoking and alcohol for four weeks or more prior to elective procedures may decrease postoperative morbidity.12 Prehabilitation, which improves a patient’s functional capacity to help withstand the stress of surgery includes preoperative dietary modifications, relaxation strategies, sleep hygiene, and exercise prescriptions. These programs alone or in combination may reduce length of stay, decrease complications, and accelerate return to preoperative functional state.13 Finally, carbohydrate loading by ingesting a clear carbohydrate drink two hours before surgery can lessen discomfort and anxiety, maintain lean body mass and muscle strength, accelerate return of bowel function, and reduce insulin resistance.14,15 This preoperative intervention may help to prevent the catabolic state resulting from preoperative fasting.

Several intraoperative ERAS steps have been shown to enhance patient safety during the perioperative period. Surgical site infection (SSI) bundles and thromboembolic/deep vein thrombosis (DVT) bundles have been successfully integrated into ERAS protocols at many institutions across the United States including Dartmouth, Mayo, and Duke.16 At NorthShore University HealthSystem, SSI and DVT bundles have been incorporated into all ERAS protocols.

NorthShore University HealthSystem has experienced a 34% reduction in SSIs (from 4.4% to 2.9%) over the past three years by presumably standardizing several antimicrobial practices including administration of intravenous antibiotics within sixty minutes prior to incision, use of pre-incision chlorhexidine-alcohol skin wipes, antibiotics with bowel preps, and glove/instrument change as well as antibiotic irrigation prior to closure. The ERAS antimicrobial bundle may not only reduce surgical site infections, but has been associated with an improvement in postoperative immune function and a decrease in perioperative inflammatory markers.17 By utilizing a number of prophylactic measures to decrease venous thromboembolism, NorthShore University HealthSystem has lowered the perioperative DVT rate to zero (from 0.8% to 0%) over the past three years in the ERAS patient population.

Multimodal prophylaxis for postoperative nausea and vomiting (PONV) is another commonly employed ERAS intervention. PONV occurs in 25%-35% of surgical patients and is a primary reason for patient dissatisfaction and increased length of stay. PONV prophylaxis has been shown to reduce PONV rate by 40% and therapy with multiple anti-emetics is additive and preferable.18

Strategies to maintain normothermia and euvolemia are also common in ERAS protocols. Vigilance in temperature management lowers the incidence of multiple postoperative complications including wound infections, bleeding, cardiac events, and delay in postoperative oral intake.19 Fluid management is an important but often controversial component of ERAS protocols. While it is debated whether restrictive versus liberal fluid therapy is appropriate for different procedures and different patient subgroups, it is generally accepted that the ultimate goal of fluid management in ERAS patients is to maintain central euvolemia and to avoid excess salt and water.20 Maintaining a euvolemic state has been shown to decrease pulmonary and renal complications, accelerate return of bowel function, and reduce surgical site and urinary tract infections.21 Finally, minimizing drains, tubes, and catheters in surgical patients and removing the necessary ones as early as possible are common and important safety measures, which have also been shown to reduce pulmonary, gastrointestinal, and infectious complications in the postoperative period.22

In multiple recent studies, postoperative elements of ERAS protocols have had the strongest association with an expeditious, safe, and complication free recovery.23 The key postoperative elements are early nutrition and early mobilization. Early nutrition improves insulin resistance, muscle function, and wound healing and lowers the incidence of pneumonia, sepsis, ileus, and surgical site infections.24 Early mobilization improves muscle strength, promotes functional organ recovery, reduces pulmonary and thromboembolic complications, and is associated with increased patient satisfaction.25 These two elements, along with overall protocol compliance and early removal of drains and catheters, are the ERAS elements associated with the greatest impact on an uneventful return to physiologic baseline.23

ERAS and Cancer Care

ERAS protocols are beneficial in the perioperative care of cancer patients and positively impact patient survival. Because cancer patients undergoing ERAS protocols can have a rapid recovery to their preoperative functional state, they are able to more quickly return to their oncologic therapy. There is a correlation between the time to continuation of therapy after surgery and improved outcomes and survival for oncologic patients most notably for those with breast, lung, pancreatic, liver, and metastatic colorectal cancers.26 In one study, cancer patients who underwent ERAS protocols experienced an improved five-year survival.21 In addition, the reduction in opioid usage associated with ERAS protocols may have the added benefits in this patient population of decreasing cancer recurrence and improving quality of life.27

ERAS and Pain Management

An essential component of all ERAS protocols is multimodal pain management. Unlike traditional opioid-centered regimens, comprehensive ERAS multimodal pain management focuses on the use of two or more non-opioid analgesic medications or techniques to minimize or negate the perioperative use of opioid medications.28,29 This new approach has resulted in improved pain scores, reduction in opioid usage, and a reduction in opioid-related side effects including nausea, vomiting, pruritis, sedation, respiratory depression, ileus, urinary retention, and long-term opioid addiction and dependence.30 Memtsoudis et al. observed 1.5 million patients who had undergone total knee and total hip replacements and reported an additive positive effect of combining two or more non-opioid modalities resulting in a proportional reduction in postoperative complications, opioid usage, and hospital length of stay.31 Comprehensive multimodal non-opioid pain management models in ERAS protocols often include combinations of peripheral or central neural blockade with non-opioid analgesics such as non-steroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, gabapentin/pregabalin, ketamine, lidocaine, steroids, alpha-2 agonists, or magnesium.

By increasing the number of non-opioid pain management modalities, more effective pain control is achieved with decreased opioid use and opioid related side effects.31 Based on the study by Memtsoudis et al. the threshold number of non-opioid multimodal pain management techniques required to result in significant benefits in opioid reduction has been estimated to be four.31 Interestingly, the authors also found that non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors are the two most effective multimodal pain interventions that lower perioperative opioid usage and decrease overall complication rates.31 ERAS protocols which implement multimodal pain management can be a safe and effective strategy to improve pain control while minimizing opioid utilization, side effects, and addiction.

At NorthShore University HealthSystem, ERAS protocols have been initiated in patients undergoing colorectal surgery, open ventral hernia repair, breast reconstruction, and abdominal hysterectomy. All NorthShore ERAS protocols utilize multimodal analgesic regimens combined with regional anesthetic blocks with the new long acting bupivacaine liposome injectable suspension. Opioid usage (in addition to many other quality metrics) was tracked in ERAS pathway patients and a reduction in postoperative opioid usage was observed: from 90%-100% pre-ERAS implementation to less than 54% post-ERAS implementation (Table 1). Those patients who required opioids were using minimal dosages, typically two to three doses of an oral opioid. In addition, for all ERAS patients, the amount of oral morphine milligram equivalents (MMEs) used postoperatively was quantified. MMEs are values assigned to opioids that represent their relative potencies and are determined by using an equivalency factor to calculate a dose of morphine that is equivalent for any “non-morphine” opioid. Patients enrolled in ERAS have had a consistent reduction by 78%-86% of MMEs used postoperatively when comparing opioid usage in pre-ERAS and post-ERAS surgical patients (Table 1).

Table 1: NorthShore University HealthSystem’s Reduction in MMEs (oral morphine milligram equivalents) for Four ERAS Protocols (unpublished data, statistical analysis yet to be executed).

ERAS® Protocol Colorectal Ventral Hernia Mastectomy w/Implant Reconstruction Abdominal Hysterectomy
Implementation 10/1/2016 10/1/2017 4/3/2018 8/13/2018
Number of patients 815 150 113 69
Median Length of Stay in Days
Pre-implementation 4 4 1 3
Post-implementation 2 2 1 2.3
% Patients Utilizing Schedule 2 or 3 Narcotics
Pre-implementation 100% 100% 91.2% 89.9%
Post-implementation 49.3% 43.2% 31.0% 53.6%
Average Oral Morphine mg Equivalents (MME’s) Utilized per Patient
Pre-implementation 375.9 388.2 79.4 159.1
Post-implementation 81.7 62.9* 14.4 23.8
Overall Reduction in Oral Morphine mg Equivalents (MME’s)
73.3% 83.8% 81.7% 85.0%
*One outlier patient accounted for 15% of total MME’s for the patient population. Removing the outlier, avg. MME’s per patient = 53.3 and % reduction = 86.3%.

In continuing the commitment to improve perioperative care and to combat the opioid crisis, NorthShore is expanding its ERAS programs by developing initiatives to reduce the doses and quantity of opioids prescribed and used by postoperative patients after discharge. Ongoing analysis of postoperative patient opioid needs at NorthShore will help guide practitioners in prescribing the appropriate quantity of discharge pain medications, since the duration of opioid usage rather than the opioid dosage itself, is more strongly associated with ultimate misuse among opioid naïve postoperative patients.1

Conclusion

ERAS care maps and systemization can improve outcomes and safety for patients in the perioperative period. As a result, ERAS strategies are being increasingly utilized in the era of value-based care. With the appropriate resources and provider support, ERAS protocols may lead to significant reductions in opioid usage, complications, and length of stay, and therefore, strong consideration should be given to implementation of ERAS in a variety of surgical subspecialties.

 

Dr. Blumenthal is an anesthesiologist and Director of Special Projects in the Department of Anesthesiology, Critical Care and Pain Medicine at NorthShore University HealthSystem and clinical assistant professor in the Department of Anesthesia and Critical Care at the University of Chicago, Pritzker School of Medicine.


The author has no conflicts of interest pertaining to this article.


The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of APSF. It is not the intention of APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.

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