What are the preoperative components of enhanced recovery after surgery (ERAS) programs for emergency GI surgical procedures?

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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The body goes into a catabolic state during surgery, as various stress hormones and inflammatory mediators are released in response to stress, which in turn leads to insulin resistance. [8, 9] The resistance largely depends on the complexity of the surgical procedure: the more complex the procedure, the greater the resistance, with the greater resistance leading to increased morbidity and prolonged recovery. Hyperglycemia correlates directly with reduction in muscle mass, which leads to infections, cardiovascular events, and poor mobilization. [10] Implementing ERAS care elements reduces surgical stress and aims at maintaining normoglycemia, thereby reducing morbidity.

In a conventional ERAS protocol, the preoperative phase includes various components, such as preadmission counseling, fluid and carbohydrate loading, no prolonged fasting, no or selective bowel preparation, antibiotic prophylaxis, thromboprophylaxis, use of nonopioid analgesics, and no premedication. [11]

Preadmission counseling must be emphasized even in an emergency preoperative setting. For effective management of a patient on an ERAS pathway, the patient, the caregivers, and the family members must all be on board. It is important to highlight the nature and extent of the surgical procedure to be performed, along with the possible complications and the expected length of the hospital stay. [12]

Prewarming of fluids should be recommended, in that it has been shown to reduce postoperative complications (eg, infections). [13] This is carried out by using a warmer device and administering prewarmed intravenous (IV) fluids 2 hours before and after surgery.

Carbohydrate loading and selective bowel preparation, which are preoperative components of ERAS in an elective setting, may not always be feasible in an emergency setting. Carbohydrate loading and reducing the fasting time, when feasible, produce an anabolic state and thereby reduce postoperative thirst, hunger, anxiety, insulin resistance, and protein loss. [9, 13]

Standard mechanical bowel preparation is not generally considered in ERAS protocols, because it is known to cause dehydration and fluid and electrolyte imbalances. [14] It also increases the risk of spillage by liquefying the feces contaminating the operative field. Accordingly, selective bowel preparation is considered when bowel preparation is necessary.

Antibiotic prophylaxis is considered crucial in an emergency setting because of the high risk of postoperative infection, especially in cases of perforation and bowel gangrene. [15]

Thromboprophylaxis is not routinely recommended. [12] When thromboprophylaxis is necessary, low-molecular-weight heparin (LMWH) is preferred to unfractionated heparin (UFH) because it has less of a tendency to induce thrombocytopenia and is more conducive to once-daily dosing.

Patients needing emergency abdominal surgery commonly present with acute abdomen and require potent analgesics postoperatively. In many cases, their pain can be managed with epidural and nonopioid analgesia without resorting to opioids, which are known to prolong postoperative paralytic ileus. [11]  Opioid analgesia can, however, be used as a component of multimodal analgesia for breakthrough pain, as was the case in a study of ERAS in perforated duodenal ulcer from the authors' center. [1] The authors also used nasogastric (NG) tube placement at the time of admission, along with IV fluids, antibiotics, and antacids, as part of preoperative care.

Another study on emergency ERAS from the authors' center focused on emergency small-bowel surgery and used the same components as the previous study, along with ultrasound-guided central venous catheter placement at the time of admission for intraoperative fluid management. [2] The authors have also used IV dexamethasone before induction to reduce surgical stress.

These studies suggest that most of the preoperative components of ERAS—such as preadmission counseling, goal-directed fluid therapy (GDFT), nonopioid analgesics for pain management, antibiotic prophylaxis, and thromboprophylaxis—are indeed feasible in the setting of emergency abdominal surgery.

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