The goals of this program are immediate mobilization, rapid and appropriate discharge from the hospital, and a timely return to productivity and normalcy.
Enhanced Recovery After Surgery (ERAS) is an approach to patient care that uses a combination of several evidence-based perioperative interventions to accelerate and optimize recovery after surgery. It is an extension of the critical pathway that incorporates modes of surgery, anesthesia and nutrition, enforces timely mobilization and nutrition in order to significantly reduce the body’s response to surgical stress. It involves significant collaboration between the surgeon and the anesthesiologist with several other specialists to form a multidisciplinary team, which can then engage in patient care. The practice of rapid surgery has yielded excellent results and there has been a significant reduction in hospital stay as well as a reduction in postoperative complications or readmissions. Effective implementation begins with formulating a protocol, implementing each intervention, and collecting data.
A patient’s care is divided into three phases: Before, during and after surgery. Each stage needs the active participation of some or all members of the interdisciplinary team. In addition to surgical technique, anesthetic medicines and techniques are very important elements to successfully perform a surgical procedure that is safely and successfully aligned with the rapid recovery protocol.
The concept of “rapid surgical recovery”, also known by the English term FastTrackSurgery, has been mentioned in the literature of Surgery for the last two decades. One of the first to describe a perioperative care regime that facilitated early recovery was Professor HenrikKehlet.
It is understood that the perioperative period is not exclusively the domain of any particular specialty. There is thought and debate that, since perioperative care is a unique area of clinical practice, a new position, that of the perioperative specialist, should be developed. There may be a long waiting period until such specialists are available in every public and/or private sector hospital in many countries. In any case, however, it is a fact that there must be a coordinated effort and a multidisciplinary team approach for every patient undergoing surgery. Collaboration between the surgeon and the anesthetist and any other specialist is essential to ensure the optimal outcome of the surgery. The same applies to the application of the principles of rapid surgical recovery in clinical practice.
What does accelerated recovery surgery involve?
The approach can be divided into three phases:
Preoperative phase
It involves preparing the patient so that they are in the best possible condition before surgery. The aim, among other things, is to identify patients at increased risk so that appropriate decisions can be made and postoperative complications can be reduced to a minimum.
Before being admitted to the hospital, it is very important that the patient has followed a diet that will help in a quick recovery, has avoided a sedentary lifestyle as well as smoking and alcohol.
During the pre-operative check, and depending on the particular case, the necessary tests are carried out:
- Hematologic
- Blood Group (for major surgeries)
- Electrocardiogram
- Chest X-ray
- Cardiological assessment
- Anesthetic Assessment
Surgical phase
The stage in which surgical and anesthetic procedures reduce the surgical stress response so that there is minimal disruption of the patient’s body physiology.
On the day of the surgery, the patient can consume clear liquids, such as water, tea, coffee without milk, up to two hours before the surgery. For more difficult and lengthy surgeries, a carbohydrate drink can be taken. Also, depending on the type of operation, the use of an epidural can help control pain.
Postoperative phase
In this phase, there is a multi-level approach to the rehabilitation of the patient. Optimum analgesia, reduction of postoperative nausea and vomiting and early mobilization are some of the important goals of the program while contributing to faster recovery.
Fast-Track surgery aims to modify the traditional surgical approach, i.e. the practices most often used in operating rooms, in the three aforementioned perioperative phases. At the base of the program, fundamental are:
- Η «προεγχειρητική συμβουλευτική» η οποία πρέπει να παρέχει στον ασθενή όλες τις πληροφορίες σχετικά με τη θεραπευτική διαδικασία που τον περιμένει.
- Abolition of bowel preparation and preoperative fasting.
- The use of the preoperative nutritional application
- A rational antibiotic-prophylaxis
- The reduction of intraoperative intravenous fluids
- The “use of techniques for intraoperative “analgesia”
- The minimally invasive surgical technique
- Abstaining from the usual use of a nasogastric tube and abdominal drainage.
In the postoperative period, the patient is required to actively participate in the recovery process with timely mobilization and refeeding
Consequently, the composition of the multidisciplinary team of a fasttrack process includes:
- Surgeon
- Anesthesiologist
- Nursing staff (including nutritionists)
- Physical therapist
- Dietitian
- Social worker
- Patient educator
This group is responsible for reviewing and adopting best practices based on a protocol. Flexibility and customization are characteristic of protocol design. There is no “one size fits all”.
Compared to “traditional” perioperative management, the process of accelerated surgical recovery is a greater commitment to care. However, this procedure can not only improve the results of surgery, but it can help the patient to better understand his illness and actively participate in the recovery stage, representing a great stimulus for the specialists involved in the procedure.
