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ERAS−−Enhanced Recovery After Surgery: Moving Evidence-Based Perioperative Care to Practice Olle Ljungqvist JPEN J Parenter Enteral Nutr published online 24 February 2014 DOI: 10.1177/0148607114523451
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PENXXX10.1177/0148607114523451Journal of Parenteral and Enteral NutritionLjungqvist
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ERAS—Enhanced Recovery After Surgery: Moving Evidence-Based Perioperative Care to Practice
Olle Ljungqvist, MD, PhD
Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–8 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607114523451 jpen.sagepub.com hosted at online.sagepub.com
Abstract ERAS is the acronym for enhanced recovery after surgery, a term often used to describe perioperative care programs that have been shown to improve outcomes after major surgery. This article gives a brief history of the development from fast-track surgery to ERAS. Today, the full meaning of ERAS goes beyond just a protocol for perioperative care with the initiation of a novel multiprofessional, multidisciplinary medical society: the Enhanced Recovery After Surgery Society for Perioperative Care (www.erassociety.org). The ERAS Society is involved in the development of evidence-based guidelines. These guidelines form the basis for an implementation program of the ERAS principles to practice. While ERAS was initially developed for colonic resections, these principles are being used in a range of operations, and there is also a continuous update of care protocols as the fields develop. A key mechanism behind the effectiveness of ERAS is the dampening of the stress responses to the surgical insult combined with the use of treatments that support return of functions that delay recovery in traditional care. The article also gives some insights to why the protocols work and reports the effects of ERAS protocols. (JPEN J Parenter Enteral Nutr. XXXX;XX:xx-xx)
Keywords surgery; anesthesia; enhanced recovery; surgical stress; fluid balance
What Is ERAS?
Short History of ERAS
ERAS is an acronym for enhanced recovery after surgery. The term ERAS is often used to describe a multimodal perioperative care program.1 Some authors use terms such as enhanced recovery programs (ERP), and previously fast-track surgery was commonly used, the latter especially in North America. These programs are all composed of several evidence-based perioperative care elements that individually have been shown to be beneficial, and when used together in a protocol, they have been shown to result in substantially improved outcomes. The number of items in such a protocol varies, but often around 20 items have been included (Table 1).1,2 A recent meta-analysis show that ERAS protocols in major surgery reduce recovery time and length of stay by 2–3 days and complications by 30%–50%.3 However, the term ERAS is developing into more than just a protocol, and in this article, the broader meaning of ERAS is outlined. While it is well recognized that important contributions in a wide range of areas of surgery and anesthesia have been made and reported from many centers worldwide that have all contributed to the refinement of perioperative care, this study aims to tell the story of the development of ERAS from the European angle, where the specific term ERAS was coined, and how the term ERAS is now at the center of a broad development in changing perioperative care in a range of operations to improve clinical outcomes for patients in many countries.
The term ERAS was invented by a group of academic surgeons who started the ERAS study group in London in 2001. The intention of the group was to develop the optimal perioperative care pathway by means of literature review and adaptation of treatments to give the best fit throughout the patient’s journey. The group consisted of research group leaders—K. F. C. Fearon (University of Edinburgh, United Kingdom), H. Kehlet (University of Copenhagen, Denmark), A. Revhaug (University of Tromsø, Norway), M. von Meyenfeldt (the Netherlands), C. deJong (University of Maastricht, the Netherlands), and the From the Orebro University, Orebro, Sweden. Financial disclosure: The author is a co-founder of the ERAS study group and the ERAS Society and serves as the Chairman of the Executive Committee. The author serves as advisor for Danone/Nutricia research and owns stock in Encare AB, a company involved in data management and implementation programs for the ERAS Society. He also has given scientific presentations at scientific meetings occasionally sponsored with travel grants from medical industries. Received for publication December 18, 2013; accepted for publication January 13, 2014. Corresponding Author: Olle Ljungqvist, MD, PhD, Chairman ERAS Society, Department of Surgery, Orebro University, Örebro University Hospital, Örebro, SE-70185, Sweden. Email: [email protected]
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Table 1. The ERAS Society Protocol for Elective Colonic Resection. Preoperative •• Detailed information •• Stop smoking •• Screen nutrition status and liberal nutrition support with oral nutrition supplements •• No oral bowel preparation
•• No “nil per os” from midnight— preoperative carbohydrate drink 2 hours before anesthesia •• No routine long-acting sedatives
•• Prophylaxis against thomboembolism •• Antimicrobial prophylaxis •• Skin preparation
Intraoperative •• Standard anesthetic technique aiming to maintain homeostasis and reduce stress •• Avoid long-acting opioids •• Open surgery: mid-thoracic epidural •• Laparoscopic: spinal or patientcontrolled analgesia as an alterative to epidural •• Multimodal postoperative nausea and vomiting prophylaxis •• Laparoscopic surgery if available
•• Prevention of hypothermia
Postoperative •• No routine nasogastric tubes •• Early (when lucid after surgery) oral intake of fluids and solids •• Liberal use of oral nutrition supplements •• Prevention of postoperative ileus: fluid balanced; avoiding opioids, chewing gum; magnesium oxide and alvimopan may be used. •• Urinary drainage removed days 1–2 postoperatively •• Glucose control; primarily avoiding insulin resistance, insulin treatment in intensive care unit for severe hyperglycemia •• Early mobilization
•• Fluid optimization using mixtures of colloids and crystalloids •• Vasopressors to control hypotension •• No routine drains
Adapted from Gustafsson et al.2
undersigned O. Ljungqvist (Karolinska Insitutet, Stockholm, Sweden)—and collaborators at the respective academic sites. The groups set off to review all the literature they could find with an impact on surgical outcomes and developed a care protocol for elective colonic resections.1 At that time, H. Kehlet had already published work that many felt was almost unbelievable. At a time when the normal length of stay after a colonic resection was 9–10 days, Kehlet reported patients fit to leave the hospital in 2 days,4 using a multimodal approach to perioperative care.5 In those days, these protocols were often called fast-track surgery. The name fast track, however, was felt by the ERAS study group to be leading focus too much toward faster discharge. The group wished to keep focus on the patient’s recovery, and in the further developments of these protocols, the ERAS study group started to use the new term, enhanced recovery after surgery or ERAS. ERAS has now been a well-recognized term in the medical literature with more than 1600 hits on PubMed. When the ERAS study group established the final first protocol, it was clear to everyone in the group that none of the collaborating units was fully compliant with such an ideal protocol. Dr Kehlet’s Danish group had higher compliance than the rest, having been using this kind of approach for several years already. It was also obvious that all the units did things differently. So it was decided that all 5 centers would aim to adopt the best practice ERAS protocol, and it was also decided
to study the change of practice. During these studies, it became obvious that just having a protocol was not enough.6 When working together to adopt a common protocol, it was decided to set up and use a common database and put all consecutive patients in this database. This led to the second revelation: the treatments actually delivered were different from what we thought. When the 5 units reviewed their own practices, it was realized that all had problems with compliance to the protocol with items thought to be working. Using the database audit revealed the true practice and helped us to make the right changes and focus where the problems actually were present. Working together was also very useful. The fact that some centers were employing treatments that were resisted by some collaborators in another unit made it easier for resisters to accept a change of practice. The group met on a regular basis over several years, and by supporting each other, improvements in compliance and outcomes emerged. The group also undertook surveys that revealed that we were not alone in keeping with old traditional and outdated care rather than changing to newer and evidence-based developments.7 The Maastricht group had the opportunity to work with CBO (Centraal Begeleidings Orgaan, Dutch Institute for Healthcare Improvement, Utrecht, the Netherlands), a government-led organization specializing in change management in healthcare on an implementation program. Taking advantage of the insights from the rest of the ERAS group, the protocol, the
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multiprofessional approach, and the use of data, they showed that indeed it was possible to have several units change longlasting outdated habits and get better results.8-10 These results showed that the tools to actually move literature evidence into practice with good results were available. The strength of working together in a growing international collaboration, along with the expanding interest in ERAS, made the group decide to take these experiences to a next level by forming a medical society to broaden the network and to give the project of improving perioperative care a more solid platform from which to work.
The ERAS Society In 2010, the ERAS study group formed a nonprofit international medical society, the Enhanced Recovery After Surgery Society for Perioperative Care—in short, the ERAS Society (www.erassociety.org). This is a multiprofessional, multidisciplinary society with the aim to improve perioperative care through research and education, but the Society also engages in the implementation of best practices (ie, evidence-based medicine in perioperative care). The Society set off to make ERAS not just a term for a protocol but a movement to constantly develop and improve the perioperative care processes. The initial ERAS study group rapidly expanded the network of centers involved in the development of perioperative care, and at present, there are such centers of excellence in more than 15 countries in Europe, North and South America, and Australasia, and it is currently expanding to other countries. In several countries, national ERAS Societies are formed and linked to the ERAS Society. The Society also engages a wider range of experts in the formation of guidelines for different operations, and the ERAS Society faculty today encompasses more than 50 leading units from different parts of the world. The first ERAS world congress was held in Cannes, France, in October 2012, and the second congress is set for April 23–27, 2014, in Valencia, Spain.
Philosophy of ERAS The basic philosophy behind ERAS is the realization that a traditional hospital works in silos that need to be broken to ensure a care protocol that follows and optimizes the journey the patient makes during the perioperative care. For instance, a doctor or nurse working in anesthesia will see the patient during a short period of the entire process and will focus primarily on ensuring that vital functions are under control during the operation. They will plan and prepare to manage this specific part of the patient care during the preoperative visit and will focus on maintaining control of these parameters for the duration of the surgery. Once the surgery is over, the patient is handed over to the next team in the recovery room or the highdependency unit or possible intensive care. The anesthesia
team then takes on the next case. Very rarely does the anesthesia team have time or feel the need to see the patient later on in the surgical ward, for instance. Nor do the ward nurses or other staff see what is ongoing in the operating room. So while ensuring vital functions are under control, the anesthesia team has little insight if the treatment they use for their purposes is beneficial a few hours or even days later. Similarly, the teams taking over the patient have no idea if the patient they are receiving could be presenting differently and potentially in a better shape because they have no insight into what occurred before their part of the care process. To overcome these potentially serious issues, the ERAS protocol has to be built with everyone involved in the entire chain of events during the patient’s journey (Figure 1). Surgeons, anesthetists, intensive care/high-dependency specialists, nurses, dietitians, and physical therapists all have to come together to form a team that runs ERAS locally. The ERAS team forms the cornerstone of the ERAS implementation process but also for the maintenance, sustainability, and further development over time. Only with the entire team around the table on a regular basis for audit can it be ensured that there is always someone there to deal with every problem occurring. The teamwork secures that there is no serious issue that escapes processing. The team is also important for the support of each other. Changes of old routines do not happen by themselves; they take hard work, and the team leading such change must have time to work with the planning and preparation of the changes that are to be put in place. The team also needs time to inform their coworkers. But finding this time for the ERAS team is sometimes a main obstacle on its own. Having a team of 5–6 people prioritizing a meeting every 2 weeks for 45 minutes or an hour sometimes takes more than one may think. Usually everyone is busy working in his or her own silo, so seeing the benefit from prioritizing this meeting and working with the team may be hard. Still, it is unlikely that the ones assigned to run ERAS in a given unit are likely to find that there is anything more important that they can do for the benefit of their patients apart from this work. To make the team find the time to work effectively, the managers of all involved departments in control of budgets and planning must ensure that the ERAS team and their meetings have the highest of priorities. This is key to the success of the implementation. As soon as this fails, the chances of success diminish rapidly. A typical example of how a change can be hard to establish is overcoming the overnight fasting routine. While this is probably the best-known medical “rule” in the world, it is interesting to find that the rule never had any scientific backing but is the result of traditions and a statement in an anesthesia textbook that then became the norm worldwide.11 Today, there is ample evidence that clear fluids are perfectly safe to take up to 2 hours before elective surgery, and all guidelines have stated this since the mid-1990s. In addition, the overnight and morning fast is very discomforting for the patients. Furthermore, the
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Figure 1. The patient’s journey through the hospital. Used by permission of the ERAS Society.
fast itself aggravates the stress responses and increases postoperative insulin resistance (see below). So there are a series of arguments in favor of changing to modern guidelines. Still, in many units, it takes a lot of work to make the change. There are many practicalities to be dealt with—when and where the drink is to be taken, how to deal with the later cases of the day, overcoming the fear of having to cancel a case because of a patient drinking too late, and so on. The change is complex, involving many units and specialties, and staff needs to be informed to create a readiness to make the change. This takes a lot of preparation. If the resistance is strong, it is sometimes necessary to have the team arrange a hearing locally where the leads of anesthesia and surgery come together and review the literature and present modern fasting guidelines. Importantly, for the change to stick, once initiated it has to be audited and followed up appropriately.
What Makes ERAS Work? Reviewing the mechanisms behind the effectiveness of ERAS protocols reveals that most of the items proposed in the protocol and shown to be beneficial support the maintenance of homeostasis via controlling metabolism and fluids, or the support of the return of key functions.12,13 The goals of perioperative care are to secure the safety of the patient but also support the return of specific functions for full recovery. In traditional surgical care, most major operations share some common problems. The patients often have difficulties eating and getting bowel movements back to normal. Very
often oral analgesics and opioids are needed to control pain, and many patients have problems mobilizing. Removing these obstacles while also avoiding complications is a common goal in ERAS protocols. Once these problems are overcome, the patient is ready to go home from a medical point of view. In practice, the return of gut function, maintaining pain relief on oral analgesics, and mobilizing to preoperative levels can serve as medical discharge criteria in the absence of complications needing hospital care.
Metabolic Stress Reduction A key factor in achieving the goals of postoperative recovery is to minimize the stress of surgery. With increased stress, more catabolism develops, and this counteracts the goals of recovery in several different ways. The development of insulin resistance has been proposed to be a key unifying factor for the explanation of the catabolic response, as reviewed elsewhere.12 In brief, with the development of insulin resistance, all parts of metabolism are disturbed, and this can help explain several of the postoperative problems facing many patients. Protein is being lost from muscle, causing loss of muscle mass and strength. Further reducing muscle function is the incapacity of insulin to move glucose into muscle cells and to store it as glycogen. These changes have been shown to last for at least 4 weeks after uncomplicated colorectal surgery.14 In addition, both insulin resistance15 and hyperglycemia16 are closely associated with postoperative complications. These reports indicate that it is the level of disturbance postoperatively that may be more
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important than, for instance, a preoperative diabetic state. With less stress, primarily infectious but also general complications are avoided.12 Many of the treatments in the ERAS protocol have direct or indirect effects on insulin action and reduce the development of insulin resistance. These include perioperative nutrition to avoid prolonged starvation periods and carbohydrate treatment that stimulates insulin sensitivity right before the onset of the operation.17 The preoperative carbohydrate treatment results in improved insulin sensitivity (less resistance) postoperatively17 probably in past via positive effects on muscle PDK4 mRNA and protein expression,18 whereas it has been shown that even a short fast (up to 24 hours) has negative effects on the mitochondrial activity of mononuclear cells.19 The use of epidurals blocks the release of catecholamines and cortisol, the 2 main stress hormones causing insulin resistance,20 and this treatment can also serve as the basis for pain control since pain itself causes insulin resistance.21 By combining several treatments that all work to reduce insulin resistance, but acting via different mechanisms, the effects are enhanced. For diabetic patients, although not specifically studied in an ERAS context, available data suggest that many principles of the protocol should be beneficial for them as well. The use of a preoperative carbohydrate drink for these patients remains to be further investigated, but available data from patients with well-controlled type 2 diabetes show that certain formulas can be given alongside the patients’ normal morning medication (insulin or oral) without delaying gastric emptying.22
Keeping Fluid Homeostasis In a similar fashion to controlling metabolism, maintaining fluid balance is also key. Giving large amounts of fluids to surgical patients has been a longstanding tradition to treat hypotension during and after surgery. In particular, the use of 0.9% saline as the crystalloid has been shown to be especially bad since this fluid is retained in the body longer than balanced salt solutions.13 This practice is still in use in many centers, even if it has been more than 10 years since the first main studies challenging the old dogma were published. These studies showed that not only did the overload of fluids result in delayed return of bowel function, but it was also associated with substantial increases in complications.23,24 Instead of managing hypotension solely with fluids, combining intravenous (IV) fluids with vasopressors helps keep fluids in balance. Further research has shown that keeping fluids balanced and avoiding both under- and overhydration are key to best outcomes, as reviewed elsewhere.13 While the use of too many fluids during surgery is often blamed on the anesthetists, it may well be that the surgeon has caused the patient hypovolemia before the operation by ordering oral bowel preparation.25 Oral bowel cleansing dehydrates the patient and leads to further hypotension when anesthesia is induced. By avoiding unnecessary treatments such as bowel cleansing, hypotension can be avoided and less fluids need to
be given. It has been shown that IV fluid loads above 3000 mL for colonic resections and 3500 mL for rectal resections during the day of surgery result in increased complications.26 A combination of colloids and crystalloids has shown to be very useful in these elective surgical cases. In addition, using short-acting anesthetics, minimizing the use of opioids, and avoiding the use of long-acting preoperative sedatives will help avoid postoperative nausea and support the drive to eat and drink within hours after the operation.
Combining Treatments in ERAS When combining all of the above, the main problems in postoperative care are counteracted: when surgery and anesthesia work together, the patient will receive care that allows the best possible chance to return to normal functions again. By keeping a fluid balance and avoiding elements that reduce appetite and drive nausea, patients will eat and drink earlier. By avoiding fluid overload and treatments that reduce gastric motility, bowel movements will return faster. By reducing the metabolic stress and insulin resistance, any energy and protein consumed will be processed in the body in a more anabolic fashion, hyperglycemia can be avoided, and less lean body mass will be lost and patients may mobilize faster. The differences in insulin resistance development with traditional and ERAS care are shown schematically in Figure 2. There are several meta-analyses on the outcomes using ERAS protocols. The analysis of colonic or colorectal surgery where fast track and ERAS started shows a reduction in length of stay by 2–2.5 days and complications reduced by 30%– 50%.3,27,28 In a recent analysis in other types of major surgery, the outcomes were similar.29 The problem with the randomized trials of ERAS vs traditional care is that it is very hard to blind studies comparing ERAS care with traditional care, and hence the level of the evidence cannot be the highest. Second, some investigators may consider certain elements as standard care while others do not, and hence there is no uniformity in what is actually tested. In the early analysis, the studies included had 4 or more elements that have been recognized as ERAS elements in the treatment groups. Despite the drawbacks of the methodology of the randomized trials and the subsequent weaknesses of meta-analysis, when combining this information with other reports, it becomes evident that ERAS protocols have major benefits for outcomes. The data from almost 1000 consecutive patients with colorectal cancer show that the better the compliance with the protocol, the better the outcomes with regard to recovery time (length of stay) and complications.26 Interestingly, and importantly, readmissions also fell with better compliance. Similarly, the results from the studies of ERAS implementation show better outcomes with improved compliance to the protocols.10,30 There is really very little magic to these findings: the more the use of elements that have been proven to improve outcomes, the better the outcomes are going to be.
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Figure 2. Schematic picture of the influence of different perioperative treatments on insulin sensitivity. Adapted from Ljungqvist O. Insulin resistance and enhanced recovery after surgery: Jonathan E. Rhoads Lecture 2011. JPEN J Parenter Enteral Nutr. 2012;3(4):389-398.12
ERAS Society Guidelines
Table 2. Goals After ERAS Society Implementation Program.
The ERAS Society, often in collaboration with other medical societies, has started to continuously review and update the literature for novel guidelines in an increasing number of surgical procedures, including colonic, rectal, and pancreatic resections,2,31,32 and most recently radical cystectomies.33 The guideline process involves engaging experienced authors involved in the development of the care in the surgery and/or anesthesia for these procedures. The authors complete a structured review of the literature and give graded recommendations. A number of international expert groups are currently working on a wide range of procedures to be presented within the coming year or two. The guideline groups also make continuous updates as the fields develop, with new data emerging. An important feature in this work is the evaluation and testing of these guidelines. For the colorectal guidelines, Gustafsson et al26 pioneered this work and showed that indeed in a single center, improved compliance with ERAS elements improved outcomes substantially and in a stepwise fashion. The intention is to follow up with similar studies in other domains as well, but also in a multicenter setting using the ERAS database as the resource.30
Perioperative care according to expert guidelines Clinical care protocol Continuous updates with new developments in care Trained to use a systematic approach to changes in practice Local ERAS team meeting at least every other week Responsible for sustainability and introduction of new treatments Continuous control of care using data Regular audit meetings Feedback with units as needed Training program for new staff
Implementation of ERAS One of the main objectives of the ERAS Society is to help other units perform modern care according to best practice. This is also the most difficult part in the development chain. It is often said that it takes up to 15 years for a proven medical
treatment to become common practice. This is obviously far too slow, but it shows how hard it is to move knowledge into daily practice. The ERAS Society aims to speed up this process. Using the guidelines and the growing experiences commencing with the Dutch experiences10 and, more recently, in collaboration with the health development group at Qulturum, Jönköping Sweden (www.lj.se/qulturum), the ERAS Society has further developed an implementation program that runs over a period of 8–10 months (Table 2).30 This program is specifically designed for care of surgical patients of all specialties. It is currently running in Sweden, Switzerland, France, and Canada, and several other countries are ready to get going. These programs are launched via a network of ERAS expert centers that supply the clinical experience and the medical expertise during these programs. During the implementation program, teams from hospital departments are coached through a series of workshops and supported by
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the ERAS Interactive Audit System (www.erassociety.org) change practice into the ERAS protocol. The ERAS Interactive Audit System, based on the ERAS Society guidelines, helps the units to keep complete up-to-date control over the process of care and their outcomes. The system allows continuous comparisons within the unit and also with others to benchmark. So far, the experiences show that during the ERAS Implementation Program, units reduce recovery time and hospital stay by 2–4 days depending on the starting point; similarly, complication rates fall while most major medical complications become less frequent. There are several reports on the cost savings of implementing ERAS in colorectal surgery, ranging from €1600 to several thousand euros.30,34
The Future of ERAS The principles of ERAS are gaining ground and spreading into a range of different surgical specialties and procedures with results of similar magnitude as those seen in colorectal surgery.3 This is not surprising given that the stress-reducing effect of the ERAS protocols is likely to be effective in any kind of surgery, as well as the impact that ERAS has on outcomes and costs. Although the insights and knowledge of ERAS are spreading, it is important to realize that doing ERAS fully means a higher level of engagement than just knowing about the principles and believing that they are being practiced in your unit. Many units use parts of an ERAS program and believe they are running ERAS fully, and many believe their outcomes are better than reality. That is why the ERAS Society works to set the ambitions higher and present a new way of working with the team as the core of ERAS in any given hospital. This team should be running regular interactive audit sessions to work with true data and feedback to the units where problems may arise. Working with true data is the only way to keep things running at their best. The field of perioperative care is developing fast. The cost of healthcare is also growing fast, and the continuous rise in costs is unsustainable. For this reason too, it is important that care is improved while reducing cost. The ERAS Society aims to provide a platform and a meeting place for the developers, researchers, and users of ERAS. The Society believes that it is by working together and unifying efforts we can all gain insights faster and learn more for the benefit of the patients. Using common platforms will simplify communications and speed up information about novel treatments and updates of guidelines and the implementation of these novelties. By working together, more powerful research can also be performed, providing more secure data to rely on for the future developments. Many of the recommendations made today are based on studies performed in more traditional care and are likely to need reevaluation in an ERAS setting, where stress is so much less. The Society also believes in the benefit of improving care with the force of the healthcare
professionals. Since ERAS is run by the people closest to the patients, the improvements in care also transform to gains in economic terms and open up a new level of dialogue between hospital managers and the staff, most often for the benefit of the patient and ultimately for society. The Society has expert centers engaged in many countries in Europe, Canada, the United States, Brazil, and Australasia, and its faculty contains many leading world experts in a range of surgical and anesthesia disciplines. The Society collaborates with a number of national and international medical societies and holds a multidisciplinary, multiprofessional congress as well as national events and sessions at other societies’ meetings. The ERAS Society aims to broaden these bases even further while expanding collaboration with others.
Further Reading ERAS Society website: www.erassociety.org (postpublication reviews of current literature in the field and for further information about the ERAS Society) Lobo DN, Lewington AJP, Allison SP. Basic Concepts of Fluid and Electrolyte Therapy. Melsungen, Germany: Medizinische Verlagsgesellschaft mbH; 2013. (Not available in bookstores, free download via website link: http:// www.erassociety.org/images/stories/Publications/Basic_Concepts_of_ Fluid_and_Electrolyte_Therapy.pdf) Nader F, Kennedy RH, Ljungqvist O, Mythen M, eds. Manual on Fast Track Recovery for Colorectal Surgery. London, UK: Springer; 2012.
Glossary ERAS—enhanced recovery after surgery ERP—enhanced recovery programs
References 1. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477. 2. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013;37(2):259-284. 3. Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2013;56(5):667-678. 4. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86(2):227-230. 5. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606-617. 6. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94(2):224-231. 7. Lassen K, Hannemann P, Ljungqvist O, et al. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ. 2005;330(7505):1420-1421. 8. Maessen JM, Hoff C, Jottard K, et al. To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands. Clin Nutr. 2009;28(1):29-33. 9. Jottard K, Hoff C, Maessen J, et al. Life and death of the nasogastric tube in elective colonic surgery in the Netherlands. Clin Nutr. 2009;28(1):26-28.
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10. Gillissen F, Hoff C, Maessen JMC, et al. Structured synchronous implementation of an Enhanced Recovery After Surgery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg. 2013;37:1082-1093. 11. Maltby JR. Fasting from midnight—the history behind the dogma. Best Pract Res Clin Anaesthesiol. 2006;20(3):363-378. 12. Ljungqvist O. Insulin resistance and enhanced recovery after surgery: Jonathan E. Rhoads Lecture 2011. JPEN J Parenter Enteral Nutr. 2012;3(4):389-398. 13. Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69(4):488-498. 14. Henriksen MG, Hessov I, Dela F, Vind Hansen H, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003;47(2):191-199. 15. Sato H, Carvalho G, Sato T, Lattermann R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab. 2010;95(9):4338-4344. 16. Jackson RS, Amdur RL, White JC, Macsata RA. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg. 2012;214(1):68-80. 17. Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate loading. Best Pract Res Clin Anaesthesiol. 2009;23:401-409. 18. Awad S, Constantin-Teodosiu D, Constantin D, et al. Cellular mechanisms underlying the protective effects of preoperative feeding: a randomized study investigating muscle and liver glycogen content, mitochondrial function, gene and protein expression. Ann Surg. 2010;252(2):247-253. 19. Awad S, Stephenson MC, Placidi E, et al. The effects of fasting and refeeding with a ‘metabolic preconditioning’ drink on substrate reserves and mononuclear cell mitochondrial function. Clin Nutr. 2010;29(4):538-544. 20. Uchida I, Asoh T, Shirasaka C, Tsuji H. Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique. Br J Surg. 1988;75(6):557-562. 21. Greisen J, Juhl CB, Grofte T, Vilstrup H, Jensen TS, Schmitz O. Acute pain induces insulin resistance in humans. Anesthesiology. 2001;95(3):578-584. 22. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand. 2008;52(7):946-951.
23. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320):1812-1818. 24. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238(5):641-648. 25. Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon Rectum. 2004;47(8):1397-1402. 26. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146(5):571-577. 27. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin Nutr. 2010;29(4):434-440. 28. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830-840. 29. Coolsen MM, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CH. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg. 2013;37(8):1909-1918. 30. Roulin D, Donadini A, Gander S, et al. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg. 2013;100(8):1108-1114. 31. Lassen K, Coolsen MM, Slim K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013;37(2):240-258. 32. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):801-816. 33. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2013;32(6):879-887. 34. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010;123(1319):61-70.
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ERAS−−Enhanced Recovery After Surgery: Moving Evidence-Based Perioperative Care to Practice Olle Ljungqvist JPEN J Parenter Enteral Nutr published online 24 February 2014 DOI: 10.1177/0148607114523451
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PENXXX10.1177/0148607114523451Journal of Parenteral and Enteral NutritionLjungqvist
Tutorial
ERAS—Enhanced Recovery After Surgery: Moving Evidence-Based Perioperative Care to Practice
Olle Ljungqvist, MD, PhD
Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–8 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607114523451 jpen.sagepub.com hosted at online.sagepub.com
Abstract ERAS is the acronym for enhanced recovery after surgery, a term often used to describe perioperative care programs that have been shown to improve outcomes after major surgery. This article gives a brief history of the development from fast-track surgery to ERAS. Today, the full meaning of ERAS goes beyond just a protocol for perioperative care with the initiation of a novel multiprofessional, multidisciplinary medical society: the Enhanced Recovery After Surgery Society for Perioperative Care (www.erassociety.org). The ERAS Society is involved in the development of evidence-based guidelines. These guidelines form the basis for an implementation program of the ERAS principles to practice. While ERAS was initially developed for colonic resections, these principles are being used in a range of operations, and there is also a continuous update of care protocols as the fields develop. A key mechanism behind the effectiveness of ERAS is the dampening of the stress responses to the surgical insult combined with the use of treatments that support return of functions that delay recovery in traditional care. The article also gives some insights to why the protocols work and reports the effects of ERAS protocols. (JPEN J Parenter Enteral Nutr. XXXX;XX:xx-xx)
Keywords surgery; anesthesia; enhanced recovery; surgical stress; fluid balance
What Is ERAS?
Short History of ERAS
ERAS is an acronym for enhanced recovery after surgery. The term ERAS is often used to describe a multimodal perioperative care program.1 Some authors use terms such as enhanced recovery programs (ERP), and previously fast-track surgery was commonly used, the latter especially in North America. These programs are all composed of several evidence-based perioperative care elements that individually have been shown to be beneficial, and when used together in a protocol, they have been shown to result in substantially improved outcomes. The number of items in such a protocol varies, but often around 20 items have been included (Table 1).1,2 A recent meta-analysis show that ERAS protocols in major surgery reduce recovery time and length of stay by 2–3 days and complications by 30%–50%.3 However, the term ERAS is developing into more than just a protocol, and in this article, the broader meaning of ERAS is outlined. While it is well recognized that important contributions in a wide range of areas of surgery and anesthesia have been made and reported from many centers worldwide that have all contributed to the refinement of perioperative care, this study aims to tell the story of the development of ERAS from the European angle, where the specific term ERAS was coined, and how the term ERAS is now at the center of a broad development in changing perioperative care in a range of operations to improve clinical outcomes for patients in many countries.
The term ERAS was invented by a group of academic surgeons who started the ERAS study group in London in 2001. The intention of the group was to develop the optimal perioperative care pathway by means of literature review and adaptation of treatments to give the best fit throughout the patient’s journey. The group consisted of research group leaders—K. F. C. Fearon (University of Edinburgh, United Kingdom), H. Kehlet (University of Copenhagen, Denmark), A. Revhaug (University of Tromsø, Norway), M. von Meyenfeldt (the Netherlands), C. deJong (University of Maastricht, the Netherlands), and the From the Orebro University, Orebro, Sweden. Financial disclosure: The author is a co-founder of the ERAS study group and the ERAS Society and serves as the Chairman of the Executive Committee. The author serves as advisor for Danone/Nutricia research and owns stock in Encare AB, a company involved in data management and implementation programs for the ERAS Society. He also has given scientific presentations at scientific meetings occasionally sponsored with travel grants from medical industries. Received for publication December 18, 2013; accepted for publication January 13, 2014. Corresponding Author: Olle Ljungqvist, MD, PhD, Chairman ERAS Society, Department of Surgery, Orebro University, Örebro University Hospital, Örebro, SE-70185, Sweden. Email: [email protected]
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Table 1. The ERAS Society Protocol for Elective Colonic Resection. Preoperative •• Detailed information •• Stop smoking •• Screen nutrition status and liberal nutrition support with oral nutrition supplements •• No oral bowel preparation
•• No “nil per os” from midnight— preoperative carbohydrate drink 2 hours before anesthesia •• No routine long-acting sedatives
•• Prophylaxis against thomboembolism •• Antimicrobial prophylaxis •• Skin preparation
Intraoperative •• Standard anesthetic technique aiming to maintain homeostasis and reduce stress •• Avoid long-acting opioids •• Open surgery: mid-thoracic epidural •• Laparoscopic: spinal or patientcontrolled analgesia as an alterative to epidural •• Multimodal postoperative nausea and vomiting prophylaxis •• Laparoscopic surgery if available
•• Prevention of hypothermia
Postoperative •• No routine nasogastric tubes •• Early (when lucid after surgery) oral intake of fluids and solids •• Liberal use of oral nutrition supplements •• Prevention of postoperative ileus: fluid balanced; avoiding opioids, chewing gum; magnesium oxide and alvimopan may be used. •• Urinary drainage removed days 1–2 postoperatively •• Glucose control; primarily avoiding insulin resistance, insulin treatment in intensive care unit for severe hyperglycemia •• Early mobilization
•• Fluid optimization using mixtures of colloids and crystalloids •• Vasopressors to control hypotension •• No routine drains
Adapted from Gustafsson et al.2
undersigned O. Ljungqvist (Karolinska Insitutet, Stockholm, Sweden)—and collaborators at the respective academic sites. The groups set off to review all the literature they could find with an impact on surgical outcomes and developed a care protocol for elective colonic resections.1 At that time, H. Kehlet had already published work that many felt was almost unbelievable. At a time when the normal length of stay after a colonic resection was 9–10 days, Kehlet reported patients fit to leave the hospital in 2 days,4 using a multimodal approach to perioperative care.5 In those days, these protocols were often called fast-track surgery. The name fast track, however, was felt by the ERAS study group to be leading focus too much toward faster discharge. The group wished to keep focus on the patient’s recovery, and in the further developments of these protocols, the ERAS study group started to use the new term, enhanced recovery after surgery or ERAS. ERAS has now been a well-recognized term in the medical literature with more than 1600 hits on PubMed. When the ERAS study group established the final first protocol, it was clear to everyone in the group that none of the collaborating units was fully compliant with such an ideal protocol. Dr Kehlet’s Danish group had higher compliance than the rest, having been using this kind of approach for several years already. It was also obvious that all the units did things differently. So it was decided that all 5 centers would aim to adopt the best practice ERAS protocol, and it was also decided
to study the change of practice. During these studies, it became obvious that just having a protocol was not enough.6 When working together to adopt a common protocol, it was decided to set up and use a common database and put all consecutive patients in this database. This led to the second revelation: the treatments actually delivered were different from what we thought. When the 5 units reviewed their own practices, it was realized that all had problems with compliance to the protocol with items thought to be working. Using the database audit revealed the true practice and helped us to make the right changes and focus where the problems actually were present. Working together was also very useful. The fact that some centers were employing treatments that were resisted by some collaborators in another unit made it easier for resisters to accept a change of practice. The group met on a regular basis over several years, and by supporting each other, improvements in compliance and outcomes emerged. The group also undertook surveys that revealed that we were not alone in keeping with old traditional and outdated care rather than changing to newer and evidence-based developments.7 The Maastricht group had the opportunity to work with CBO (Centraal Begeleidings Orgaan, Dutch Institute for Healthcare Improvement, Utrecht, the Netherlands), a government-led organization specializing in change management in healthcare on an implementation program. Taking advantage of the insights from the rest of the ERAS group, the protocol, the
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multiprofessional approach, and the use of data, they showed that indeed it was possible to have several units change longlasting outdated habits and get better results.8-10 These results showed that the tools to actually move literature evidence into practice with good results were available. The strength of working together in a growing international collaboration, along with the expanding interest in ERAS, made the group decide to take these experiences to a next level by forming a medical society to broaden the network and to give the project of improving perioperative care a more solid platform from which to work.
The ERAS Society In 2010, the ERAS study group formed a nonprofit international medical society, the Enhanced Recovery After Surgery Society for Perioperative Care—in short, the ERAS Society (www.erassociety.org). This is a multiprofessional, multidisciplinary society with the aim to improve perioperative care through research and education, but the Society also engages in the implementation of best practices (ie, evidence-based medicine in perioperative care). The Society set off to make ERAS not just a term for a protocol but a movement to constantly develop and improve the perioperative care processes. The initial ERAS study group rapidly expanded the network of centers involved in the development of perioperative care, and at present, there are such centers of excellence in more than 15 countries in Europe, North and South America, and Australasia, and it is currently expanding to other countries. In several countries, national ERAS Societies are formed and linked to the ERAS Society. The Society also engages a wider range of experts in the formation of guidelines for different operations, and the ERAS Society faculty today encompasses more than 50 leading units from different parts of the world. The first ERAS world congress was held in Cannes, France, in October 2012, and the second congress is set for April 23–27, 2014, in Valencia, Spain.
Philosophy of ERAS The basic philosophy behind ERAS is the realization that a traditional hospital works in silos that need to be broken to ensure a care protocol that follows and optimizes the journey the patient makes during the perioperative care. For instance, a doctor or nurse working in anesthesia will see the patient during a short period of the entire process and will focus primarily on ensuring that vital functions are under control during the operation. They will plan and prepare to manage this specific part of the patient care during the preoperative visit and will focus on maintaining control of these parameters for the duration of the surgery. Once the surgery is over, the patient is handed over to the next team in the recovery room or the highdependency unit or possible intensive care. The anesthesia
team then takes on the next case. Very rarely does the anesthesia team have time or feel the need to see the patient later on in the surgical ward, for instance. Nor do the ward nurses or other staff see what is ongoing in the operating room. So while ensuring vital functions are under control, the anesthesia team has little insight if the treatment they use for their purposes is beneficial a few hours or even days later. Similarly, the teams taking over the patient have no idea if the patient they are receiving could be presenting differently and potentially in a better shape because they have no insight into what occurred before their part of the care process. To overcome these potentially serious issues, the ERAS protocol has to be built with everyone involved in the entire chain of events during the patient’s journey (Figure 1). Surgeons, anesthetists, intensive care/high-dependency specialists, nurses, dietitians, and physical therapists all have to come together to form a team that runs ERAS locally. The ERAS team forms the cornerstone of the ERAS implementation process but also for the maintenance, sustainability, and further development over time. Only with the entire team around the table on a regular basis for audit can it be ensured that there is always someone there to deal with every problem occurring. The teamwork secures that there is no serious issue that escapes processing. The team is also important for the support of each other. Changes of old routines do not happen by themselves; they take hard work, and the team leading such change must have time to work with the planning and preparation of the changes that are to be put in place. The team also needs time to inform their coworkers. But finding this time for the ERAS team is sometimes a main obstacle on its own. Having a team of 5–6 people prioritizing a meeting every 2 weeks for 45 minutes or an hour sometimes takes more than one may think. Usually everyone is busy working in his or her own silo, so seeing the benefit from prioritizing this meeting and working with the team may be hard. Still, it is unlikely that the ones assigned to run ERAS in a given unit are likely to find that there is anything more important that they can do for the benefit of their patients apart from this work. To make the team find the time to work effectively, the managers of all involved departments in control of budgets and planning must ensure that the ERAS team and their meetings have the highest of priorities. This is key to the success of the implementation. As soon as this fails, the chances of success diminish rapidly. A typical example of how a change can be hard to establish is overcoming the overnight fasting routine. While this is probably the best-known medical “rule” in the world, it is interesting to find that the rule never had any scientific backing but is the result of traditions and a statement in an anesthesia textbook that then became the norm worldwide.11 Today, there is ample evidence that clear fluids are perfectly safe to take up to 2 hours before elective surgery, and all guidelines have stated this since the mid-1990s. In addition, the overnight and morning fast is very discomforting for the patients. Furthermore, the
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Figure 1. The patient’s journey through the hospital. Used by permission of the ERAS Society.
fast itself aggravates the stress responses and increases postoperative insulin resistance (see below). So there are a series of arguments in favor of changing to modern guidelines. Still, in many units, it takes a lot of work to make the change. There are many practicalities to be dealt with—when and where the drink is to be taken, how to deal with the later cases of the day, overcoming the fear of having to cancel a case because of a patient drinking too late, and so on. The change is complex, involving many units and specialties, and staff needs to be informed to create a readiness to make the change. This takes a lot of preparation. If the resistance is strong, it is sometimes necessary to have the team arrange a hearing locally where the leads of anesthesia and surgery come together and review the literature and present modern fasting guidelines. Importantly, for the change to stick, once initiated it has to be audited and followed up appropriately.
What Makes ERAS Work? Reviewing the mechanisms behind the effectiveness of ERAS protocols reveals that most of the items proposed in the protocol and shown to be beneficial support the maintenance of homeostasis via controlling metabolism and fluids, or the support of the return of key functions.12,13 The goals of perioperative care are to secure the safety of the patient but also support the return of specific functions for full recovery. In traditional surgical care, most major operations share some common problems. The patients often have difficulties eating and getting bowel movements back to normal. Very
often oral analgesics and opioids are needed to control pain, and many patients have problems mobilizing. Removing these obstacles while also avoiding complications is a common goal in ERAS protocols. Once these problems are overcome, the patient is ready to go home from a medical point of view. In practice, the return of gut function, maintaining pain relief on oral analgesics, and mobilizing to preoperative levels can serve as medical discharge criteria in the absence of complications needing hospital care.
Metabolic Stress Reduction A key factor in achieving the goals of postoperative recovery is to minimize the stress of surgery. With increased stress, more catabolism develops, and this counteracts the goals of recovery in several different ways. The development of insulin resistance has been proposed to be a key unifying factor for the explanation of the catabolic response, as reviewed elsewhere.12 In brief, with the development of insulin resistance, all parts of metabolism are disturbed, and this can help explain several of the postoperative problems facing many patients. Protein is being lost from muscle, causing loss of muscle mass and strength. Further reducing muscle function is the incapacity of insulin to move glucose into muscle cells and to store it as glycogen. These changes have been shown to last for at least 4 weeks after uncomplicated colorectal surgery.14 In addition, both insulin resistance15 and hyperglycemia16 are closely associated with postoperative complications. These reports indicate that it is the level of disturbance postoperatively that may be more
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important than, for instance, a preoperative diabetic state. With less stress, primarily infectious but also general complications are avoided.12 Many of the treatments in the ERAS protocol have direct or indirect effects on insulin action and reduce the development of insulin resistance. These include perioperative nutrition to avoid prolonged starvation periods and carbohydrate treatment that stimulates insulin sensitivity right before the onset of the operation.17 The preoperative carbohydrate treatment results in improved insulin sensitivity (less resistance) postoperatively17 probably in past via positive effects on muscle PDK4 mRNA and protein expression,18 whereas it has been shown that even a short fast (up to 24 hours) has negative effects on the mitochondrial activity of mononuclear cells.19 The use of epidurals blocks the release of catecholamines and cortisol, the 2 main stress hormones causing insulin resistance,20 and this treatment can also serve as the basis for pain control since pain itself causes insulin resistance.21 By combining several treatments that all work to reduce insulin resistance, but acting via different mechanisms, the effects are enhanced. For diabetic patients, although not specifically studied in an ERAS context, available data suggest that many principles of the protocol should be beneficial for them as well. The use of a preoperative carbohydrate drink for these patients remains to be further investigated, but available data from patients with well-controlled type 2 diabetes show that certain formulas can be given alongside the patients’ normal morning medication (insulin or oral) without delaying gastric emptying.22
Keeping Fluid Homeostasis In a similar fashion to controlling metabolism, maintaining fluid balance is also key. Giving large amounts of fluids to surgical patients has been a longstanding tradition to treat hypotension during and after surgery. In particular, the use of 0.9% saline as the crystalloid has been shown to be especially bad since this fluid is retained in the body longer than balanced salt solutions.13 This practice is still in use in many centers, even if it has been more than 10 years since the first main studies challenging the old dogma were published. These studies showed that not only did the overload of fluids result in delayed return of bowel function, but it was also associated with substantial increases in complications.23,24 Instead of managing hypotension solely with fluids, combining intravenous (IV) fluids with vasopressors helps keep fluids in balance. Further research has shown that keeping fluids balanced and avoiding both under- and overhydration are key to best outcomes, as reviewed elsewhere.13 While the use of too many fluids during surgery is often blamed on the anesthetists, it may well be that the surgeon has caused the patient hypovolemia before the operation by ordering oral bowel preparation.25 Oral bowel cleansing dehydrates the patient and leads to further hypotension when anesthesia is induced. By avoiding unnecessary treatments such as bowel cleansing, hypotension can be avoided and less fluids need to
be given. It has been shown that IV fluid loads above 3000 mL for colonic resections and 3500 mL for rectal resections during the day of surgery result in increased complications.26 A combination of colloids and crystalloids has shown to be very useful in these elective surgical cases. In addition, using short-acting anesthetics, minimizing the use of opioids, and avoiding the use of long-acting preoperative sedatives will help avoid postoperative nausea and support the drive to eat and drink within hours after the operation.
Combining Treatments in ERAS When combining all of the above, the main problems in postoperative care are counteracted: when surgery and anesthesia work together, the patient will receive care that allows the best possible chance to return to normal functions again. By keeping a fluid balance and avoiding elements that reduce appetite and drive nausea, patients will eat and drink earlier. By avoiding fluid overload and treatments that reduce gastric motility, bowel movements will return faster. By reducing the metabolic stress and insulin resistance, any energy and protein consumed will be processed in the body in a more anabolic fashion, hyperglycemia can be avoided, and less lean body mass will be lost and patients may mobilize faster. The differences in insulin resistance development with traditional and ERAS care are shown schematically in Figure 2. There are several meta-analyses on the outcomes using ERAS protocols. The analysis of colonic or colorectal surgery where fast track and ERAS started shows a reduction in length of stay by 2–2.5 days and complications reduced by 30%– 50%.3,27,28 In a recent analysis in other types of major surgery, the outcomes were similar.29 The problem with the randomized trials of ERAS vs traditional care is that it is very hard to blind studies comparing ERAS care with traditional care, and hence the level of the evidence cannot be the highest. Second, some investigators may consider certain elements as standard care while others do not, and hence there is no uniformity in what is actually tested. In the early analysis, the studies included had 4 or more elements that have been recognized as ERAS elements in the treatment groups. Despite the drawbacks of the methodology of the randomized trials and the subsequent weaknesses of meta-analysis, when combining this information with other reports, it becomes evident that ERAS protocols have major benefits for outcomes. The data from almost 1000 consecutive patients with colorectal cancer show that the better the compliance with the protocol, the better the outcomes with regard to recovery time (length of stay) and complications.26 Interestingly, and importantly, readmissions also fell with better compliance. Similarly, the results from the studies of ERAS implementation show better outcomes with improved compliance to the protocols.10,30 There is really very little magic to these findings: the more the use of elements that have been proven to improve outcomes, the better the outcomes are going to be.
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Figure 2. Schematic picture of the influence of different perioperative treatments on insulin sensitivity. Adapted from Ljungqvist O. Insulin resistance and enhanced recovery after surgery: Jonathan E. Rhoads Lecture 2011. JPEN J Parenter Enteral Nutr. 2012;3(4):389-398.12
ERAS Society Guidelines
Table 2. Goals After ERAS Society Implementation Program.
The ERAS Society, often in collaboration with other medical societies, has started to continuously review and update the literature for novel guidelines in an increasing number of surgical procedures, including colonic, rectal, and pancreatic resections,2,31,32 and most recently radical cystectomies.33 The guideline process involves engaging experienced authors involved in the development of the care in the surgery and/or anesthesia for these procedures. The authors complete a structured review of the literature and give graded recommendations. A number of international expert groups are currently working on a wide range of procedures to be presented within the coming year or two. The guideline groups also make continuous updates as the fields develop, with new data emerging. An important feature in this work is the evaluation and testing of these guidelines. For the colorectal guidelines, Gustafsson et al26 pioneered this work and showed that indeed in a single center, improved compliance with ERAS elements improved outcomes substantially and in a stepwise fashion. The intention is to follow up with similar studies in other domains as well, but also in a multicenter setting using the ERAS database as the resource.30
Perioperative care according to expert guidelines Clinical care protocol Continuous updates with new developments in care Trained to use a systematic approach to changes in practice Local ERAS team meeting at least every other week Responsible for sustainability and introduction of new treatments Continuous control of care using data Regular audit meetings Feedback with units as needed Training program for new staff
Implementation of ERAS One of the main objectives of the ERAS Society is to help other units perform modern care according to best practice. This is also the most difficult part in the development chain. It is often said that it takes up to 15 years for a proven medical
treatment to become common practice. This is obviously far too slow, but it shows how hard it is to move knowledge into daily practice. The ERAS Society aims to speed up this process. Using the guidelines and the growing experiences commencing with the Dutch experiences10 and, more recently, in collaboration with the health development group at Qulturum, Jönköping Sweden (www.lj.se/qulturum), the ERAS Society has further developed an implementation program that runs over a period of 8–10 months (Table 2).30 This program is specifically designed for care of surgical patients of all specialties. It is currently running in Sweden, Switzerland, France, and Canada, and several other countries are ready to get going. These programs are launched via a network of ERAS expert centers that supply the clinical experience and the medical expertise during these programs. During the implementation program, teams from hospital departments are coached through a series of workshops and supported by
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the ERAS Interactive Audit System (www.erassociety.org) change practice into the ERAS protocol. The ERAS Interactive Audit System, based on the ERAS Society guidelines, helps the units to keep complete up-to-date control over the process of care and their outcomes. The system allows continuous comparisons within the unit and also with others to benchmark. So far, the experiences show that during the ERAS Implementation Program, units reduce recovery time and hospital stay by 2–4 days depending on the starting point; similarly, complication rates fall while most major medical complications become less frequent. There are several reports on the cost savings of implementing ERAS in colorectal surgery, ranging from €1600 to several thousand euros.30,34
The Future of ERAS The principles of ERAS are gaining ground and spreading into a range of different surgical specialties and procedures with results of similar magnitude as those seen in colorectal surgery.3 This is not surprising given that the stress-reducing effect of the ERAS protocols is likely to be effective in any kind of surgery, as well as the impact that ERAS has on outcomes and costs. Although the insights and knowledge of ERAS are spreading, it is important to realize that doing ERAS fully means a higher level of engagement than just knowing about the principles and believing that they are being practiced in your unit. Many units use parts of an ERAS program and believe they are running ERAS fully, and many believe their outcomes are better than reality. That is why the ERAS Society works to set the ambitions higher and present a new way of working with the team as the core of ERAS in any given hospital. This team should be running regular interactive audit sessions to work with true data and feedback to the units where problems may arise. Working with true data is the only way to keep things running at their best. The field of perioperative care is developing fast. The cost of healthcare is also growing fast, and the continuous rise in costs is unsustainable. For this reason too, it is important that care is improved while reducing cost. The ERAS Society aims to provide a platform and a meeting place for the developers, researchers, and users of ERAS. The Society believes that it is by working together and unifying efforts we can all gain insights faster and learn more for the benefit of the patients. Using common platforms will simplify communications and speed up information about novel treatments and updates of guidelines and the implementation of these novelties. By working together, more powerful research can also be performed, providing more secure data to rely on for the future developments. Many of the recommendations made today are based on studies performed in more traditional care and are likely to need reevaluation in an ERAS setting, where stress is so much less. The Society also believes in the benefit of improving care with the force of the healthcare
professionals. Since ERAS is run by the people closest to the patients, the improvements in care also transform to gains in economic terms and open up a new level of dialogue between hospital managers and the staff, most often for the benefit of the patient and ultimately for society. The Society has expert centers engaged in many countries in Europe, Canada, the United States, Brazil, and Australasia, and its faculty contains many leading world experts in a range of surgical and anesthesia disciplines. The Society collaborates with a number of national and international medical societies and holds a multidisciplinary, multiprofessional congress as well as national events and sessions at other societies’ meetings. The ERAS Society aims to broaden these bases even further while expanding collaboration with others.
Further Reading ERAS Society website: www.erassociety.org (postpublication reviews of current literature in the field and for further information about the ERAS Society) Lobo DN, Lewington AJP, Allison SP. Basic Concepts of Fluid and Electrolyte Therapy. Melsungen, Germany: Medizinische Verlagsgesellschaft mbH; 2013. (Not available in bookstores, free download via website link: http:// www.erassociety.org/images/stories/Publications/Basic_Concepts_of_ Fluid_and_Electrolyte_Therapy.pdf) Nader F, Kennedy RH, Ljungqvist O, Mythen M, eds. Manual on Fast Track Recovery for Colorectal Surgery. London, UK: Springer; 2012.
Glossary ERAS—enhanced recovery after surgery ERP—enhanced recovery programs
References 1. Fearon KC, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477. 2. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013;37(2):259-284. 3. Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2013;56(5):667-678. 4. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86(2):227-230. 5. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606-617. 6. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94(2):224-231. 7. Lassen K, Hannemann P, Ljungqvist O, et al. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ. 2005;330(7505):1420-1421. 8. Maessen JM, Hoff C, Jottard K, et al. To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands. Clin Nutr. 2009;28(1):29-33. 9. Jottard K, Hoff C, Maessen J, et al. Life and death of the nasogastric tube in elective colonic surgery in the Netherlands. Clin Nutr. 2009;28(1):26-28.
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10. Gillissen F, Hoff C, Maessen JMC, et al. Structured synchronous implementation of an Enhanced Recovery After Surgery program in elective colonic surgery in 33 hospitals in the Netherlands. World J Surg. 2013;37:1082-1093. 11. Maltby JR. Fasting from midnight—the history behind the dogma. Best Pract Res Clin Anaesthesiol. 2006;20(3):363-378. 12. Ljungqvist O. Insulin resistance and enhanced recovery after surgery: Jonathan E. Rhoads Lecture 2011. JPEN J Parenter Enteral Nutr. 2012;3(4):389-398. 13. Varadhan KK, Lobo DN. A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open abdominal surgery: getting the balance right. Proc Nutr Soc. 2010;69(4):488-498. 14. Henriksen MG, Hessov I, Dela F, Vind Hansen H, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003;47(2):191-199. 15. Sato H, Carvalho G, Sato T, Lattermann R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab. 2010;95(9):4338-4344. 16. Jackson RS, Amdur RL, White JC, Macsata RA. Hyperglycemia is associated with increased risk of morbidity and mortality after colectomy for cancer. J Am Coll Surg. 2012;214(1):68-80. 17. Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate loading. Best Pract Res Clin Anaesthesiol. 2009;23:401-409. 18. Awad S, Constantin-Teodosiu D, Constantin D, et al. Cellular mechanisms underlying the protective effects of preoperative feeding: a randomized study investigating muscle and liver glycogen content, mitochondrial function, gene and protein expression. Ann Surg. 2010;252(2):247-253. 19. Awad S, Stephenson MC, Placidi E, et al. The effects of fasting and refeeding with a ‘metabolic preconditioning’ drink on substrate reserves and mononuclear cell mitochondrial function. Clin Nutr. 2010;29(4):538-544. 20. Uchida I, Asoh T, Shirasaka C, Tsuji H. Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique. Br J Surg. 1988;75(6):557-562. 21. Greisen J, Juhl CB, Grofte T, Vilstrup H, Jensen TS, Schmitz O. Acute pain induces insulin resistance in humans. Anesthesiology. 2001;95(3):578-584. 22. Gustafsson UO, Nygren J, Thorell A, et al. Pre-operative carbohydrate loading may be used in type 2 diabetes patients. Acta Anaesthesiol Scand. 2008;52(7):946-951.
23. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320):1812-1818. 24. Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg. 2003;238(5):641-648. 25. Holte K, Nielsen KG, Madsen JL, Kehlet H. Physiologic effects of bowel preparation. Dis Colon Rectum. 2004;47(8):1397-1402. 26. Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146(5):571-577. 27. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin Nutr. 2010;29(4):434-440. 28. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830-840. 29. Coolsen MM, van Dam RM, van der Wilt AA, Slim K, Lassen K, Dejong CH. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg. 2013;37(8):1909-1918. 30. Roulin D, Donadini A, Gander S, et al. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg. 2013;100(8):1108-1114. 31. Lassen K, Coolsen MM, Slim K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013;37(2):240-258. 32. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):801-816. 33. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2013;32(6):879-887. 34. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010;123(1319):61-70.
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