The enhanced recovery (ER) programme refers to an approach to delivering surgery in a number of specific surgical specialities (colorectal, orthopaedic, urology, gynaecological). It refers to a package of evidence based interventions that can improve patient outcomes. Much of the initial driver for this was to reduce hospital length of stay, but the benefits extend beyond this to better patient outcomes. It is the accumulation of the marginal gains of the package that helps deliver these notable improvements.
t was initially developed in Denmark for colorectal surgery by Professor Kehlet. Since then, the principles have been extended to patients undergoing a wide range of surgical procedures. Uptake of the principles through the UK was rather fragmented initially.
The key themes that run through the ER programme include:
Multidisciplinary team involvement
Extensive patient involvement with preparation
Optimising the patient for surgery
Minimising the surgical stress response
These specific aspects in colorectal surgery can be broken down into the different stages of the surgical journey.
Patient involvement with management options
Optimisation of chronic disease
Optimising haemoglobin levels
Commencing discharge planning
Informed consent and shared decision making
Optimisation of medical conditions
Clear explanation of process to patient: duration of stay, physiotherapy involvement, course of recovery
Day of surgery admission
Minimising/avoiding bowel prep
Minimally invasive surgery e.g. laparoscopic, transverse abdominal incisions
Avoiding NG tubes
Regional/neuraxial anaesthesia (inc epidural)
Goal directed fluid therapy
Planned early mobilisation
Avoidance of invasive tubes - wound drains, NGs, early catheter removal.
Aim rapid return to oral nutrition and hydration
Multimodal opioid sparing analgesia
Discharged when criteria met
Telephone follow up at 24h
Surgical technique The use of laparoscopic surgery has made significant progress in GI surgery. The reduced tissue trauma appears to reduce the surgical insult and resulting inflammatory response. Their is also reduced analgesia requirements. These fit in well with the other arms of the ER approach.
Fluid balance This remains a somewhat debated topic. The theory revolves around optimising circulating volume to allow adequate tissue perfusion, whilst avoiding excessive fluid administration, and the adverse consequence of the resulting oedema.
Appropriate fasting criteria, minimising the time that patients can’t drink, combined with the oral carbohydrate loading, means that patients are less dehydrated when they come to theatre. Similarly, avoiding bowel preparation minimises their dehydrating effects.
Goal directed fluid therapy describes the use of cardiac output assessment in theatre e.g. oesophageal doppler, to try and assess the patient's volume status based on their position in the Frank-Starling curve. There are some conflicting data on the effectiveness of this. Excessive fluid therapy is recognised to impair post operative outcomes. Each excess litre of fluid prolongs hospital stay by 1 day.
Aggressive anti-emetic control is important to allow an early return to eating and drinking postoperatively. This is an effective way to allow a return to optimal fluid balance control.
Analgesia Multimodal, opioid sparing analgesia is a central point of ER. The adverse effects of opioids are well recognised and impair recovery. As such, strategies to minimise their use are an important anaesthetic aspect:
NSAIDs where able
Adjuncts e.g. lidocaine, ketamine, clonidine
Epidural anaesthesia remains commonly used for open surgery. However, it is associated with a fairly high failure rate, and a number of complications. In the ER approach, the hypotension may be a particular problem with mobilisation. Alternative strategies such as rectus sheath catheters have been considered.
For minimally invasive surgery, single shot spinal anaesthetic (with opioid) is commonly used. This may have an improved recovery profile compared to epidural anaesthesia.
Anaesthetic technique The approach to the anaesthetic technique runs similar to the rest of the goals of ERAS, i.e. to minimise the impact on the patient. As such, an anaesthetic with minimal hangover effects is desirable. Short acting agents are generally preferable, including avoidance of long-acting sedative premedication. TIVA may have some positive profile in this regard, but no technique has a clear benefit.
Patient Engagement This is a central part of the ERAS process. Patients are heavily involved in the process, with extensive preparation about what to expect at each stage of the process e.g. mobilisation goals. Some of this information is important, as it may go against some commonly held beliefs (including amongst medical personal) such as the degree of bed rest postoperatively. The use of specific postoperative daily goals can be very helpful e.g. sitting out, walking on spot.
Many steps will occur in the community preoperatively, such as optimisation of lifestyles factors. Engagement with specialists such as stoma nurses can be very helpful for patients.
The benefits from the ERAS approach appear to be to both the patients and healthcare systems. These include: