ERAS

Placing the patient at the centre of Enhanced Recovery After Surgery (ERAS) protocols

 

Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, perioperative care pathway designed to improve recovery after surgery.3

Danish Professor Henrik Kehlet pioneered the fast-track surgery in 1997. The term ERAS was adopted in 2001. The 22 components comprising modern ERAS guidelines are driving improved outcomes in reduced length of stay, reduced post-operative complications, reduced mortality and decreased re-admission rates.

We should encourage institutions that do not have an ERAS program in place to apply goal-directed therapeutic strategies because the current evidence supports patient benefit.4

LiDCO, ERAS, Preston et al 2013, reduced length of stay

The transfer and implementation of a standardized oesophagectomy clinical pathway (SOCP) was examined by Preston et al. in the UK as a ERAS protocol on postoperative outcomes.

ERAS Reduces Length of Stay (LOS)

“Improvements in length of hospital stay from 17 to 7 days, with no increase in mortality, complications or readmissions over a 6-month period, shows that the pathways that took 20 years to evolve in one centre can be implemented in a short period in another high-volume centre, as long as there is an institutional commitment to changing process, perceptions and infrastructure.”

 

LiDCOrapid was used to monitor real-time continuous assessment of patient’s hemodynamic status and facilitate stroke volume optimization. Goal-directed fluid therapy was administered for 6 h to maximise fluid status utilising LiDCOrapid.

 

  1. Preston SR, Markar SR, Baker CR, Soon Y, Singh S, Low DE. Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Br J Surg. 2013;100(1):105-12.
LiDCO, ERAS, reduced medical complications, Jones et al 2013

The impact of enhanced recovery programmes (ERPs) were investigated in this RCT by Jones et al. in open liver resection.

ERAS reduced medical complications

“The ERP significantly reduced the rate of medical complications (7 versus 27 per cent; P = 0.020)”

 

LiDCOrapid was used to monitor cardiac output and to guide intravenous fluid therapy administration in patients in the ERP group and GDFT for 6h after hepatic resection. LiDCOrapid was used because the patients were awake during the period of fluid optimisation.

 

  1. Jones C, Kelliher L, Dickinson M, Riga A, Worthington T, Scott MJ, Vandrevala T, Fry CH, Karanjia N, Quiney N. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg. 2013;100(8):1015-24
LiDCO, ERAS, decreased re-admission rates, Mosquera et al 2016

Patients undergoing elective abdominal procedures by a surgical oncologist were examined in this retrospective chart review before and after the implementation of an ERAS protocol.

ERAS decreased re-admission rates

“Readmission rates were significantly lower for patients in the ERAS group (11.5 vs. 21.4%; P = 0.029).”

 

LiDCOrapid was utilized to help guide goal-directed resuscitation.

 

  1. Mosquera C, Koutlas NJ, Fitzgerald TL. A Single Surgeon’s Experience with Enhanced Recovery after Surgery: An Army of One. Am Surg. 2016;82(7):594-601.
LiDCO, ERAS, GDT, Cannesson et al 2016, ERP

In this 2016 Anesthesia Analgesia editorial, Cannesson & Gan debate perioperative fluid management in influencing patient outcome. Concluding that the main goal of PGDT in complex surgery is to make fluid administration rational, consistent and standardized.

Hemodynamic monitoring improves outcomes when used as part of an ERAS pathway

“We believe that goal-directed therapy has the potential to reduce length of stay in the hospital and decrease post-operative complications in patients undergoing major and high-risk surgery. In fact, recent studies using goal-directed therapy in an ERAS setting have demonstrated a reduction in length of stay and complications.”

 

  1. Cannesson M, Gan TJ. PRO: Perioperative Goal-Directed Fluid Therapy Is an Essential Element of an Enhanced Recovery Protocol. Anesth Analg. 2016;122(5):1258-60.

The aim of this study in patients undergoing acute high-risk abdominal (AHA) surgery was to evaluate the effect of standardised multidisciplinary peri-operative protocol on 30-day mortality.

ERAS protocols showed reduced mortality

“The 30-day mortality rate was 15.5 per cent in the intervention cohort compared with 21.8 per cent in the control cohort (P =0.005; relative risk reduction 29 per cent.”

 

LiDCOrapid was used for stroke volume (SV)-guided hemodynamic optimisation, before, during and after surgery (pulse-contour analysis) carried out in PAU/operating theatre.

The authors noted that “The adoption of standardised SV-guided resuscitation might be associated with reduced morbidity, as shown in high-risk surgery.”

 

  1. Tengberg LT, Bay-Nielsen M, Bisgaard T, Cihoric M, Lauritsen ML, Foss NB, AHA study group. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg. 2017;104(4):463-471.