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ERAS - The key points

In this article Professor Joshua Bloomstone outlines some of the evidence base for enhanced recovery, as well as the key treatment points during the pathway. Professor Bloomstone is Clinical Professor of Anesthesiology at the University of Arizona College of Medicine, Chairman of the Department of Anesthesiology and Perioperative Medicine, and is affiliated to the Banner Thunderbird Medical Center, Glendale, AZ, and Valley Anesthesiology Consultants, Inc. Phoenix.

234 million major operations are performed worldwide annually. [1] Of these, 1 in 5 patients [2], [3] are expected to suffer post-surgical complications that are known to increase morbidity, hospital length of stay, cost, and decrease long term survival.[4], [5].

Several evidence-based perioperative care elements exist that have potential to reduce post-surgical complications by up to 50%, [6] length of stay by 30%, [6] and overall costs. [7], [8] Collectively, these elements form the basis of published enhanced recovery after surgery (ERAS) guidelines [9] now implemented in over 20 countries. [10] It is currently believed that strict adherence to all guideline elements yields the best outcomes, [11] however, it remains unclear which of these elements, or combination of elements, provides the greatest impact on post-surgical outcomes. [12], [13] Furthermore, the importance of individual elements has changed over time as exampled by the apparent reduced impact of goal-directed fluid therapy when incorporated into an ERAS program. [14] Even staunch supporters of GDFT have questioned its impact within ERAS protocols,[15], [16] and zero-balance appears to represent the ideal perioperative fluid goal within ERAS [17]

The original ERAS question, posed by Henrik Kehlet in 1997, was whether mitigation of the surgical stress response led to accelerated convalescence and improved surgical outcomes. Dr. Kehlet’s work focused largely on patient education and activation and attenuation of the surgical stress response through aggressive pain relief modalities, early mobilization, and early enteral nutrition. [18]

Today, over 20 ERAS elements have been described and are detailed below.


  • Patient and carer education relative to their roles and expected milestones within the enhanced recovery pathway
  • Individualized patient risk-assessment
  • Optimize medical management
  • Ensure 12.5% carbohydrate beverage loading within 2 hours of surgery
  • Ensure adherence to ASA nil-by-mouth guidelines allowing for clear liquid consumption until 2 hours prior to surgery


  • Assure multimodal, narcotic-sparing analgesia including regional anaesthesia
  • Assure multimodal postoperative nausea and vomiting prophylaxis
  • Assure goal-directed fluid therapy including goal-directed haemostasis management
  • Assure that appropriate standard measures have been completed including maintenance of normothermia


  • Assure pain management is adequate to allow for early ambulation
  • Assure continued postoperative nausea and vomiting management to allow for early alimentation
  • Post-operative patient follow-up including the post-acute care phase
  • Audit all steps for compliance, review and process improvement

Broadly, these elements focus on patient engagement, pre-surgical medical optimization including smoking cessation, [19] anesthetic protocols geared at perioperative fluid management, temperature control, multi-modal narcotic sparing analgesia, and postoperative nausea and emesis prophylaxis.

Key surgical elements include minimally invasive surgery, the avoidance of dehydrating bowel preparations where appropriate, early removal or avoidance of tubes, drains, and catheters, and early postoperative ambulation and alimentation. [20] 
Though expert consensus grades the majority of these elements as “strong” [Table II], recent meta-analysis and systematic reviews on the topic regard the data supporting the underlying elements as often poor and/or subject to bias. [21], [22] Nonetheless, enhanced recovery pathways (ERPs) with as few as two elements have shown value. [23]

Table 1. Expert consensus grading of elements of enhanced recovery [19]

ERPs have also shown benefit in select patients undergoing outpatient surgery including colectomy, [24] and thus are no longer simply a consideration for patients undergoing major inpatient surgery.

Implementing protocolled, evidence-based care pathways is in line with the Institute for Healthcare Improvement’s triple aim and appears to achieve its goals within the surgical patient population.


  1. Weiser, T.G. et al. (2008). An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. Jul. 12;372(9633):139-44
  2. Ghaferi, A.A., Birkmeyer, J.D., Dimick, J.B. (2009). Variation in hospital mortality associated with in-patient surgery. N Engl J Med. Oct. 1;361(14):1368-75
  3. Pucher, P.H., Aggarwal, R., Qurashi, M., Darzi, A. (2014). Meta-analysis of the Effect of Postoperative In-Hospital Morbidity on Long-term Patient Survival. Br J Surg. Nov;101(12):1499-508
  4. Khuri, S.F. et al. (2005). Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. Sep;242(3):326-41
  5. Moonesinghe, R., Harris, S., Mythen, M., Rowan, K., Haddad, F., Emberton, M., Grocott, M. (2014). Survival after postoperative morbidity: A Longitudinal Observational Cohort Study. British journal of anaesthesia
  6. Greco, M., Capretti, G., Beretta, L., Gemma, M., Pecorelli, N., Brag, M. (2014). Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. Jun;38(6):1531-41
  7. Miller, T.E. et al. (2014). Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anaesth Analg. May;118(5):1052-61
  8. Ebm, C., Cecconi, M., Sutton, L., Rhodes, A. (2014). A cost-effectiveness analysis of postoperative goal-directed therapy for high-risk surgical patients. Crit Care Med. May;42(5):1194-203
  9. Enhanced Recovery for Major Abdominopelvic Surgery
  10. Enhanced Recovery After Surgery: A Review. First Edition.
  11. Gustafsson, U., Oppelstrup, H., Thorell, A., Nygren, J., Ljungqvist, O. (2016). Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study. World J Surg. Jul;40(7):1741-1747
  12. Bloomstone, J.A., Loftus, T., Hutchinson, R. (2015). ERAS: enhancing recovery one evidence-based step at a time. Anaesth Analg. Jan;120(1):256
  13. Nicholson, A., Lowe, M.C., Parker, J., Lewis, S.R., Alderson, P., Smith, A.F. (2014). Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg. Feb:101(3):172-88
  14. Rollins, K.E., Lobo, D.N. (2016). Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials. Ann Surg. 263:465-476
  15. Gupta R, Gan TJ. Perioperative Fluid Management to Enhance Recovery. Anaesthesia 2016, 71 (Suppl. 1): 40-45
  16. Miller TE, Roche AM, Michael Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can J Anesth/J Can Anesth (2015) 62:158–168
  17. Awad S, Lobo D. Fluid Management. In The SAGES / ERAS Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery. Chapter 11. Pg 119. Springer. 2015 ISBN 978-3-319-20364-5
  18. Kehlet, H. (1997). Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. May;78(5):606-17
  19. Lindstrom, D. (2008). Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial. Ann Surg. Nov;248(5)739-45
  20. Feldheiser, A. et al. (2016) Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. Mar;60(3):289-334
  21. Bond-Smith, G., Belgaumkar, AP., Davidson, B.R., Gurusamy, K.S. (2016). Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database Syst Rev. Feb 1;2
  22. Spanjersberg, W., Reurings, J., Keus, F., Van Laarhoven, C. (2011). Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Databse Syst Rev 2.
  23. Loftus, T.J., Stelton, S., Efaw B.W., Bloomstone, J. (2015). A System-Wide Enhanced Recovery Program Focusing on Two Key Process Steps Reduces Complications and Readmissions in Patients Undergoing Bowel Surgery. J Healthc Qual. Apr. 22.
  24. Gignouse, B., Pasquer, A., Vuvvliez, A., Lanz, T. (2015). Outpatient colectomy within an enhanced recovery program. J Visc Surg. Feb;152(1):11-5

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Perioperative Medicine in Action

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