According to the ERAS Society, enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, decrease hospital length of stay, expedite recovery following elective procedures.
We spoke to Refaat Hegazi, MD, PhD, MPH, MS, PNS, MBA, Medical Director of Abbott Nutrition Scientific & Medical Affairs (Columbus, Ohio, USA)—our resident ERAS expert—to learn more about the commonalities and differences in protocols across surgical disciplines, discuss the role of the multidisciplinary team, and to better understand the positive implications of adopting an ERAS protocol in the surgical setting.
IN WHAT SURGICAL DISCIPLINE DID ERAS BEGIN?
Enhanced Recovery After Surgery as a protocol started in the early 1990s with a Danish physician/scientist [Henrik Kehlet] whose PhD was on the trauma and surgery effects on the body. He started something called “fast-track” surgery, which is a combination of pre- and post-surgery procedures that could help decrease the impact of surgical stress on the body and reduce length of hospital stay. That developed into the Enhanced Recovery After Surgery, which evolved into The ERAS Society, which started in Europe and expanded throughout the years, throughout the globe, and now includes the US.
ERAS started in colorectal surgery, and then expanded easily and nicely into different types of surgery. Preoperatively, the nutritional status—assessing the nutritional status before surgery—was added a little bit later in the process, but it’s very important that it was highlighted in the American Society for Enhanced Recovery (ASER) guidelines in 2018—which were developed by American surgeons and anesthesiologists.
HOW DOES THE FIELD OF MEDICINE DEFINE “ENHANCED RECOVERY AFTER SURGERY”? CAN YOU DISCUSS THE GOALS OF SUCCESSFULLY IMPLEMENTING ERAS CARE PATHWAYS?
The whole idea of Enhanced Recovery After Surgery is to decrease the stress impact of surgical insult on the body. And by that, we’re talking about decreasing the metabolic insult, decreasing the inflammatory insult, and decreasing the nutritional insult, because surgery as an injury imposes a lot of nutritional, metabolic and immunological changes of the body. The whole idea is to enhance the speed of recovery after surgery by addressing those changes.
The combination of procedures before and after surgery were meant to address this. For example, you don’t have to wait to feed patients until their bowel function comes back. You can start feeding them within the first 24 hours post-surgery. This is a change in paradigm that has been shown by a lot of clinical studies to improve outcomes, including mortality, as compared to the conventional way we used to do it, which was waiting for a bowel movement or passing gas as a sign of resuming bowel function.
The other thing is early ambulation. Start to move patients as early as you can when they’re conscious and alert. They don’t have to wait in the bed, lying flat. This is very important because moving the patient increases their chances of recovery, because in fact it can induce or enhance insulin sensitivity and improve intestinal motility. One of the most impactful metabolic changes that surgery does—especially major surgeries—is post-operative insulin resistance. That’s a syndrome that has been very well described. The body starts to maximize utilization of food substrates unfortunately, because there is a lot of release of counter-regulatory hormones, like glucagon, growth hormone, epinephrine, norepinephrine, cortisol. All of these hormones counteract the effect of insulin, and that can send surgical patients into a state of post-operative insulin resistance.
THE ERAS SOCIETY HAS ESTABLISHED A SET OF GUIDELINES SPECIFIC TO CERTAIN TYPES OF SURGERY. WHAT ARE THE COMMONALITIES AND DIFFERENCES AMONG THE PROTOCOLS?
Post-operative insulin resistance is a commonality that could happen in any type of surgery—especially in major surgery. Whether it’s a colorectal surgery, a cardiac surgery, the body will go through this metabolic resistance after surgery, irrespective of the type of surgery.
What can we do perioperatively, so we can decrease the insult and decrease a lot of the patient-reported outcomes like anxiety and a feeling of stress or anxiousness is something very simple: We don’t have to fast the patient 12-hours or stop them from eating or drinking at midnight or the night before surgery. Experts now allow patients to take solid food up to 6 hours before surgery, and fluids up to 2 hours before surgery. With that also came the idea of carb loading, meaning to give a complex carbohydrate drink before surgery to reduce the post-operative insulin resistance and enhance the chance the patient will get a little bit more insulin sensitivity. There is a lot of research that backs this, especially in colorectal surgery and other types of surgery as well.
The guidelines also talk about decreasing the need for general anesthesia and optimizing pain medication—which is very logical, that patients don’t have to receive tons of pain medication, especially opioids, because of their negative effect on gut motility. Start to talk about different types of sedation, enhance or promote regional anesthesia and not general—all of this is directed at the same thing: to promote the process of faster recovery after surgery
WE TOUCHED ON THIS EARLIER: THE GUIDELINES SUGGEST FIVE BENEFICIAL OUTCOMES TO SUCCESSFULLY IMPLEMENT ERAS PROTOCOLS:
- Minimize surgical trauma and postoperative pain
- Reduce complications
- Improve outcomes
- Decrease hospital length of stay
- Expedite recovery following elective procedures
HOW SPECIFICALLY SOULD APPLYING ERAS PROTOCOLS DRIVE THESE POSITIVE OUTCOMES?
When you start moving patients early, when you start feeding them, they don’t have to wait in the hospital that long. ERAS has been shown to decrease post-operative complications including infectious complications. It decreases the patient’s feeling of stress and anxiety because you don’t have to wait—no fasting, no food, no fluid for 16 hours. It also has an economic benefit. Many studies and meta-analyses show that it decreases the surgical cost by up to 60%, and it has to do with length of hospital stay being reduced by about 2-3 days in average of most the studies that have been shown up to date. So we’re talking about:
- An overall 30% average reduction of post-operative complication
- A 2-day reduction of length of hospital stay, post-operative
- 60% reduction in economic and cost burden of the surgery
- The patient-reported outcome that stress or feeling anxious improved, these are all outcomes of ERAS
WITH ALL OF THESE POSITIVE OUTCOMES, WHY IS IT THAT NOT EVERYONE HAS IMPLEMENTED ERAS? WHAT ARE SOME OF THOSE BARRIERS?
I think it’s two facets to answer this question:
- You have surgeon or clinician behavior, which is: “I’ve been doing my type of surgery and I’m getting good outcomes. Why should I change?”
- ERAS is not studied in every type of surgery, and some surgeons say, “I will wait until I have enough studies in my type of surgery,” so it’s that feeling of patients being different. It is that technicality and evidence aspect. The technicality is surgery and behavior; the need for multidisciplinary team to get alignment from everyone that, “Hey, we’re going to do this.” But, to be honest, what I’m seeing is, this is happening. Many hospitals around the US and around the world are implementing ERAS because of the many clinically proven results of decreased post-operative complications and decreased length of hospital stay.
SO YOU’RE SEEING AN INCREASE IN IMPLEMENTATION OVER TIME. WOULD YOU SAY THAT INCREASE HAS PICKED UP IN RECENT YEARS OR HAS IT BEEN A STEADY RATE OF GROWTH OVER A LONG PERIOD OF TIME?
I would say it’s increasing because of that very important economic outcome. With the current landscape of healthcare in the US, the focus on how to efficiently do surgery with decreased cost is very important because you get the alignment of the administrators of the hospitals with surgeons and clinicians, and they together try to implement it.
LET’S TALK ABOUT THE ROLE OF THE MULTIDISCIPLINEARY TEAM. CAN YOU EXPLAIN WHO IS PART OF THAT TEAM, WHAT SORT OF ROLES EACH MEMBER PLAYS, AND HOW PATIENTS INTERACT WITHIN THE SET?
The Anesthesiologist. If we’re talking about pre-operative carb-loading or decreasing the amount of time the patient has to stop eating and drinking, that has to be anesthesiologist-driven. Anesthesiologists have to feel confident to recommend it to their patients. The thought is, “No, I would jeopardize my patient’s safety because I’m going to feed them up to two hours before, and that might increase gastric residual and vomiting aspiration. In fact, to the contrary of this misbelief, the American Society of Anesthesiologists (ASA) were one of the first societies to adopt and recommend that patients should not be waiting for 12 hours to eat and clear liquids up to two hours before surgery.
The dietitian. I cannot stress enough the role of the dietitian because that added layer of preoperative nutritional assessment and seeing who is malnourished or at risk of malnutrition, because the impact of malnutrition on surgical outcome has been in the literature since the 1970s. We know that those patients who walk into the OR malnourished get into worse complications than patients who are well-nourished. So addressing malnutrition earlier before you walk into the OR and have enough time to replete their nutritional status by diet or by order of nutritional supplements you have a window of opportunity to improve outcome.
I did surgery in my early career. If patients come into the OR with albumin less than 3 g/dL, we’ll delay their surgery. But in our mind, it wasn’t necessarily about nutrition; rather serum albumin is a significant prognostic marker, not a nutritional marker.
Post-operatively, you need the dietitian—once the patient is aware and oriented—to start the PO (per os) intake very early on. And also the dietitian will help with immunonutrition, which addresses the inflammatory changes associated with surgery. A lot of immunological changes happen because of the effect of surgery. Now, we have immuno-nutrient products, high protein-nutritional supplements that are supplemented with both fish oil and arginine. These nutrients in combination have been shown to decrease the inflammatory changes that happen after surgery. And many studies of just immuno-nutrition away from being part of ERAS, have been shown to decrease post-operative infections and length of hospital stay, which are exactly the same outcomes that are helped by ERAS. So, the dietitian’s role is also to offer this immuno-nutrition. The optimal timing and doses of these supplements is to be taken 5-7 days before surgery and 5-7 days after surgery. Hence, the dietitian’s role is to make sure this is implemented and adjusted within the daily requirements and make the calculation that this justifies satisfying the patient’s nutrition needs.
The surgeon. The surgeon has to absolutely buy in, because when the surgeon is on board, that actually makes things happen. At the end of the day, this surgical patient is the main responsibility of the surgeon, and they have to have total comfort that ERAS is going to help patients and improve the care of the patients.
The nurse practitioner/ERAS coordinator. Nurse practitioners play a major role, and some of them are called ERAS coordinators to make sure that all of these elements of ERAS are coordinated and implemented. Ambulating and making sure the patient is moving would be the function of the surgical resident and the ERAS coordinator, working with the nurse or nurse practitioner.
The pharmacist. The pharmacist would be involved in the selection of pain medication and alternatives to the opioids as well as assisting to optimize fluid management. Fluid management during the OR would be also the function of the anesthesiologist. The type of anesthesia—whether it’s regional versus general—would [be up to] the anesthesiologist.
Administrators. Having hospital administrators believe ERAS can improve economic and clinical, is pivotal for implementing protocols that are system wide and hospital-wide.
HOW DO ALL OF THESE FOLKS WITHIN THE MIX COMMUNICATE WITH ONE ANOTHER? AT WHAT POINT DO THEY START TO TALK ABOUT WHAT THE PATIENT’S TREATMENT SHOULD LOOK LIKE THROUGH THIS WHOLE RECOVERY PROCESS?
That’s the job of the ERAS coordinator. That’s what I’ve seen in hospitals who have successfully implemented ERAS. The surgeon sees the patient and then refers to the ERAS coordinator, and she or he will take care of coordinating with all services and make sure protocols are implemented and SOPs (standard operating procedures) are followed for every station of the patient journey.
WANT TO LEARN MORE?
- Enroll in our free continuing education course (1.0 CE/CPEU), “Enhancing Recovery After Surgery: Maximizing the Role of Nutrition,” Featuring David Evans, MD, FACS, Director of Nutrition Support Services and Trauma Medical Director at The Ohio State University Wexner Medical Center (Columbus, Ohio, USA).
- Watch our new video series on perioperative nutrition
- Video: The Importance of Perioperative Nutrition: Paul Wischmeyer, MD, EDIC
- Video: The Importance of Perioperative Nutrition: Kathryn Starr, PhD
- Video: Nutrition is a Team Sport
- Video: How to Prepare
- Download our new surgery toolkit for patients