FAST TRACK SURGERY/ENHANCED RECOVERY AFTER SURGERY (ERAS)

Definition:
• It is an evidence based multimodal and multidisciplinary practice to aim speeding up post operative
recovery by
◦ operating on preoperatively appropriately optimized patients
◦ with meticulous attention to intra-operative surgical and anaesthetic techniques to minimize
inflammatory and neuroendocrine responses
◦ and proactive postoperative care that promote earlier return to normal physiology

History:
• Enhanced Recovery After Surgery (ERAS) was originally designed by a Danish surgeon - Henrik Kehlet in 1990s with the
main objective of reducing post-op complications and length of hospital stay
• Many individual interventions were already there shown to promote quicker recovery
◦ Multimodal analgesia
◦ Goal directed intraoperative fluid management
◦ Reduction in postoperative nausea and vomiting (PONV)
• Kehlet brought all these under one umbrella as a multimodal package called ERAS pathway
• Initial application was for colorectal patients → subsequently utilized by other surgical specialties (Orthopaedics,
Gynaecology, Urology)

Aims of ERAS
1. Reduce surgical stress response (Inflammatory response + Neuroendocrine response)

SURGERY
• Afferent sensory input • Sympathetic flow
(pain)
• Inflammatory response • Neuroendocrine response

• Cytokines and acute

phase reactants

• ACTH like substances • ACTH, TSH, GH • ADH

• Counter regulatory (Catabolic) hormones

(CORTISOL, GLUCAGON, CATECHOLAMINES)
• Proteolysis
• Insulin resistance • Na+ and water
retention

• Hyperglycemia • Electrolyte
imbalance

• INFECTIVE COMPLICATIONS • ILEUS

DELAYED DISCHARGE

2. Maintain physiology and metabolic homeostasis

3. Early enteral feeding
3. Expedite patient recovery to baseline status
Components of Fast track surgery (ERAS)
1. PRE-OPERATIVE COMPONENTS
A. Pre-op assessment
a. Done at pre-op assessment clinics
b. Has the following components
1. Assessment of fitness for surgery by
A. Assessing
a. Patient's general fitness
b. Co-morbidities
c. Drug history etc.
B. Investigating
a. FBC, RT, ECG, CXR, Stress test/6 minute walk test
b. Newer assessments - Objective evaluation of functional capacity with CPET (cardiopulmonary
exercise testing), myocardial perfusion scanning
2. Optimises pre-existing conditions
3. Assessment of social situation, social habits
c. Good pre-op assessment should therefore
1. Facilitate same day admissions (as fitness is assessed already and pre-existing problems optimised
2. Aids discharge plan (as assessment of social situation is done)
3. Aids reduction of risks associated with smoking and alcohol (as social habits assessment is done)
B. Preoperative education
a. Information regarding
1. Surgery
2. Anaesthesia
3. Anticipated problems
b. Helps alleviating anxiety → encourages patients to participate in their own recovery (e.g. pre-operative stoma
education)
C. Smoking and alcohol cessation
a. Smoking increases risk of
1. Post op wound sepsis
2. Pulmonary complications
3. DVT
b. Alcohol increases risk of
1. Post op wound infection, wound breakdown
2. Pulmonary complications
c. Recommendation
1. Cessation of smoking for at least 4 weeks
2. Cessation of alcohol for at least 4 weeks
D. Nutrition
a. Preop fasting inhibits insulin secretion and promotes catabolic hormone release
b. Recommendations
1. No prolong fasting
2. Allowed solids 6 hours before, clear liquids 2 hours before induction of anaesthesia
3. Oral carbohydrate drinks up to 2 hours prior to surgery → shown to
A. reduce post-op insulin resistance
B. reduce protein break down
C. improve muscle strength
D. shorten hospital stay
4. Pre-op supplemental nutrition for patients with unintentional LOW or malnourishment
A. Unintentional LOW is associated with
a. increased risk of post op cardiovascular complications
b. increased mortality
c. increased hospital stays
d. .following colorectal surgery
E. Mechanical bowel preparation
a. No impact in reducing anastomotic leak rates or septic complications
b. Has the potential to cause greater morbidity
1. Intravascular fluid depletion
2. Electrolyte imbalance
3. Poor tolerance
c. Recommendations
 1. MBP no longer recommended in colorectal surgery
2. Exceptions → Need for on-table colonoscopy to identify small lesions or bleeding points
F. Thromboprophylaxis
a. Risk is higher in
1. Old age
2. Major abdominal or pelvic surgery
3. Pregnancy
4. OCP use
5. Obesity
6. Underlying malignancy
7. Past history of DVT
8. Patients who develop complications like sepsis, AKI, bleeding requiring transfusions
b. Recommendations
1. Major surgery → both mechanical (pneumatic compression device or embolic stockings) and chemical
thromboprophylaxis (prophylactic LMWH or unfractionated heparin, if intolerant → Fondaparinux or
Aspirin)
2. For those who need chemical thromboprophylaxis, but who also have higher risk of bleeding →
thromboprophylais should only be omitted if the risk of bleeding outweighs the risk of DVT → if so may
need a caval filter
3. Post-operatively chemical thromboprophylaxis should continue for 7-10 days, but if underlying cancer,
morbid obesity, major prolong abdominopelvic surgery → 28 days
2. INTRA-OPERATIVE STRATEGIES
A. Anaesthesia
a. To facilitate rapid awakening and reduce post op monitoring time
1. Rapid short acting anaesthetic agents
2. Short acting opioids
3. Short acting muscle relaxants
b. Use of regional anaesthesia - it's a mode of opiod sparing anaesthesia and include epidural/central neuroaxial
blocks and regional blocks helps
1. Post-op pain management
2. Prevention of PONV
3. Reducing patient stress response → reduces catabolic hormones → reduces insulin resistance → reduces
hyperglycemia → reduces wound infection
4. Reducing post-op cardiovascular complications
B. Antimicrobial prophylaxis
a. Reduces post-op wound infection by 20-30% following colorectal surgery
b. Effect of oral antibiotic prophylaxis is less than IV antibiotics
c. Combined oral and IV is better than just IV
1. Reduction of infections is 12%→4.5%
d. Recommendations
1. IV antibiotic prophylaxis is strongly recommended to reduce SSI
2. Antibiotic should cover both aerobic and anaerobic for colorectal surgery
3. Antibiotic use should be based on local guidelines
4. Combination is better than single antibiotic
5. Should be given within 60 minutes before incision
6. Should be repeated 3 hours later in prolong surgery or surgery with significant intra-op blood loss
7. Should not use post-operatively beyond 24-48 hours (if done can lead to Clostridium difficile infection)
C. PONV prophylaxis
a. PONV affects 25% of surgical patients
b. PONV is associated with
1. Delayed commencement of oral intake
2. Delayed recovery of gut function
3. Delayed hospital discharge
c. Risk factors for PONV (APFEL score)
1. Female gender
2. Non-smokers
3. H/o PONV or motion sickness
4. Major abdominal surgery
5. Use of volatile anaesthetic agents or parenteral opiates
d. Recommendations
1. Non-pharmacological preventive methods
 A. Minimise pre-operative fasting
B. Do carbohydrate loading and hydration prior to surgery
2. Pharmacological preventive methods
A. Minimise the use of opiates and volatile anaesthetic agents → Use TIVA instead (Total Intravenous
Anaesthesia)
B. 4 Antiemetic subtypes - Cholinergic, Dopaminergic, Serotonergic, Histaminergic → Two or more
subtypes in combination should be used to improve the potency of anti-emetic effect
C. Dexamethazone has shown positive effect in preventing and managing PONV → Can be used → but it
has hyperglycemic and psychiatric disturbance side effects → so should not be used in diabetics,
elderly, and patients with mental health problems
3. When PONV develops → use the anti-emetic subtypes that were not used during prophylaxis
D. Fluid manangement
a. Liberal use of fluid is detrimental on
1. Cardiorespiratory function
2. Tissue handling during surgery
b. Goal directed intra-operative fluid therapy is associated with
1. Low rates of post op infection
2. Low rates of cardiorespiratory complications
3. Low rates of PONV
4. Less gut edema → faster return to bowel motions
c. GDIOFT is based on cardiac output → cardiac output monitoring is done by
A. Oesophageal doppler
B. Invasive arterial pressure monitoring
d. Recommendations
1. Intra-operative fluid management should be based on cardiac output
2. Post-operatively stop IV fluids as soon as oral intake is sufficient
3. IV N.saline should not be used routinely
4. Epidural induced hypotension should be managed with vasopressors and not with fluids (provided patient is
normovolemic)
E. Thermoregulation
a. Hypothermia predisposes to
1. Coagulopathy
2. Impaired immunity
3. Increased surgical stress response
b. Maintaining normothermia reduces
1. Bleeding
2. Wound infection
3. Cardiac events
c. Recommendations
1. Intra-op use of
A. forced-air warming blanket
B. Heating mattress
C. Warmed IV fluids
2. Monitor patient's temperature to avoid over-warming and hyperpyrexia
F. Surgery
a. Laparoscopy preferred over open for bariatric surgery
1. Laparsocopic surgery in colonic surgery is associated with
A. Reduced inflammatory response
B. Improved cardiorespiratory function
C. Earlier return of gut function
D. Shorter hospital stay
E. No compromised oncological outcome
2. Benefits are with colonic surgery, not with rectal surgery
b. Transverse/oblique incisions
G. NG
a. Routine NG insertion has increased the risk of
1. Post op fever
2. Atelectasis
3. Pneumonia
b. NG does not prevent post-op ileus
c. NG increases delay in passage of flatus
 d. Recommendation
1. Remove NG before patient waking up from GA in colorectal surgery
H. Peritoneal cavity drainage
a. Pancreatic surgery → drain should be removed on day 3 if drain fluid amylase is <5000 → reduces the risk of
pancreatic fistula
b. Putting a drainage
1. Wouldn't
A. protect against anastomotic leak
B. protect against intra-abdominal sepsis
C. detect anastomotic leaks earlier
2. Can cause
A. Drain site infection
B. Pain
C. Bleeding
D. False reassurance due to a blocked drain
E. Small bowel or omental eviseration
F. Injury to bowel or adjacent structures
G. Entero-cutaneous fistula formation
H. Bowel obstruction
c. Recommendation for colorectal surgery
1. Drain can be placed when there is a need to monitor for potential post-op bleeding
3. POST-OPERATIVE STRATEGIES
A. Nutritional care
a. Early feeding has shown
1. To reduce the risk of post op infection
2. To reduce hospital stay
3. Not to increase any anastomotic dehiscence
4. Reduce insulin resistance
b. Recommendations
1. No prolong post-op fasting anymore
2. Early feeding should be done
3. If PONV occurs with early feeding → antiemetic multimodal regime use
4. If delayed gastric emptying → Naso-jejunal feeding
5. Parenteral nutrition is not recommended unless prolong gut dysfunction
B. Early mobilization
a. Reduces
1. Pulmonary complications
2. Muscle atrophy
3. Insulin resistance due to immobilisation
b. Poor mobilization can occur due to
1. Poor pain control
2. Indwelling catheter
3. Indwelling drain
4. Continuation of IV fluids
5. Poor patient motivation
6. Lack of staff encouragement
c. Recommendations
1. Mobilise ASAP
2. Exercise plans from post-op day 1 onwards
3. Trial of voiding on day 1 or 2
4. Cessation of IV fluids on day 1 or as soon as they tolerate oral fluids
C. Post-op analgesia
a. Good analgesics should
1. Should allow pain relief and early mobilization
2. Should not cause drowsiness, respiratory compromise or nausea/vomiting
b. Recommendations
1. Opiates should be avoided if possible → slows gut function
2. Multimodal regimen with PCM, NSAIDS
3. Other opioid-sparing methods
A. Transverse abdominis plane block (TAP)
B. IV lidocaine
 C. Thoracic epidural
a. .A good functioning epidural
1. Reduces PONV
2. Allows early return of gut function (preserves vagal and reduces sympathetic)
3. Reduces insulin resistance (stops afferent pathway of stress response to surgery →
D. Prevention of post-op ileus
a. .Recommendations
1. Early nutrition
2. Goal directed fluid therapy (prevents fluid overload and gut edema)
3. Avoiding prophylactic and unnecessary NG decompression
4. Opting for laparoscopic surgery
5. Pharmacological measures
A. Mixed results with
a. Pro kinetics
b. Magnesium oxide
c. Bisacodyl
B. Alvimopan (opiod receptor blocker) - shown to have facilitated gut recovery, reduced ileus
6. Chewing gum has shown to improve ileus

Team:
• Nurse
• Anaesthetist
• Surgeon
• Dieticians
• Physiotherapists
• Pharmacy staff
• Pain management staff
• Pre-assessment staff
• Medical staff
• Patient's representatives

Should always include an audit