Enhanced Recovery After Anesthesia
A female doctor helping a patient breathe using a respirator

Enhanced Recovery After Anesthesia

Recovery after surgery can be a long and onerous process. It may include pain, fatigue and loss of functional capacity, and a patient may even require months of physical therapy after discharge.1 Modern day surgery has become multimodal and multidisciplinary, aiming to “fast track” patients to full recovery.2 These contemporary changes in perioperative care, known as Enhanced Recovery After Surgery (ERAS), have resulted in improved quality of care and cost savings.3 According to the American Association of Nurse Anesthetists (AANA), ERAS outlines patient-centered, evidence-based, multidisciplinary team-developed programs for surgical teams to reduce patient stress, optimize their physiological function and facilitate quick recovery.4 ERAS interventions are highly specialized and standardized; in fact, the ERAS Society publishes guidelines for surgeries ranging from esophagectomy to breast reconstruction.5 Thanks to the success of ERAS programs and their coordinators, patients have seen evidence-based modern care approaches including changes from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization and provision of drinks and food the day of the operation.3 Given their role in medication and vital signs management, anesthesiology professionals are key to a successful ERAS program before, during and after surgery.2

Before surgery, the anesthesia provider using an ERAS protocol will begin with a preanesthesia consultation to reduce the patient’s anxiety and take an accurate medical history.2 Based on the patient’s condition, the anesthesiologist will also provide the patient with medications such as beta blockers and benzodiazepines to deliver sedation, reduce anxiety, optimize intraoperative hemodynamic stability and decrease postoperative complications.6 The anesthesia provider is also responsible for keeping the patient hydrated. In an ERAS protocol, this includes allowing oral hydration up to two or three hours before surgery and giving intravenous hydration before anesthesia induction.7,8 ERAS guidelines—contrary to traditional protocols—also state that for many surgeries, patients can actually consume solid food up to six hours before anesthesia induction.7 Clearly, an anesthesia provider using ERAS may have altered recommendations for a patient during preparation for anesthesia induction.

ERAS pathways have also standardized intraoperative anesthesia care. These standardizations include guidelines for induction and maintenance techniques, as well as mechanical ventilation and fluid management.2 Evidence-based ERAS protocols outline anesthetic drug selection depending on procedure type, including inhalation, intravenous, epidural, opioids, nerve blocks and nitrous oxide.2,7 Anesthesia providers following ERAS use prophylactic drugs, such as antibiotics, antiemetics and pain medications, during the intraoperative period to reduce postoperative side effects.2,8 Glycemic control is also important during the intraoperative period, as use of glucocorticoid steroids as part of ERAS technique may lead to hyperglycemia during and after surgery.8 Finally, ERAS guidelines advise temperature control through blankets or warming intravenous fluids to prevent wound infection, cardiovascular complications, blood loss or prolonged hospital stay.9-12 These contemporary ERAS practices are accompanied by the anesthesia provider’s duty to monitor patient vital signs intraoperatively.13

After surgery, ERAS aims to reduce the patient’s stress response.14 This includes pain management, which may accelerate the patient’s recovery time and allow for sooner discharge.8 Multimodal anesthesia/analgesia involves the use of more than one type of medication, and it is especially helpful in reducing the side effects of opioid drugs during the postoperative period.8 The anesthesia provider may also give medications to reduce nausea, vomiting and constipation after surgery, all with the goal of returning patients quickly to their previous qualities of life.2,8 Also, an anesthesiologist following ERAS guidelines will provide postoperative nutrition as early as possible as to avoid deficiencies,15 and preferably through the patient’s mouth.16

ERAS programs have been associated with shorter hospital stays3,17 reductions in complications3 and better recovery.7,18,19 Anesthesia providers are crucial to the ERAS process before, during and after surgery, and their changed practices may contribute to any benefits associated with ERAS.8 Future health professionals should aim to implement ERAS in more settings and assess its efficacy across different types of surgery.

1.         National Health Service. Getting back to normal. Having an operation (surgery) February 7, 2018; https://www.nhs.uk/conditions/having-surgery/recovery/.

2.         Joshi GP. Anesthetic management for enhanced recovery after major surgery (ERAS) in adults. In: Nussmeier NA, ed. UpToDate January 15, 2019.

3.         Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surgery. 2017;152(3):292–298.

4.         American Association of Nurse Anesthetists. Enhanced Recovery after Surgery. 2019; https://www.aana.com/practice/clinical-practice-resources/enhanced-recovery-after-surgery.

5.         ERAS Society. List of Guidelines. Guidelines 2016; https://erassociety.org/guidelines/list-of-guidelines/.

6.         White PF. Pharmacologic and Clinical Aspects of Preoperative Medication. Anesthesia & Analgesia. 1986;65(9):963–974.

7.         Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Canadian Urological Association Journal. 2011;5(5):342–348.

8.         White PF, Kehlet H, Neal JM, et al. The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care. Anesthesia & Analgesia. 2007;104(6):1380–1396.

9.         Kurz A, Sessler DI, Lenhardt R. Perioperative Normothermia to Reduce the Incidence of Surgical-Wound Infection and Shorten Hospitalization. New England Journal of Medicine. 1996;334(19):1209–1216.

10.       Nesher N, Zisman E, Wolf T, et al. Strict Thermoregulation Attenuates Myocardial Injury During Coronary Artery Bypass Graft Surgery as Reflected by Reduced Levels of Cardiac-Specific Troponin I. Anesthesia & Analgesia. 2003;96(2):328–335.

11.       Schmied H, Reiter A, Kurz A, Sessler DI, Kozek S. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. The Lancet. 1996;347(8997):289–292.

12.       Lenhardt R, Marker E, Goll V, et al. Mild Intraoperative Hypothermia Prolongs Postanesthetic Recovery Anesthesiology: The Journal of the American Society of Anesthesiologists. 1997;87(6):1318–1323.

13.       Min JY, Kim HI, Park SJ, Lim H, Song JH, Byon HJ. Adequate interval for the monitoring of vital signs during endotracheal intubation. BMC Anesthesiology. 2017;17(1):110.

14.       Steenhagen E. Enhanced Recovery After Surgery. Nutrition in Clinical Practice. 2016;31(1):18–29.

15.       Gabor S, Renner H, Matzi V, et al. Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction. British Journal of Nutrition. 2005;93(4):509–513.

16.       Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: A randomised multicentre trial. Lancet (London, England). 2001;358(9292):1487–1492.

17.       Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clinical Nutrition. 2010;29(4):434–440.

18.       Zhuang C-L, Ye X-Z, Zhang X-D, Chen B-C, Yu Z. Enhanced Recovery After Surgery Programs Versus Traditional Care for Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials. Diseases of the Colon & Rectum. 2013;56(5):667–678.

19.       Fearon KCH, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition. 2005;24(3):466–477.