Enhanced Recovery After Surgery: Applicability and Results for Abdominal Surgery and Impediments for Universal Usage
Surgery is a cause of stress, the intensity of which depends on the procedure. Despite a better understanding of the sequence of events leading to the physiological stress response, there has not been any major change in the perioperative care of patients. Perioperative care is often based on the age old so-called inviolable principles . Elements of perioperative care such as prolonged use of drains, forced bed rest, graduated diets, etc. were deemed essential and were taught to successive generations of surgeons as the standard of care. However, in the light of evolving evidence, many of these traditional principles were not found to be evidence based, and some of them may have been detrimental to the patient’s recovery [2–5]. This has led to the need for a judicious evidence-based approach for accelerating the patients’ recovery. The field of perioperative care has witnessed a revolutionary change in the form of enhanced recovery after surgery (ERAS) pathways or ‘fast-track’ protocols, which primarily aim at sustainable improvements in patient care, both in terms of speed of recovery and more importantly quality.
We acknowledge Dr. Pankaj Kundra, Professor (Senior Scale), Department of Anaesthesiology and Critical Care, JIPMER, and Dr. Suresh Kumar S, Associate Professor, Department of Surgery, JIPMER, for their valuable inputs during the writing of this chapter.
The enhanced recovery after surgery (ERAS) protocols that are being discussed and implemented today are essentially based on evidence. This addresses patient care even before the start of the surgery and is followed both during and after the surgery. The ERAS society guidelines incorporate 22 interventions during the three periods . These are:
Preoperative: Patient education, shared decision-making, nutrition, medical optimization, fluid and carbohydrate loading, avoid fasting, avoid bowel preparation and starting antibiotics
Intraoperative: Prophylaxis for deep vein thrombosis, avoid premedication, guarding against nausea and vomiting, using short-acting anaesthetics, avoid fluid electrolyte overload, control normothermia and avoid drains
Postoperative: Epidural anaesthesia/analgesia, avoid Ryles tube, avoid fluid overload, avoid nausea and vomiting, initiation of oral nutrition at the earliest, non-opioid analgesia, early mobilization, stimulating gut motility and audit of compliance
All these strategies promote recovery, decrease stress, alleviate pain, improve gut dysmotility and reduce length of hospitalization. Even the severity of complications is reported to be less . Early discharge from hospital makes patients satisfied .
Clearly, ERAS is useful. Unfortunately, despite enough available evidence in favour of ERAS, it is not implemented routinely. It is possibly because surgeons are worried about complications and changing behaviour is always difficult. The things particularly difficult to dispense with are fasting before operation, early mobilization, early oral feeding and avoidance of a drain. Treating physicians feel overawed by these new measures and unjustifiably see these contradictory to prevailing practices. It therefore needs educating the care providers properly and addressing their concerns with evidence. To what extent the 22 facets of care mentioned above are implemented will decide the adoption of ERAS with better patient outcome . It is a pity that not much research has gone into making ERAS acceptable more widely. It is heartening that a group from Canada has taken a lead in this direction. They used theoretical domains framework (TDF) in changing surgical care in hospitals in Alberta. They applied Quality Enhancement Research Initiative (QUERI) model to assess the implementation of ERAS in colorectal surgery in their province. They have undertaken the project to assess compliance of guidelines, duration of hospitalization, complications and readmission. Through surveys, focus groups, interviews, minutes of meetings and status updates, they have imparted knowledge translation. What they achieved is quite good, e.g. compliance at base level was 40% and increased to 65% after compliance implementation. I feel it is through such measures we can successfully implement ERAS for the benefit of our patients to whom we owe a responsibility.
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