Enhanced Recovery After Surgery (ERAS) Guideline

Contributor: Dr. Benji Mills
Last Updated: 01/24/18

Background:

The goal of postoperative recovery and management is to restore the patient to a state of normalcy after a surgical event.  Reducing surgical stress, maintaining normal physiological function postoperatively, and increasing mobilization after surgery can achieve a significant decrease (as much as 50%) in complications from surgery.  The Enhanced Recovery After Surgery (ERAS) Guidelines were published in 2016 for gynecologic oncology patients, but are adaptable for patients with benign gynecologic conditions.

 

Care is divided into 5 stages:
1. Preoperative care (at time of decision for surgery and at preop visit)

• Smoking cessation for 4 weeks before surgery
•  Avoiding alcohol before surgery
•  Optimization of medical conditions including glycemic control for diabetic patients
•   Discussion on expectations for postoperative pain, early ambulation, discharge goals and return to normal activities

2. Perioperative care

•  Perioperative fasting
  • No solids after midnight prior to surgery
  • High carbohydrate/high electrolyte drinks (12-20 oz.) up to 3 hours prior to surgery to avoid dehydration.  Diabetic               patients get sugar-free, high electrolyte beverages.
•  Pain management
  • Celecoxib 400 mg PO on day of surgery
  • Pregabalin 75 mg PO on day of surgery
  • Acetaminophen 1 gm PO on day of surgery

3. Intraoperative care

• Anesthesia
  • Induction using propofol/rocuronium, lidocaine, dexamethasone, ketamine and esmolol (prn)
  • Maintenance with lidocaine, ketamine infusion, and esmolol prn
  • At end of case, ondansetron and bupivacaine 0.5% injection in the incision
• Fluid management – LR 1 liter bolus at start of case with maintenance of 3 mL/kg/hr
•  Venous thromboembolism prophylaxis with mechanical compression and low molecular weight heparin if indicated (see               Benign Gynecology Postoperative Venous Thromboembolism Prophylaxis Guidelines)
• Antimicrobial skin preparation
  • Prophylactic intravenous antibiotics are given within 1 hour of incision
  • Use of hair clippers (no shaving)
  •  Chlorhexidine-alcohol based skin prep
• Avoid use of peritoneal drains and remove nasogastric tubes prior to awakening if possible

4. Immediate postoperative care

• Analgesia
  • Pregabalin 75 mg PO q 12 hrs for 7 days
  • Acetaminophen 650 mg PO q 6 hrs for 48 hours
  • Celecoxib 200 mg BID for 7 days
  • Ketamine 1-2 mcg/kg/min for 48 hours
  • Narcotic pain medication for rescue or break-through pain only
•  Urinary catheter removal within 8 hours after surgery, if possible
•  Early mobilization
  •  Out of bed to chair for 2 or more hours on day of surgery
  •  Out of bed to chair for 6 or more hours starting postop day 1
  • Use of incentive spirometry
• Fluid management
  •  LR or NS at 40 mL/hr on day of surgery
  • Discontinue IV fluids on postop day 1
• Nutrition and bowel function
  • Start solid diet four hours postoperatively (regular or patient indicated diet)
  •  Docusate sodium 100 mg PO BID on day of surgery
• Venous thromboembolism prophylaxis with mechanical compression when not ambulating and low molecular weight                     heparin if indicated (see Benign Gynecology Postoperative Venous Thromboembolism Prophylaxis Guidelines)
•  Diabetic glucose control – maintain blood glucose below 180 mg/dL.

5. Extended postoperative care

• Analgesia
  • Pregabalin 75 mg PO q 12 hrs x 7 days total
  • Acetaminophen 650 mg PO q 6 hrs x 48 hrs
  • Celecoxib 100 mg PO BID x 7 days

OB/GYN Center and Gyn Teaching Service Workflow for ERAS Patients

1. Decision for surgery

•  ERAS is for patients undergoing laparoscopic hysterectomy or laparotomy.
• When completing the Case Request, add the phrase “with ERAS protocol”
• Prescriptions
  • Celebrex 200 mg BID for 7 days (send to Upstate Medical Pharmacy at GMH if possible)
  • Lyrica 75 mg BID x 7 days (send to Upstate Medical Pharmacy at GMH if possible)
  • These prescriptions, if not covered by insurance, will cost $37.00 at Upstate Medical Pharmacy
• Notify Gyn RN that these prescriptions have been written and may need preauthorization

2. Preop clinic visit

• Ensure receipt of postoperative Lyrica and Celebrex, or that the patient will receive them prior to discharge from the                       hospital.
• Counsel the patient on expectations
  • Pain control
    1.  Expect pain on a scale of 3-4/10, not complete pain relief
    2.  Decreased use of narcotics decreases complications, improves bowel function, and allows earlier restoration             to normalcy
    3. Alternative pain medications are aimed at treating inflammation, the primary cause of postoperative pain
  • Early ambulation on day of surgery
  • Early advancement of diet
  • Removal of foley catheter on day of surgery
• Give the patient a bottle of high carbohydrate/high electrolyte beverage (or sugar-free/high electrolyte beverage for                                   diabetic patients) at the visit.
• Give the patient a printed patient handout on ERAS.
• Documentation
  • ERASCOUNSELING – Documentation of ERAS counseling in the progress note.
  •  ERASPATIENTEDUCATION – Documentation for the patient in the After Visit Summary

3. Intraoperative and postoperative order management

• Note the use of ERAS protocol in the Time Out and Postoperative Debrief
•  Floor unit placement
  • 5D is the unit of choice, but patients can go to 3C
•  Use the Gyn Oncology Postoperative Order Set
•  Use the phrase .ERASACTIVITY as a nursing communication

4. Postoperative documentation – use the phrase .GTSERASPOSTOP for your daily postop rounding note

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References

1. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology   surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – Part I. Gynecol Oncol. 2016 Feb;140(2):313-22.
2. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology   surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – Part II. Gynecol Oncol. 2016 Feb;140(2):323-32.