AANA Journal Course

Perioperative Goal-Directed Fluid Therapy: A Prime

Component of Enhanced Recovery After Surgery
Nina McLain, PhD, CRNA
Stephanie Parks, DNP, CRNA
Mary Jane Collins, DHA, CRNA

Perioperative goal-directed fluid therapy (GDFT) is a
prime component of the Enhanced Recovery After
Surgery (ERAS) protocol. Multiple studies have demon-
strated a relationship between GDFT and positive patient
outcomes, including shorter hospital stays, decreased
ileus formation, reduced gastrointestinal-related issues,
decreased nausea, and hemodynamic stability. Electro-
lyte disturbances following a positive fluid balance may
occur, and GDFT is aimed at euvolemia to avoid a hyper-
volemic state. Carbohydrate loading, early discontinua-
tion of postoperative intravenous fluids, and use of iso-
osmotic solutions all are components of GDFT. Lactated
Ringer’s solution is the fluid recommended for nonrenal
patients and patients with hepatic compromise. The
negative consequences associated with hypervolemia
deem it pertinent to devise an individualized GDFT plan
in the ERAS protocol.
Keywords: Anesthesiology, Certified Registered Nurse
Anesthetist, goal-directed fluid therapy.

Objective
Upon completion of this course the learner will be able to:
1. Describe the primary factors related to goal-directed
fluid therapy utilized in an ERAS protocol to
improve patient outcomes.
Introduction
Perioperative goal-directed fluid therapy (GDFT), also
called goal-directed therapy, is a prime component of
the Enhanced Recovery After Surgery (ERAS) program.
As such, anesthesia providers can influence patient out-
comes using GDFT. Multiple studies have demonstrated
a relationship between GDFT and positive outcomes such
as shorter hospital stays, decreased ileus and gastrointes-
tinal-related issues, reduced postoperative nausea, and
hemodynamic stability.1 Postoperative fluid management
aimed at euvolemia and early oral intake demonstrated a
reduced risk of infection in colorectal surgical patients.2
Although earlier studies do not support reduced fluid
administration as a method to improve outcomes, the
current evidence is largely in favor of GDFT.1,3-7
Fluid overload in the perioperative period may lead to
an increased morbidity.8 Lowell et al8, in 1990, found that
fluid overload correlated with vasopressor dependence
and increased morbidity in surgical intensive care patients.
Electrolyte disturbances following a positive fluid balance
may also occur, and patients may have difficulty excreting
the excess fluid and sodium that has accumulated in an
overloaded condition.9 Additionally, in a hypervolemic
state, interstitial fluid collection occurs because of elevated
hydrostatic pressure and increased vascular permeabil-
ity.10 For the prudent anesthesia provider, the negative
consequences of hypervolemia deem it necessary to devise
an individualized GDFT plan. This AANA Journal Course
was developed to present primary concepts of GDFT and
evidence supporting use of an ERAS protocol.
Review of Literature
Literature searches were conducted via databases includ-
ing PubMed, PubMed Central, PLoS One, the National
Library of Medicine, Google Scholar, MEDLINE, Embase,
and The University of Southern Mississippi Library
Seymour search engine. Terms were searched individually
as well as in combination and included goal directed fluid
therapy, GDFT, enhanced recovery after anesthesia, ERAS,
intraoperative fluid maintenance, surgery program, bowel
preparation, fast track anesthesia, multimodal, perioperative
fluid therapy, and central venous pressure monitoring.
• Enhanced Recovery After Surgery. The concept of
ERAS, a multimodal approach to perioperative care for
patients undergoing colon surgery, evolved in the 1990s.11
In 2005, The ERAS Society published the first protocol

The AANA Journal Course is published in each issue of the AANA Journal. Each article includes objectives for the reader and sources
for additional reading. A 5-question open-book exam for each course is published on the CRNA Knowledge Network and will remain
live on the site for a period of 3 years. One Class A CE credit can be earned by passing the examination (a score of 80% or greater)
and completing the evaluation. Journal Courses released after September 1, 2020 are free to AANA members as a benefit of
membership. For details, go to https://knowledgenetwork.aana.com/home.

www.aana.com/aanajournalonline AANA Journal  August 2021  Vol. 89, No. 4 351

for an evidence-based, multimodal approach for colonic
surgery. Since that time, ERAS has been a pathway for fast
track recovery that has been widely studied, and the bulk
of literature supports ERAS as beneficial. Early feeding
to promote normal bowel function is one tenet of ERAS.
Sugisawa et al12 found anastomotic leakage occurrence to
be in line with previous studies and did not attribute the
incidence to early feeding. The ERAS protocol includes al-
terations to the typical 8-hour nothing-by-mouth expecta-
tions and allows clear liquid intake as well as carbohydrate
drink loading 4 hours before surgery. This disagrees with
nothing-by-mouth standards of the past and may raise con-
cerns regarding aspiration. No increased risk of incidence
of aspiration pneumonia was noted by Sugisawa et al,12 and
a 2003 Cochrane review also reported similar findings.13
Historically, nasogastric tubes have been used to suction
stomach contents to avoid aspiration in the induction
phase and during surgery, as well as to decompress the in-
testines to reduce strain on anastomoses. Nasogastric tubes
are not part of ERAS in colonic surgery, and this has been
a suspected drawback. However, Grass et al14 reported a
reduction in postoperative ileus occurrence using an ERAS
protocol while avoiding the use of nasogastric tubes.
Additional benefits of ERAS include shorter recovery
times and improved surgical outcomes.15 Shorter recov-
ery times of 30% to 50% were reported by Ljungqvist et
al15 as well as similar findings for a reduction in reported
complications. These benefits were attributed to multiple
components of ERAS protocols such as carbohydrate
loading and elimination of overnight fasting, seeking a
zero fluid balance while avoiding large volumes of fluid,
early ambulation, and early oral intake postperatively.15
Lau and Chamberlain16 reviewed 42 randomized clinical
trials with 5,241 patients in a meta-analysis. Significant
differences (P<.001) were reported for length of stay,
overall complications, and cost decrease.16
Moningi et al17 reviewed elements of ERAS and the
levels of evidence supporting different aspects of ERAS.
Interestingly, many of the elements advising strong rec-
ommendations for inclusion in various programs had
weak or limited evidence in support.17 Although the
literature widely supports use of ERAS protocols, there
are concerns regarding coagulopathies, electrolyte dis-
turbances, hypotension with epidural use, thrombopro-
phylaxis, and postoperative organ dysfunction in patients
undergoing liver resection.18
• Fasting and Carbohydrate Loading. Surgery places
numerous stressors on the body and causes pathophysi-
ologic changes in the surgical patient. Although not a
new concept, the correlation of perioperative hypergly-
cemia and surgical complications continue to stimulate
new studies and broaden our understanding of surgical
stress. According to Fawcett and Ljungqvist,19 the stress
of major surgery promotes the occurrence of hyper-
glycemia and numerous other systemic inflammatory
352 AANA Journal  August 2021  Vol. 89, No. 4 www.aana.com/aanajournalonline
responses that negatively affect patient outcomes. The
impact of surgical stress is the basis for the development
of an enhanced recovery system.
Preoperative fasting yields unmodulated physiologic
changes that adversely affect patient outcomes and is a
major contributor to the stress response, as demonstrated
by hyperglycemia, lipolysis, and systemic inflammatory
responses.19 Surgical stress also activates a neuroendocrine
response that includes cortisol fluctuation, catecholamine
release, and insulin resistance. In response to surgery,
the body uses insulin and fuels from multiple sources to
support tissue healing. The body stress response is to limit
the uptake of glucose in the tissues and liver gluconeogen-
esis, each creating the condition of hyperglycemia. A shift
in energy metabolism occurs where lipolysis and protein
catabolism begin, further reducing energy supplies and
promoting a weakened postsurgical state. The impact of
insulin resistance and severity of dysfunction directly cor-
relates with the degree of surgical insult.19 Catabolism and
increased insulin resistance are associated with increased
length of stay as well as greater postoperative infection
rates.20 Fawcett and Ljungqvist19 found that for every 20%
increase in insulin resistance, the risk of severe mortality
doubled. Laparoscopic surgery was shown to cause the
least amount of insulin resistance, whereas larger, open
cases had the greatest. Although individual severity of
insulin resistance varies, the greatest measure of resistance
occurs the day after surgery and can raise the amount of
insulin resistance by 50% to 90%, with effects lasting a
minimum of 5 days up to several weeks.19
Many medical organizations adhere to the standard
practice of 8 hours with nothing by mouth before anes-
thesia induction unless the need for surgery is emergent.
The strict adherence to the clinical guideline of withhold-
ing nutrition the day of surgery is followed to minimize
the possibility of pulmonary aspiration with induction of
anesthesia. Studies have shown that no detrimental effect
on stomach content volume or pH of gastric contents
exists when water is administered up to 2 hours before
surgery.13 The selection of carbohydrate loading is also
important when considering the oral dose the morning
of surgery. Although a complex carbohydrate drink with
maltodextrin took longer to clear the stomach of its con-
tents when compared with water, it took only 90 minutes
to empty the stomach when assessment was done via
a gamma camera.21 It may be prudent to consider the
nothing-by-mouth requirement of 6 hours extreme, espe-
cially when fragile or vulnerable patients are concerned.
Oral carbohydrate loading is not without drawbacks.
One of the negative aspects is the disruption of sleep
from voiding during the night after consuming a car-
bohydrate drink before sleep, and another disadvantage
is the responsibility of funding of carbohydrate drinks
that are not considered a pharmaceutical necessity.19
Research and recommendations for the amount of car-
bohydrate, exact timing of the morning load, and type of
loading drink is still evolving. A controversial issue with
carbohydrate loading is its effect on patients with diabe-
tes. Regardless of the specific type of diabetes, carbohy-
drate loading is not well tolerated and may predispose
them to hyperglycemia.22 Additionally, gastroparesis
associated with diabetes is well documented and could
present aspiration issues with induction of anesthesia.
There are still many unanswered questions regarding the
implementation of carbohydrate loading before surgery.
However, the physiologic damage of surgical stress may
precipitate finding a better solution.
• Euvolemic State. For GDFT, anesthesia should
be provided to a patient in a euvolemic state who has
received intravenous (IV) fluids.1 Euvolemia in the peri-
operative period has been found to reduce complications
such as nausea, gastric edema, and postoperative ileus as
well as to reduce length of stay, according to Gupta and
Gan.1 Balanced salt crystalloid IV fluids are preferable
to a 0.9% sodium chloride solution for maintenance of
euvolemia.1 Avoidance of hypervolemia, hyperchloremia,
and reduced amounts of perioperative fluids to maintain
euvolemia can reduce postoperative complications and
shorten hospital length of stay. In an early study, Gan
et al5 reported a hospital stay reduction of 2 days when
GDFT was used, and gastrointestinal tract complica-
tions also were reduced. Although this seems to be the
consensus, other studies have shown no improvement in
outcomes when using GDFT in an ERAS protocol.3,4 A
more recent study, by Makaryus et al,23 reports optimiza-
tion of the patient’s fluid status and metabolic rate before
surgery has the advantages of reducing complication
rates and length of stay.
• Perioperative Goal-Directed Fluid Therapy.
Perioperative GDFT uses a combination of hemodynamic
indicators, fluids, and vasopressors to maintain a eu-
volemic state in an ERAS protocol.23 (See Table) Cardiac
output indicators such as heart rate, blood pressure, and
central venous pressure (CVP) alone are not reliable esti-
mators of volume status but may be used in conjunction
with vasopressors and small fluid boluses of 200 to 250 mL
to maintain a euvolemic state.1,23 Intraoperative fluid man-
agement has been widely investigated, and debate exists
between those preferring very limited fluid replacement
and those who liberally administer fluids.24,25 Euvolemia
is the focus for GDFT in ERAS. One simple measure of
fluid status is to observe changes in pulse pressure and
systolic pressure during the ventilatory cycle. Variation by
13% is predictive of a positive response to fluid therapy.26
Lansdorp et al27 report that when low tidal volumes are
used, this predictor is much less accurate.
Close observation of pulse and systolic pressures, as
well as using CVP measurements to guide small fluid
bolus volumes, may avoid short hypotensive episodes
leading to renal and myocardial injury.28,29 Salmasi et al28
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and Maheshwari et al29 report that very short episodes
of hypotension are enough to cause significant organ
damage. Given that CVP monitoring for fluid status is
not exact, transesophageal echocardiography (TEE) may
be used as a more specific guide to fluid status in com-
promised patients.
Anesthesia providers often use urine output to guide
fluid administration and historically, IV fluids were ad-
ministered liberally. Periods of oliguria and decreased
urine output are considered acceptable with GDFT in
ERAS protocols for uncompromised patients and should
be expected.1 This is likely due to the body’s response
to surgical stress that triggers neurohormonal processes.
Kheterpal et al30 found that surgical stress and neurohor-
monal responses decreased urine output below 0.5 mL/
kg/h without renal failure.
Other neurohormonal responses from surgical stress
include hypermetabolism and hypercatabolism, which
lead to delayed wound healing, impaired immune func-
tion, and organ damage.31 The responses correlate to the
severity of the injury so it is likely that periods of oliguria
will occur in larger surgical cases. To counter the symp-
toms from the neurohormonal responses, vasopressors
and small fluid boluses are recommended as treatment
for hypotension and may indirectly increase renal output.
Rather than traditional fluid volume loading and nothing-
by-mouth restrictions, patient-specific GDFT is key in pro-
viding the individualized approach required in an ERAS
protocol aimed at homeostasis for physiologic processes.
Weinberg et al32 conducted a prospective multicenter
randomized controlled trial to evaluate patient outcomes
using a restrictive intraoperative fluid optimization algo-
rithm. Fifty-two patients undergoing pancreaticoduede-
nectomy procedures were recruited and randomized to
2 groups: normal care and GDFT groups. The median
surgery times were 8.6 hours and 7.8 hours, respectively.
The GDFT group received 2,050 mL, and the usual care
group received 4,088 mL (P<.0001) of fluid. Vasoactive
medications were used in both groups. No significant
difference (P=.179) was found in the proportion of pa-
tients demonstrating overall complications; however,
the GDFT group had fewer complications. The median
length of stay was 9.5 days in the GDFT group, whereas
the usual care group’s median stay was 12.5 days. The
authors suggest using enough fluid without causing
edema, yet enough to avoid hypovolemia.32
Multiple literature searches revealed little research on
postoperative fluid therapy in an ERAS protocol. In the lit-
erature regarding IV fluids and an ERAS protocol, general
consensus exists that IV fluids should be discontinued as
early as possible and restarted if clinically indicated.2,33,34
Research on postoperative IV fluid administration spe-
cifically related to an ERAS protocol was unable to be
located, although a vast amount of perioperative IV fluid
and ERAS research included postoperative suggestions.
 August 2021  Vol. 89, No. 4 353
 Strategy Description

Carbohydrate loading • Give preoperative drink containing maltodextrin 2 h before surgery.

• Controversial in patients with type 1 diabetes
•M
 onitor glucose in patients with type 2 diabetes, as maltodextrin may predispose to
hyperglycemia.
Intraoperative fluid management • Titrate to cardiac output and stroke volume when monitoring is available.
•F
 or stable patients, use physiologic parameters such as ECG, heart rate, mean arterial
blood pressure, and urine output.
Perioperative hemodynamics • Individualize fluid therapy to the patient but consider in relationship to relative baseline
values.
• Keep MAP <20% of baseline.
• Use vasoactive medications as needed to maintain blood pressure and stroke volume.
Fluid challenge • 200-mL to 250-mL test
• If <10% response in stroke volume or blood pressure, repeat challenge.
• Repeat until no further improvement in stroke volume or blood pressure occurs.
Fluid type • Administer Ringer’s lactate or balanced crystalloid solution (PlasmaLyte).
•F
 or fluid replacement after mechanical bowel preparation, administer crystalloid up to
500 mL.
• Administer crystalloids for minor intraoperative blood loss.
•U
 se colloids for rapid replacement for moderate to large acute intraoperative blood loss
in a 1:1 ratio.
•R
 eserve normal saline for hyponatremic or hypochloremic patients or those for whom
large volumes of gastric drainage are expected.
NG tubes • Suction contents of tube to reduce aspiration.
• Decompress intestines to reduce anastomoses strain.
 rass et al14 reported a reduction in postoperative ileus occurrences while avoiding NG
•G
tubes.

Table. Goal-Directed Fluid Therapy Strategies

Abbreviations: ECG, electrocardiogram; MAP, mean arterial pressure; NG, nasogastric.

• Fluid Balance. Complications associated with posi-
tive fluid balances include endothelial damage, vascular
permeability, and edema of the intestinal wall leading
to a postoperative ileus formation.10 Avoiding collateral
damage with fluid administration should be a focus of
the anesthesia provider. Chappell et al10 recommended
altering the mindset from that of fluid “therapy” to that
of fluid “substitution” to direct us away from the liberal
administration of crystalloids, as seen frequently. The
authors suggest a fluid replacement program since the
extracellular compartment cannot be monitored. They
state the following:
1. Extracellular deficit after usual fasting is low.
2. Basal fluid loss via insensible perspiration is ap-
proximately 0.5 to 1 mL/kg/h during major abdominal
surgery.
3. A primarily fluid-consuming third space does not exist.
Chappell et al10 further suggest that plasma losses from
surgery be replaced with iso-oncotic colloids in a timely
manner and that the routine preoperative fluid loading in
normovolemic patients be eliminated for a GDFT approach.
In ERAS, lactated Ringer’s solution and similar bal-
anced saline solutions are preferred for intraoperative
fluid administration, with avoidance of normal saline to
avoid hyperchloremic acidosis.35 Historically referred to
as “dilutional” acidosis, it can occur with administration
of normal saline to a significant degree. In a randomized
controlled trial, Scheingraber et al35 found a significant
difference in blood pH between groups receiving normal
saline infusion vs lactated Ringer’s solution: 7.41 and
7.28, respectively. Since hypochloremic acidosis is as-
sociated with nausea and vomiting, cardiac irritability,
cardiac arrest, mentation changes, and other electrolyte
disturbances, lactated Ringer’s solution is the preferred
option for crystalloids.
Postoperatively, dextrose saline solutions have been
recommended, whereas Miller et al reported that col-
loids restored blood pressure and organ perfusion more
quickly than crystalloids when giving bolus amounts to
treat hypotension.2 An exception to this is hydroxyethyl
starches that have been replaced with newer starch solu-
tions.6,36 Renal replacement therapy has been necessary
after receiving starches and is not recommended for pa-
tients with preexisting dysfunction of the renal system.36

354 AANA Journal  August 2021  Vol. 89, No. 4 www.aana.com/aanajournalonline

Although newer starches are an option in the ERAS
protocol, discontinuation is prudent at the first signs of
coagulopathy or renal impairment.
There seems to be no widely accepted consensus for
fluid type when it comes to minifluid boluses (200-250
mL) to hypotension treatment but general indications
direct providers toward the balanced saline solutions
such as lactated Ringer’s solution. With the patient’s
condition and severity of the surgery in mind, the goal of
euvolemia throughout the perioperative period appears
to create the best environment for improved patient out-
comes and reduced length of stay.
• Complications of Increased or Decreased Fluid
Balances. A zero-balance fluid approach, or euvolemia,
is ideal for ERAS to avoid complications. Hyponatremia,
hypochloremia, splanchnic hypoperfusion, and ileus
have been reported when hypervolemic states are present
postoperatively.37 Lactic acidosis can also be attributed to
hypervolemic states. Large volumes of IV lactated Ringer’s
solution can contribute to lactic acidosis. Historically,
IV fluids were liberally given by anesthesia providers
with the belief that nothing by mouth restriction, bowel
preparation fluid loss, and insensible losses should be
replaced, with overhydration being preferable to under-
replacement. As Agarwal et al18 reported, overhydration
was attributed to significant complications, whereas
underhydration and lower CVP complications were con-
sidered milder. Agarwal et al also found lower CVPs were
needed to reduce complications in major surgeries such
as liver cases. Associated hepatic and renal postopera-
tive dysfunction was low and negated the need for the
increased infusion of IV fluids as done historically. Given
that liver cases are typically those with higher blood loss
and that hypervolemic states are associated with slower
gut motility and gastrointestinal recovery, maintaining a
lower CVP with minimal fluids seems prudent.
• Monitoring Central Venous Pressure. In large cases
or cases where patients are deemed fragile, monitoring
may require a TEE approach. Routine CVP monitoring is
affected by nonphysiologic components such as position-
ing, transducer placement, or instrument retraction and
is not fully reliable as a means to assess fluid status.37
Stroke volume variation (SVV) and pulse pressure can be
useful indexes of fluid status. Using the M-type mode of
monitoring the TEE, SVV can be evaluated and may have
a place in volume status assessment during surgery.38
Potentially, TEE could provide advantageous informa-
tion over traditional CVP monitoring approaches since
CVP is not a reliable measure of fluid status.1
• Postoperative Fluid Considerations. Lactate clear-
ance is a concern for patients with hepatic and renal
compromise.18 In liver resection or long major surgical
cases in which acute renal dysfunction may occur, lactate
clearance can be affected. Diabetes, organ manipulation,
blood transfusion, and administration of large volumes of
www.aana.com/aanajournalonline AANA Journal
lactate-containing IV fluids can have an impact on lactate
concentration; the degree of liver resection with remain-
ing liver function should be considered when selecting
postoperative fluids.18 In patients with normal liver and
renal function, lactated Ringer’s solution is preferable.
Postoperatively, patients are less able to excrete fluid
and sodium.9 Recommendations for postoperative fluid
administration include discontinuing fluids as soon as
possible and restarting them only if clinically indicated.1
A normal stress response to surgery is oliguria, and it is
not recommended that fluid infusions be restarted as a
result.1 Some authors recommend prophylactic potas-
sium administration in the ERAS protocol for patients
undergoing gastrointestinal and pancreatic surgery since
they may predisposed to electrolyte disturbances.39
• Controversies Related to Fluids. Controversies exist
in the body of ERAS literature. Safety concerns for epidural
perioperative and postoperative pain control exist related
to coagulopathies after liver resection.40 For this reason,
the ERAS Society recommends avoiding epidural catheters
in patients undergoing liver resection. However, Mallett
et al41 studied patients undergoing hepatic resection who
presented with normal parenchyma and found an initial
decrease in procoagulant clotting factors but a rise to
within the normal range or higher thereafter. The authors
go on to suggest a prothrombotic environment exists after
surgery. Multiple studies reviewed did not report spinal or
epidural hematomas, perhaps for this reason.40,42,43
Another area of concern with ERAS protocols is that of
maintaining a normal vs low CVP. Authors disagree as to
which provides the best outcome.40,44 It is accepted that
maintaining a normal CVP will increase intraoperative
bleeding and maintaining a low CVP can reduce bleed-
ing but may result in organ hypoperfusion; therefore,
authors agree that using SVV is a more specific guide to
fluid status.37,38,45
Intravenous crystalloid recommendations in ERAS
protocols were found to be primarily Ringer’s lactate,
with some authors recommending nonlactate-containing
fluid.40,46 Lactate metabolism is a concern after liver re-
section or in the presence of renal and hepatic disease.40
The ERAS Society recommends a balanced solution such
as Ringer’s lactate; however, a large review study found
reports of hyperchloremia.40,47 Kumar et al48 evaluated a
combination therapy of preoperative Ringer’s lactate and
normal saline during the resection and liver transplant
periods. No significant difference in lactate levels was
found between the control and treatment groups.48 No
studies were found whose results clearly demonstrate that
balanced crystalloid administration improves outcomes.
Resistance to implementation of ERAS protocols
has been reported.49,50 Resistance to change was most
commonly reported as the barrier to implementation.
Decades of caring for surgical patients included rules for
nothing by mouth after midnight, and the ERAS recom-
 August 2021  Vol. 89, No. 4 355
mendations include carbohydrate loading 2 hours before
surgery. Buy-in to the ERAS concept may be hindered
because of long-held beliefs that nothing by mouth for 6
hours before surgery is required.
Conclusion
Goal-directed fluid therapy in the ERAS protocol can
affect patient outcomes. As prudent anesthesia providers,
special consideration is required with frail or compro-
mised patients. Surgery-specific issues need to be con-
sidered, such as organ resection and resultant function
or those requiring transfusion due to blood loss. Enough
evidence in favor of improved patient outcomes is offered
to support use of an ERAS protocol. Management of
perioperative hemodynamics by using small fluid boluses
guided by SVV provides a strategic approach to GDFT
to improve outcomes. Although carbohydrate loading,
use of nasogastric tubes, and considerations with bowel
preparations are not directly related to GDFT, they can
affect the overall euvolemic state and should be consid-
ered. Reduced administration of iso-osmotic fluids and
euvolemia is supported in the GDFT process to improve
patient outcomes. Decreased length of stay, reduced
overall complications, and cost reduction have strong
support in the literature as advantages of ERAS. Improved
patient outcomes support the use of ERAS and GDFT as
effective tools to benefit and speed recovery after surgery.
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AUTHORS
Nina McLain, PhD, CRNA, earned her PhD from Virginia Commonwealth
University in Richmond, Virginia, in 2007. She has served as faculty at
Samford University in Homewood, Alabama, and is currently the Nurse
Anesthesia Program administrator at The University of Southern Missis-
sippi (USM) in Hattiesburg, Mississippi.
Stephanie Parks, DNP, CRNA, received her doctorate from USM in
2015. She served as faculty at Franciscan University in Baton Rouge, Loui-
siana, and is currently a professor at USM in the Nurse Anesthesia Program.
Mary Jane Collins, DHA, CRNA, received her doctorate in healthcare
administration from the University of Mississippi Medical Center in Jack-
son, Mississippi, where she also completed a yearlong fellowship in health
policy with the Mississippi legislature. She currently serves as the assistant
program administrator at USM.
DISCLOSURES
Name: Nina McLain, PhD, CRNA
Contribution: This author made significant contributions to the concep-
tion, synthesis, writing, and final editing and approval of the manuscript
to justify inclusion as an author.
Disclosures: None.
Name: Stephanie Parks, DNP, CRNA
Contribution: This author made significant contributions to the concep-
tion, synthesis, writing, and final editing and approval of the manuscript
to justify inclusion as an author.
Disclosures: None.
Name: Mary Jane Collins, DHA, CRNA
Contribution: This author made significant contributions to the concep-
tion, synthesis, writing, and final editing and approval of the manuscript
to justify inclusion as an author.
Disclosures: None.
The authors did not discuss off-label use within the article. Disclosure
statements are available for viewing upon request.
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