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Dr. Steven Williams in Boise, Idaho


Enhanced Recovery After Surgery Protocols: E.R.A.S

Dr. Steve Williams | General Surgery | | View Counts (7610) |Return|

Enhanced Recovery After Surgery (ERAS) are programs that are being created to help with quicker recovery and reduced complications after surgery. It is a patient-centered, evidence-based, approach. Evidence based means that instead of an experienced doctor, nurse, or operating room manager’s opinion of what is best for the patient, ERAS uses measures that have been proven to work by studies and investigations in actual operative patient populations. By using these programs, a surgical facility hopes to reduce the patient’s stress response, improve their physiologic function, reduce complications, and expedite their postoperative recovery. This method weaves an integrated continuum as the patient goes through the pre-hospital, preoperative, operative, and postoperative phases of surgery.

Many hospitals across the nation are reviewing these protocols department by department to see where portions of them or the entire protocol developed at a different facility can be instituted in order to improve care. Many of these protocols have been developed for a single surgical line of care such as bowel surgery, vascular, or urologic surgery. They have been formulated based on what evidence has shown through large patient studies. Sometimes, long standing rules such as not consuming any liquid for many hours before surgery have been shown to be counter-productive. Now we know that for some surgeries, such as bowel surgery, certain clear drinks containing carbohydrates consumed up to two hours prior to surgery can provide better glucose control and effect better outcomes postop.

Some Key Features of ERAS Protocols Include:

  • Preoperative counseling
  • Nutritional optimization
  • Standardized analgesic schedule
  • Standardized anesthetic regimen
  • Early mobilization

ERAS was initiated by Professor Henrik Kehlet in the 1990s. It is also called Enhanced recovery programs (ERPs) or Fast track programs. These are now becoming an important program for perioperative management after general surgery, vascular surgery, colorectal surgery, thoracic surgery, and radical cystectomy. These programs aim to improve processes by modifying the psychological and physiological responses of patients to major surgeries and lead to a reduction in complications, hospital stay, improvement in cardiopulmonary function, earlier resumption of routine activities, and earlier return of bowel function.

Several components mentioned in ERAS are common across many medical specialties. The ERAS program can be broken down into 3 main components: Preoperative, Intraoperative and Postoperative. It is a multifaceted approach that can be used for all patients; the goal is for anyone undergoing surgery to benefit from enhanced recovery.

Let us Look at the Components of ERAS

Preoperative Components

  • Patient education and counseling provided by the surgeon, allied health providers, and the nursing staff
  • Prehabilitation- optimizing patient’s health before the surgery
  • Anemia investigated and treated
  • Cessation of smoking and alcohol 4 weeks before surgery
  • Evaluation of ceasing HRT (Hormone Replacement Therapy) and OCP (Oral Contraceptive Pills) medications
  • Nutritional counseling
  • Avoidance of prolonged fasting
  • Antibiotic prophylaxis
  • Carbohydrate drink prior to surgery
  • Evaluation of appropriate bowel preparation

Intraoperative Components

  • Laparoscopic surgery where indicated and possible
  • Regional blocks or local anesthesia
  • Maintaining normal body temperature
  • Multimodal pain management
  • Avoidance of nasogastric tube insertion unless absolutely indicated
  • Minimal drain insertion
  • Avoiding excessive amounts of intravenous fluid administration

Postoperative Components

  • Urinary catheter to be removed on the day of surgery or postop day one
  • Mobilize the patient on the day of surgery
  • Start diet early (early feeding, with high protein diet)
  • Drains to be removed as early as possible
  • Management of nausea
  • Patient-controlled analgesia: transition to oral medicines on day one
  • Appropriate VTE (Venus thromboembolism) prophylaxis
  • Avoidance of nasogastric suction and intraabdominal drains if possible
  • The patient should complete a diary to document their diet and how mobile they are after surgery

What Are the Benefits of ERAS for the Patient Undergoing Surgery?

Benefits may include:

  • A structured approach towards patient care before, during and after the surgery
  • Clear communication between the patient and the medical team
  • Lower risk of post-operative complications
  • Patients and their family members are more involved and aware of the procedure
  • Patients are more active in their preop and postop care
  • Decreased readmission rates
  • Reduced length of hospital stay
  • Reduced mental stress, anxiety, and depression in patients
  • Decreased number of patients on the surgery waiting list
  • Increased cooperation from the patient and their family
  • Increased confidence of the medical staff towards clinical management
  • Clinical guidelines to simplify postoperative care


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