Introduction

Within the perioperative environment, the members of the perioperative team work together to
provide care for patients undergoing surgery. Each team member work towards a shared goal
such as promoting the health and well-being of the surgical patient through multidisciplinary
collaboration.

Enhanced recovery after surgery is a program of evidence-based interventions that minimize the
body's response to surgical stress, enables patients to be safely discharged from hospital earlier
than previously thought possible. Enhanced recovery pathways is a non-traditional model of care
that is standardized and includes multidisciplinary approaches in caring for patients in order to
guide the entire health care team toward working together to ensure positive patient outcomes.
The goals of the perioperative enhanced recovery pathway model is to integrate all elements of
preoperative, intraoperative and postoperative patient care, to provide education that empowers
patients and their caregivers to better understand and participate in the recovery process, as well
as decrease length of stay and care costs. The use of enhanced recovery pathway has improved
the effectiveness of patient care, accelerate recovery, reduced length of stay without
compromising safety or increasing readmission rates, and optimizing health care use for patients
undergoing surgery. The exact needs, roles and contributions of nurses have not been defined
and discussed in studies conducted regarding enhanced recovery after surgery.

In some English countries, many enhanced recovery programs have been implemented and
nursing has undergone much change with an increased emphasis on patient information provision
and far less on physical aspects of care. Nursing workload did not change but there was a great
highlight on information delivery, a reduction in the time to get to know the patient and the need
for less physical care, as patient were well enough to attend to their own needs. While the
surgeon-patient focus and anesthetist-patient focus remained relatively unchanged in relation to
contact time, while the nurse-patient focus and contact time have become slightly more diffuse.
Nursing groups have brief interactions in the outpatients’ department and pre-assessment clinic,
as well as on the day of surgery, during in patient stay, then during post-discharge care in the
community. The modern and inherently fragmented approach of enhanced recovery pathway
must now be embraced by nursing profession because it can be used to seek solutions in
combating the unique challenges that arises in order to make a more significant contribution to
contemporary surgical nursing.

Beyond the knowledge and skill required to aid the implementation of enhanced recovery
programs, nursing expertise can still make a significant contribution in pre-assessment,
communication and information provision, psychosocial support, discharge planning and post-
discharge support. With the application of surgical nursing moving away from a traditional, acute,
ward-based activity, there is a tremendous opportunity for a wider holistic approach, coordinated
from a central location giving greater attention to the once marginalized psychosocial aspects of
care. Surgical nursing can excel with opportunity to provide seamless support between hospital
and community as enhanced recovery programs grow. Such intervention has the potential to
become an essential element of peri-operative nursing practice and offer greater continuity of
care.

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 Rationale

The concept of enhanced recovery following elective surgery is becoming increasingly prominent
in the world of perioperative practice. By observing the enhanced recovery after surgery
guidelines, will it minimize the occurence pain and fatigue experience by patients, promote early
mobilization and diet tolerance soon after surgery, will it significantly decrease the length of stay
and decrease care cost of patient without affecting the patient outcomes or increasing
complications, empower nurses in decision making and assessment skills, change the role of the
nurse and implications for nurse education and can it be applied to developing countries both in
private and government hospitals, and will its guidelines and standards of programme fits every
patient demand in specific surgical operations.

Complications, one of the main reason why we are into ERAS because there is a higher number
of patients have complications after resections or surgery. Patient centered outcomes is another
interesting idea in ERAS because recovery to baseline function takes longer than we think.
Significant differences between centers in perioperative processes, complications, and hospital
stay and increasing and unsustainable cost of health care are other topics relating to ERAS. There
are a lot of things that we are actually eager to discern about Enhanced Recovery after Surgery,
but the above mentioned topic are our top most reasons why we wanted to learn this.

Feature

Improving Pre-operative Care

Typically, as its name implies, pre-operative assessment prepares patients for admission and
surgery. Discharge planning has traditionally been delayed until after surgery or begun at the
point of admission, and this may prove inadequate. In a study of the effect of discharge
information on surgical patients, those who received information were less likely to access
healthcare services than those who did not. Enhanced Recovery after Surgery improves on the
traditional model in that pre-operative assessment is perceived as preparation for discharge as
well as for surgery itself. Educational intervention before admission has been shown to reduce
post-operative pain levels after laparoscopic cholecystectomy and to increase significantly
patients’ knowledge of self-care and management of complications. No matter how thorough pre-
operative assessment is, what can be achieved on a single occasion before admission is limited.
Providing information that patients can use at their own pace is clearly important, and several
trusts provide specific advice about Enhanced Recovery after Surgery.

The more you understand about what is going to happen, what you will feel like and what can
be done if things don’t quite go to plan, then the more confident you will feel during your recovery.
Reducing levels of anxiety helps lessen stress reactions of the body which allows for a faster
recovery.

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Reducing the Physical Stress of Surgery

Many traditional peri-operative interventions are now recognized as being unnecessary or even
counterproductive. Even when a conventional surgical approach is taken, pre-operative
medication is not usually given and patients remain active until the point of surgery, usually
walking to the operating department. A systematic review of pre-emptive analgesia (starting
analgesics before the operation) showed no benefit over starting analgesics post-incision. Nor is
a strict regimen of fasting adhered to, because drinking clear fluids up until two hours before
anesthesia is safe, although the fasting time after eating solid food is generally six hours. Fasting
before surgery means that patients are operated on in a catabolic state, but taking a clear
carbohydrate-rich drink (carbohydrate loading) before midnight and two to three hours before
the operation is an attempt to avoid this. In addition, patients who receive carbohydrate loading
before colorectal surgery seem to recover more quickly and have a shorter hospital stay than
those who do not. Pyrexia, atelectasis and pneumonia were less common in patients without a
nasogastric tube. A meta-analysis of controlled trials of early enteral or oral feeding versus fasting
found no advantage of fasting after gastrointestinal resection.

Maintaining a body temperature within the normal range can also be important. Conventional
surgery involves several factors that lead to cooling. These include being semi-clad in an operating
theatre that, at 20-25°C, is below a thermo-neutral temperature, the temperature at which the
body neither cools down nor heats up. General anesthesia may affect the body’s set point for
temperature regulation (rather like turning down the body’s thermostat), while both spinal and
epidural anesthesia affect thermoregulatory responses such as vasoconstriction. Normothermia
may be maintained by warming intravenous fluids and by forced heating of the upper body.

Increasing Comfort after Surgery

Comfort is a wider concept than freedom from pain and includes freedom from nausea and
vomiting, as well as having questions answered and not feeling anxious. Enhancing post-operative
comfort is a laudable aim in itself, but in enhanced recovery after surgery, the focus is for patients
to mobilize and resume eating normally as soon as possible, and nausea and vomiting clearly
threaten this. Since drugs such as opioids and some gaseous anesthetics may cause nausea,
these are avoided if possible and anti-emetics are used selectively. People with risk factors such
as a history of motion sickness or post-operative nausea should receive anti-emetics. Patient-
controlled analgesia using intravenous opioids may produce similar pain scores, but patients may
be sedated as a result of the medication and so remain in bed. Paracetamol is recommended as
the ‘baseline’ analgesic, with the addition of non-steroidal anti-inflammatory drugs for
breakthrough pain.

Changes in the Role of the Nurse and Implications for Nurse Education

The three key features of enhanced recovery after surgery reviewed above clearly have an effect
on the role of the nurse. Some anticipated problems with early discharge, such as an increase in
the workload of district nurses, should not occur, but nurse education will need to take account
of changing care in hospital. Nasogastric tubes and urinary catheters are passed in fewer patients,
wound drains are less commonly used, and resumption of eating and drinking soon after surgery

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means that intravenous infusions are usually discontinued on the first morning after the operation.
Technical aspects of care still need to be taught, but once common interventions such as these
will be confined to the most seriously ill patients and those who need traditional surgical
management.

As more experience is gained and ERAS is introduced in a wider range of specialties, it will become
the ‘conventional’ approach to surgery. As this happens, the care that patients need will change,
with many patients requiring physical care only in the immediate peri-operative period. This does
not mean that physical aspects of care or the biological science basis for them can be neglected.
For example, as a key element of ERAS is a reduction in peri-operative stress, the physiological
meaning of stress as a threat to homeostasis is important. Understanding the significance of the
anaerobic threshold as the basis for triage (Older et al 1999) is another example of the importance
of biological science, as is the metabolic basis for current insights into patients’ nutrition.

The increased importance of education and communication does not, however, mean that more
time is available for these activities – quite the reverse. Many patients are discharged after
hospital stays of only one or two nights, even after major surgery. Nurses have to give careful
consideration to how to prepare patients psychologically for discharge when little time is available
to give explanations and answer questions.

Nursing Pre-operative Assessment and Anxiety Management

As pre-assessment is frequently the first point of contact with nurses following a decision to
operate, undertaking a more comprehensive nursing preoperative assessment may be necessary.
Patients would thereby become immediately aware of the nursing services available throughout
their surgical experience and be more informed regarding each stage of treatment.

The clinical application of psychosocial aspects of nursing care can have a much needed impact
on patient care through planned provision of anxiety-relieving strategies. Patient anxiety prior to
modern surgery should not be underestimated as 85% of patients undergoing surgery and
general anesthesia were anxious.

Methods of Creating and Implementing Enhanced Recovery Pathways

There are three steps in implementing enhanced recovery pathways in surgical setting. Defining
the population and surgical service area is the first step involved. On a study conducted, they
defined surgical specialties that involves abdominal surgery including the analysis of colorectal
surgery, general surgery, surgical oncology, urology and hepatobiliary surgery. Enhanced
recovery pathways have been used successfully in the colorectal patient population and have
demonstrated decreased length of stay, complications, readmissions and costs. The enhanced
recovery pathway principles where replicated across each surgical specialties within the
Department of Surgery in an attempt to realize the same benefits. The service areas identified to
participate in pathway implementation where laparoscopic procedures, open procedures, upper
gastrointestinal procedures, same day observation procedures and other miscellaneous
procedures. These procedures were chosen because they can be easily grouped under broad
categories across all divisions.

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The next step in implementing enhance recovery pathway is to define the care processes under
each surgical service area that requires such. The six care pathways identified includes one pre-
operative pathway, four surgical care pathway and one patient experience pathway. The
preoperative pathway typifies the stages of comprehensive patient preparation which includes
the established standards included in the criteria for pre-operative patient consultation, day of
surgery, time in the pre-operative holding area, and anesthesia and surgical components of the
patient experience.

In the surgical services department, care providers obtain baseline information that includes
laboratory tests and results, anesthesia patient optimization, a frailty score patients are rated
from very fit to terminally ill based on their activity levels and comorbidities, and a retrospective
grade of fitness score, which helps identify patients who may not progress quickly after surgery
and helps clinicians anticipate the patient’s needs at the time of discharge. During the
preoperative visit, the health care team reviews specific information with the patient and his or
her family members regarding what to expect during the hospital experience. We developed four
surgical care pathways that outlined a standardized regimen of early diet progression; early
ambulation; consistent medication choices, including opioid sparing medications; and limited use
of tubes, drains, and blood draws. We also established a miscellaneous care pathway to
standardize approaches to common postoperative complications. This included criteria for blood
transfusion, wound infection management, disposition issues at discharge, and discharge criteria.
The most important of these is the criteria for discharge because, in our experience, it is helpful
to outline discharge criteria at the onset of the patient experience. Patients are considered
appropriate candidates for discharge after they can tolerate some diet, are experiencing pain
relief with oral pain medications, are passing flatus or having bowel movements, and are ready
and amenable to being discharged home. In conjunction with the care pathways, we have set up
other standard approaches that have been implemented to minimize complications and added
days for unnecessary procedures. Care providers start discharge planning at the beginning of the
hospital experience to minimize last-minute planning and delays in discharge.

The third step is the process of designing ERPs. Coordination on many fronts is essential to
develop the necessary order sets. Our design team includes medical content experts, electronic
medical record (EMR) personnel, and pharmacists. The hospital’s quality team members also
ensure that the order sets include all necessary documentation. After developing the order sets,
and after they are approved and implemented, it is essential that the multidisciplinary care team
members embrace these as the new standard of care. As part of the enhance recovery pathway
design process, we identified evidence-based best practices, general standards, and specific
variables for each pathway. Each surgeon was given the opportunity to weigh in on the process;
a consensus of all surgeons was reached to facilitate successful implementation of this project.

Our standardized ERPs for all surgical services include establishing a preoperative education plan
for patients and their family members; implementing a standardized preoperative plan (high
protein drink, no bowel prep for colon resections in selected patients); minimizing the
administration of intraoperative IV fluids; ensuring early removal of nasogastric tubes; avoiding
postoperative drains; introducing food early in the postoperative period; facilitating early
postoperative ambulation (the night of surgery); converting patients to taking oral pain
medications as quickly as possible; choosing consistent medications, including opioid-sparing
medications; and performing laboratory blood draws every other day.

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Pre-Operative Education

Perioperative education for patients and their family members is essential for successful
navigation through the surgical experience. There are limited studies that address the benefits of
education before surgery; however, evidence shows preoperative teaching conducted before
hospital admission is most success-ful.14 After the plan for surgery is confirmed, the patient
should begin to receive information from his or her medical team. The education that the patient
receives in the office will set the tone for the surgical experience. The goal of an effective patient
education plan is to inform the patient and his or her family members about what to expect during
each phase of the experience. Patients often worry about how long they will be hospitalized,
types of dressings, driving restrictions, and when they can return to work and household activities,
among other things. The goal of education is to address these stresses and help the patient
adequately prepare for and anticipate needs during recovery. A comprehensive education plan
helps the patient and caregivers engage in the process to prepare for the surgical experience.

Intra-operative Education

The perioperative nursing staff members also are educated about and participate in the
intraoperative and postoperative stages of the multimodal pathway. The intraoperative care
measures provided by nurses include verifying the correct patient, procedure, and site, if
applicable, with the patient and reinforcing education about the planned procedure. The nurses
help ensure that a proper time-out procedure is performed, antibiotics and antithrombotic agents
are administered in a timely fashion, and the patient is positioned and secured appropriately. In
keeping with cost containment efforts, nurses’ select reusable equipment (laparoscopic ports)
and, to avoid waste, do not open instruments (energy devices, staplers) until the surgeon
requests them. Opioid-sparing pain management is used even in the OR, and nurses participate
in administration of transversus abdominis plane blocks before the end of the procedure. Before
transporting the patient to the post anesthesia care unit (PACU), the nurse assesses the patient’s
skin and temperature. In the PACU, the perioperative nurse provides a standardized hand-over
report to ensure that pertinent information is provided to the PACU RN.

Post-operative Education

In the PACU, nurses play a key role in patient pain management and satisfaction. Even at the
early postoperative stage, by using standardized ERPs, nurses can directly affect the reduction of
postoperative infections and ileus and facilitate the patient’s safe and timely hospital stay. By
following ERPs, nurses are empowered to discontinue use of Foley catheters, reduce IV fluids,
change pain medication from IV to PO, discontinue patient-controlled analgesia, and advance
patients’ diets. The physicians have the option to alter orders, but to do this they must manually
uncheck the standardized order and address any option that deviates from the standardized
pathway.

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Components of ERAS Protocols and Current Recommendations

Components of ERAS protocols can be broadly categorized into pre-operative, peri-operative and
post-operative interventions. These shall be considered in turn, together with a brief review of
the evidence and current recommendations.

Pre-operative components

1) Pre-operative counselling and training

Recommendation: All patients undergoing elective surgery should be counselled. Patients should
be provided with both verbal as well as written information.

All patients undergoing elective surgery should be counselled adequately. This process involves
not only members of the surgical team who will be directly involved with the proposed procedure,
but should also include other health professionals, such as physiotherapists, dieticians, stoma and
nutrition nurses, who will also be involved in the peri-operative care of the patient. Some units
have a dedicated ERAS nurse. Counselling necessitates close collaboration between all members
of the surgical team and the provision of both written and verbal information. Provision of this
information to patients may occur in the out-patient clinic, the pre-assessment clinic or the
patient’s home. Patient information leaflets on ERAS should be produced to facilitate patient
education. Information discussed should include:

i.) What enhanced recovery involves, its core components and envisaged benefits
ii.) What the patient should expect during the course of the hospital stay. This should include
specifics of how ERAS is implemented locally and which modalities are employed.
iii.) Specific issues which may delay discharge (such as lack of social support).
iv.) Clear and specific instructions should be given about mobilization, early introduction of
diet and breathing exercises. Active participation of the patients themselves in their recovery
should be sought, and daily targets for the patient to achieve should be set up.
v.) Patients who may require a stoma should be identified and appropriately trained such
that they are proficient at stoma care, ideally prior to surgery.

Pre-operative information and education has been shown to improve patient satisfaction, allay
anxiety and improve pain and other outcomes.

2) Curtailed fasting and preoperative carbohydrate loading

Recommendation: Patients should be fasted for 6 hours to solids but they should be allowed small
amounts of clear free fluids for up to 2 hours before induction of general anaesthesia. In addition,
a clear carbohydrate rich drink (e.g. Polycal Liquid® (Nutricia Clinical Ltd, Trowbridge, Wiltshire,
UK), Preload® (Vitaflo International Ltd. Liverpool, UK), Maxijul® (SHS- Nutrition, Liverpool, UK))
should be administered orally the night before surgery and 3 hours prior to induction of
anaesthesia.

Fasting for a minimum of 8 hours before a general anesthetic has been normal surgical practice
for many years. It aims to reduce the volume and acidity of stomach contents, thereby reducing
the risk of regurgitation or aspiration. Recent studies, however, have demonstrated that a short

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(3 hour) period of fasting after ingestion of clear fluids is safe and more acceptable to patients.
This minimizes patient thirst and improves post-operative wellbeing. A short fast in combination
with pre-operative carbohydrate loading has been shown to maintain nitrogen balance and reduce
post-operative insulin resistance. Carbohydrate loading involves the administration of apposite
carbohydrate drinks, such as Polycal Liquid® (200 ml), the night before surgery and 3 hours prior
to surgery. Each carton of Polycal Liquid® provides 494 Kcal, equivalent to approximately 120
grams of carbohydrates. Any commercially available preparation may be used. However, care
should be taken that the formulation used is clear and residue free.

Special circumstances:
Non-insulin dependent diabetics: Pre-operative carbohydrate loading has been shown to be safe
in non-insulin dependent diabetic patients, and their use is also recommended in this subgroup
of patients. In diabetic patients, a pre-operative carbohydrate load has not been shown to result
in adverse effects such as hyper-glycaemia or delayed gastric emptying. However, monitoring of
blood glucose levels should be carried out at regular intervals.

3) Avoidance of mechanical bowel preparation

Recommendation: Oral mechanical bowel preparation should not be used routinely in patients
undergoing colonic resection. If clearance of the rectum is required for a left sided anastomosis,
a single phosphate enema on the morning of the surgery may be used to evacuate the rectum.
Oral mechanical bowel clearing has traditionally been thought to reduce the severity of sepsis in
the event of an anastomotic leak. However, a number of meta-analyses have suggested that, in
patients undergoing colorectal procedures, the avoidance of mechanical bowel preparation is safe
and does not result in increased sepsis in the event of an anastomotic leak.

Additionally, the use of mechanical bowel preparation can result in serious adverse events, such
as fluid imbalance, in certain patient subgroups, including the elderly. We recognize that the
evidence for omitting bowel preparation in patients undergoing rectal surgery alone is equivocal.

4) Deep vein thrombosis prophylaxis

Recommendation: All patients undergoing surgery should be started on a once daily low molecular
weight heparin (Enoxaparin 20 mg) the night before surgery and continued for the entire length
of the patient’s hospital stay. In addition, graduated compression thromboembolic deterrent
stockings (TEDs) should be used. During the procedure, pneumatic mechanical compression
stockings should be used. Prophylaxis should be considered for up to one month after discharge,
especially in those at a higher risk of thromboembolic complications, such as those with residual
malignancy or previous episodes of thrombosis.

A single daily dose of low molecular weight heparin is recommended for deep vein thrombosis
prophylaxis because of its ease of administration and lower risk of bleeding complications. The
use of low molecular weight heparin in conjunction with graduated compression stockings was
found to be the most effective anti-thromboprohylactic prophylaxis in a recent Cochrane review .
There is an increased risk of thrombotic complications up to one month after surgery, due to a
hypercoaguble state, and prolonged (up to 1 month after discharge) antithrombotic prophylaxis
with low molecular weight heparin confers significant benefit in terms of reduction of thrombotic
complications.

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5) Antibiotic prophylaxis

Recommendation: A single dose of antibiotics, covering both aerobic and anaerobic organisms,
should be administered just prior to incising the skin. In prolonged procedures (more than 4
hours) or if there is major blood loss (greater than 1500 mls.) a second dose may be administered.

Antibiotic prophylaxis is used to reduce the rates of wound infection after surgery. Multiple doses
have not been found to confer any additional advantages and result in increased costs and risk
of infections such as Clostridium difficile. For this reason, a single dose of antibiotics covering
both aerobic and anaerobic organisms should be administered just prior to incising the skin in all
clean procedures which do not involve the insertion of prosthetic materials. When deciding the
type of antibiotic used, local resistance patterns should be considered. Increased risk of acquiring
a Clostridium difficile infection after using a third generation cephalosporin should also be
considered. In those who are known to be carriers of MRSA (Methicillin resistant Staphylococcus
aureus), prophylaxis with a glycopeptide antibiotic (Vancomycin, Teicoplanin) should be
considered.

Peri-operative components

1) High inspired oxygen concentrations

Recommendation: Eighty percent (80%) oxygen should be administered during anesthesia and
then continued for at least 6 hours postoperatively. A face mask may be required to deliver this
high concentration of oxygen.

Molecular oxygen is required by polymorph nuclear cells to produce free radicals which form an
important line of defense against pathogens. In addition, it plays an important role in the
synthesis of collagen for wound healing and angiogenesis. Higher tissue oxygenation levels in the
immediate post-operative period as a result of 80% inspired oxygen have been shown to improve
perfusion at the anastomotic site and reduce the risk of surgical site infections. In addition, there
is some evidence that it may also reduce postoperative nausea and vomiting (PONV) although
this is contentious.

2) Prevention of hypothermia

Recommendation: Hypothermia (core temperature less than 36°C) should be actively prevented
using warm-air blankets. Warming should be continued for as long as the patient is in recovery.
If the procedure is expected to last for more than an hour, then warmed intravenous fluids should
be used. An esophageal probe should be used during the procedure for measurement of core
body temperature.

General anesthesia can disrupt the normal thermoregulatory processes and result in hypothermia.
In addition, exposure of the patient to the cold theatre environment also contributes. Hypothermia
(core temperature less than 36°C) can, in turn, lead to an increase in the incidence of surgical
site infections, thought to be due to peripheral vasoconstriction induced hypoxia and an altered
immune response. Other undesirable effects of hypothermia include coagulopathy, increased
cardiac morbidity and increased levels of circulating catecholamine with a resultant exaggerated

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catabolic response. Active prevention of hypothermia during the peri-operative period has been
shown to reduce blood loss and prevent infective and cardiac complications.

For these reasons, hypothermia should be actively prevented using warm-air blankets. Warming
should be continued for as long as the patient is in recovery. If the procedure is expected to last
for more than an hour, then warmed intravenous fluids should be used. An esophageal probe
should be used during the procedure for measurement of core body temperature.

3) Goal directed intra-operative fluid therapy

Recommendation: An esophageal Doppler probe (or other minimally invasive methods of stroke
volume measurement such as LiDCO plus™ and LiDCO rapid™) should be used to continuously
measure the cardiac output, and fluid administration should be titrated according to variations in
the cardiac output.

A degree of intra-operative splanchnic hypo perfusion may go undetected with conventional

monitoring, and this plays an important role in post-operative delay of return of gut function. In
addition, occult hypo perfusion can lead to bacterial translocation across the gut wall which can
result in sepsis syndrome. On the other hand, the administration of excessive amounts of fluid
during surgery can also result in delayed return of gut function and cardiac morbidity. An
esophageal Doppler probe is a minimally invasive method of determining the hemodynamic status
in the peri-operative period and allows guided fluid management targeted against indicators of
cardiac output. The intra-operative use of an esophageal Doppler probe has been shown to
accelerate the return of gut function and expedite discharge after surgery. The hemodynamic
status of the patient should first be optimized using an esophageal Doppler probe such that the
cardiac output is maximum. Further boluses of colloids (on a background of maintenance fluids)
should then be administered against variations in stroke volume (SV) and velocity of blood flow
in the descending aorta (FTc). If resources do not permit the universal use of esophageal Doppler,
then its use may be restricted to high risk (ASA 3 and above) and elderly patients.

Other minimally invasive methods of optimizing the fluid balance include LiDCO plus™ and LiDCO
rapid™ and may be used instead of the esophageal Doppler. These systems depend on a Lithium
dilution technique to measure changes in hemodynamic parameters, such as cardiac output and
stroke volume, and provide continuous real-time measurements.

4) Surgical approach and incisions

Recommendation: Both a laparoscopic or an open approach may be used, depending on local

expertise and available resources. For open surgery, a lower transverse incision should be used
whenever possible. If a transverse incision is not possible, then a selectively lower or upper
midline incision is recommended. The length of the incision should be kept as short as possible.

Laparoscopic colorectal techniques have been shown to improve outcomes over similar open
surgery techniques. These improvements include an earlier return of organ function, reduced
post-operative analgesic requirement and an earlier discharge from hospital. However, the major
trials which have compared laparoscopic to open colorectal surgery have not taken ERAS into
account and have, instead, compared laparoscopic surgery to conventional open surgery. Only
three, single-centered and small-sized, randomized trials have compared the outcomes of

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laparoscopic and open colorectal surgery within the setting of ERAS, and these have produced
conflicting results. At least two large multi-center randomized trials, investigating the role of
laparoscopic surgery within ERAS pathways, are currently ongoing and their results should,
hopefully, clarify this issue to some extent. It is currently not possible to recommend whether or
not the use of the laparoscopic approach within an ERAS pathway would result in indisputable
advantages to the patient, over and above to those offered by open surgery in conjunction with
ERAS. However, laparoscopic colorectal resection may be undertaken if local resources and
expertise allow.

When undertaking open procedures, a number of considerations need to be borne in mind. Short
transverse incisions are thought to be less painful, impair lung function to a lesser extent, and
reduce subsequent post-operative analgesic requirement when compared to vertical wounds. In
addition, there is some evidence that the incidence of wound dehiscence may be reduced in
transverse incisions. These were the conclusions of a Cochrane review in 2005. However, the
results of a recent large randomized trial did not find that transverse incisions were less painful
than longitudinal ones.

5) Avoidance of post-operative drains and nasogastric tubes

Recommendation: Routine abdominal drains and nasogastric tubes should be avoided. If gastric
decompression is required during surgery, a nasogastric tube may be inserted temporarily and
removed at the end of the procedure. Nasogastric tubes may be painful and cause considerable
discomfort. This can render post-operative mobilization difficult. There is good evidence that
routine use of nasogastric decompression delays the return of gut function, leads to an increase
in pulmonary complication and fever and prolongs hospital stay. These findings are supported by
at least two meta-analyses. Abdominal drains have been traditionally placed to evacuate post-
operative collections at the site of surgery and drain any possible anastomotic leak. However,
similar to nasogastric tubes, they cause considerable discomfort and can hinder mobilization.
Moreover, at least three meta-analyses have revealed that routine prophylactic drainage of the
abdominal cavity does not confer any advantages.

6) Short duration of epidural analgesia and local blocks

Recommendation: All patients undergoing open colorectal surgery should receive epidural
analgesia. It should be initiated at the beginning of the procedure and continued for a maximum
of 48 hours. Weaning from epidural analgesia should start 12 hours post-operatively. Care should
be taken that the equipment does not interfere with mobilization. Patients undergoing
laparoscopic resection may or may not be administered epidural analgesia depending upon the
preference of the operating surgeon and anesthetist.

A fine bore catheter placed into the epidural space at the level of T9 and T10 can be used to
deliver a mixture of a short acting opiate (Fentanyl 2mcg/ml) and a local anesthetic solution
(Bupivacaine 0.15%). This results in a blockade of the spinal nerves. Epidurals analgesia directly
attenuates the post-operative stress response and promotes the return of gut function by blocking
the sympathetic activity. However, this sympathetic blockade can result in hypotension due to
vasodilatation which can prove difficult to manage as it may not respond to intravenous fluids. In
these situations, an early decision to transfer the patient to a high dependency unit must be taken
and inotropic or vasopressor support initiated. Another disadvantage is that the equipment can

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interfere with postoperative mobilization. Whenever epidurals are utilized, these should be
initiated at the beginning of the procedure and continued for a maximum of 48 hours. Weaning
from epidural analgesia should start 12 hours post-operatively. Alternatives to epidural analgesia
include transversus abdominis plane (TAP) blocks and other infiltrations with local anesthetic
aimed at reducing post-operative opiate usage. The role of epidural analgesia in relation to
laparoscopic colorectal surgery is not clear. A small number of studies have questioned the use
of epidural analgesia in the setting of laparoscopic surgery.

They argue that analgesic requirements after laparoscopic surgery are lower and, as such,
epidurals may not have an added advantage and, on the other hand, only increase the risk of
epidural related complications. However, a small number of trials have produced contradictory
results and have shown that additional advantages may be obtained when epidurals and
laparoscopic surgery are used together. The current evidence level is weak and insufficient to
advocate the universal use of epidural analgesia in laparoscopic colorectal resection. However,
this should not preclude the surgeon or the anesthetist to use epidural analgesia for laparoscopic
surgery if they deem it to be safe and useful in their local setting.

Post-operative Components

1) Avoidance of opiates and the use of Paracetamol and non-steroidal anti-inflammatory drugs
(NSAIDS)

Recommendation: Post-operatively, patients should be prescribed regular Paracetamol and

NSAIDS such as Ibuprofen or Diclofenac if there are no contraindications to their use. Opiates,
including Codeine preparations and Tramadol, should only be reserved for breakthrough pain.
Whenever opiates are used, attention should be paid to prevent nausea and vomiting and regular
antiemetic prescribed.

Early return of gut function and prevention of its various adverse sequels is thought to be one of
the underlying mechanisms by which ERAS protocols work. Opiates are known to delay the return
of gut function and should be avoided whenever possible. In addition, they can cause considerable
post-operative nausea and vomiting (PONV). Opiate minimization should include the avoidance
of Codeine and Tramadol preparations as well as opiate containing patient controlled analgesia
(PCA) infusions. In their stead, patients should be prescribed paracetamol and NSAIDS, if there
are no contraindications to their use. Opiates should be used only for purposes of rescue
analgesia. Liberal use of antiemetic should be employed, but the limitation of these medications
in expediting the recovery of post-operative gut function should be recognized.

2) Early postoperative diet

Recommendation: Patients should be allowed oral fluids as tolerated on the day of the surgery
and built up to an oral diet over the next 24 hours. Patients who are not meeting their nutritional
requirements by 72 hours after surgery should be assessed by a dietician.

Traditionally, oral diet and fluid has been reintroduced cautiously and gradually after bowel
surgery, often rendering the patients nil by mouth or on oral sips only for many days in the post-
operative period. This, it was thought, was necessary for adequate healing of bowel anastomoses.
However, recently, early introduction of diet and fluids (within 24 hours post-operatively) has

12
been shown to be safe. In addition, there is some evidence that early feeding may be beneficial
in reducing the risks of anastomotic dehiscence, infections and reducing the length of stay. In
our view, tolerance to early feeding provides a more objective evaluation of gut function than
assessment on the basis of bowel sounds of passage of flatus.

3) Early postoperative mobilization

Recommendation: A structured mobilization plan should be in place. Patients should be helped to

sit out in a chair on the evening of surgery and definitely by the first post-operative day. This
should be followed by gentle assisted mobilization either the same day or the next day. Patients
should be seen by a named physiotherapist pre-operatively with the aim of explaining the
mobilization plan. This physiotherapist should then help enforce this plan throughout the post-
operative period. Even short periods of immobilization can lead to deleterious consequences such
as thromboembolism, loss of muscle strength, pulmonary atelectasis and worsening of pulmonary
function. Continuous patient education regarding the benefits of mobilization is recommended. It
was shown in a randomized trial that avoidance of bed-side entertainment systems is one
pragmatic approach to encourage mobilization.

4) Restricted amounts of intravenous fluid

Recommendation: It is not possible to recommend a single point in time by which all intravenous
fluid administration should be stopped. However, in the majority of patients, this should be
possible by the second post-operative day, by which time adequate oral fluids should be tolerated
and indwelling epidural catheters removed.

During the post-operative phase, intravenous fluids may be required as long as adequate oral
fluid intake has not been achieved and/or epidural catheters are still in situ. However, excessive
amounts of intravenous fluid should be avoided. A daily regime of 1.5 to 2.5 L should suffice for
most patents. The ability of individuals to get rid of accumulated sodium is greatly curtailed in
the post-operative period. For this and other reasons, balanced intravenous solutions such as
Hartmann’s™ should be prescribed in preference to Normal Saline (0.9% NaCl) in an attempt to
avoid sodium overload, hyperchloremic acidosis and a delayed return of gut function.

5) Audit

Recommendation: Clinical outcomes, including readmission rates and compliance to the various
ERAS strategies, should be regularly audited. Readmission rates after ERAS implementation
should not exceed 10%. Audit findings should be discussed in regular audit meetings attended
by medical, nursing and other ancillary staff. Results should also be disseminated using the local
IT systems such as the intranet and e-mail.

A perceived disadvantage of many ERAS protocols is that, by discharging patients home sooner,
one is simply transferring their responsibility on to primary care providers whilst also predisposing
patients to higher readmission rates, despite the risks associated with such practices. This has
not been borne out in trials, where the emphasis was to enhance patients’ recovery in preference
to “fast tracking” patients through their hospital stay.

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 Merits

The application of the ERAS pathway has been showing great promise of improving the kind of
perioperative work being exercised in the operating room, as evidenced by recent studies and
works in the field of surgical specialties including orthopedics, urology, vascular surgery and
mainly colorectal surgery. The following are the cited merits of utilizing ERAS strategies in the
perioperative managements of patients. Improved pre-operative care and maximizes chances of
patient’s understanding and compliance with prescribed therapeutic treatments. Reduce patients’
physical stress with regards to the surgical operation, improved pain relief, and management of
fluids and diet leading to a speedy recovery. Patients can ambulate and resume a normal diet as
early as possible after operation. ERAS will shorten length of hospital stay and may lessen
readmission rates. Can produce major improvements to patient care and outcomes leading to
financial savings and increased availability of services for other users. This could bring about
improved patient’s condition and increased potential for new challenges in the perioperative realm
of nursing and medicine.

Feeding patients prior to surgery is one of the components of enhanced recovery after surgery,
by implementing such management patient will be able to decrease the possible experience of
thirst, anxiety, PONV, postoperative insulin resistance, postoperative nitrogen and protein losses,
maintain lean body, promotes and increases patients’ muscle strength, better metabolic state to
benefit from early postoperative nutrition, decrease postoperative hyperglycemia, can give oral
CHO. This is only an example of what advanced management the ERAS pathway can provide to
patient for surgery. To summarize the advantages of ERAS, it involves patient’s education, patient
can have water at least 2 hours prior to surgery, can have carbohydrate taken 4-6 hours prior to
surgery, follows a goal directed fluid management, the urinary catheter is removed within 1-2
days, early mobilization, post op food consumptions, patient can resume to personal errands soon
after the surgical pain is well managed.

Demerits

Firstly, some guidelines are not applicable to such developing countries. In addition to that,
hospital facilities are not fully equipped to fit with the needs of the program. Moreover, members
of the health team has limited trainings and knowledge regarding enhanced recovery after
surgery. Patients and significant caregivers were not yet entirely involved with the planning and
management from pre-operative to recovery after surgery. Pathways should be reviewed, as well
as modifications regarding the nutritional requirements. They have to tune in their pathways on
specific cases, according to patients’ need and hospital set up.

Specialists, resident surgeons, anesthesiologists, nurses and other health care team members
should undergone training and year to year update of the guidelines. Also, the chiefs and the
head of different surgical specialties should form a group and study the international guidelines
of ERAS, how it could be implemented in Philippine setting, what changes in the guidelines must
be done, and what certain limitations and scenarios it can be implemented. On the other hand,
the hospital personnel’s and patients should be open-minded and willing to be involved in this
patient centered program. A good collaboration and teamwork is needed to achieve the outcome
that ERAS is made for.

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 Application

Enhanced recovery aims to provide better care with more patient involvement, improved patient
satisfaction and a faster return to levels of pre-operative activity by reducing the stress of surgery
physiologically and physically. This may in turn reduce the drain on resources in terms of bed
days, length of stay and resultant hospital acquired complications.

Nursing Research

The implementation of enhanced recovery after surgery will aid the healthcare professionals to
continue in finding means how to promote wellness. Strong initiative for further studies focusing
on other surgical specialties and its applicability to suit the needs and current set-up of institutions
in third world countries.

Nursing Practice

Institutions ought to provide trainings and updates to members of health care team so that proper
care will be applied. Activities that were previously regarded as ‘academic’ may come to have a
wider application in the implementation of Enhanced Recovery after Surgery, but perhaps we
need to explore improved ways of teaching and testing these skills in practice.

Nurses should be equipped with knowledge regarding Enhanced Recovery after Surgery. Nurses
must further be involved with the opportunities that this program offers.

Nursing Education

Nurse education needs to take account of these changes, but as the findings of research are often
only slowly implemented in practice, nurse education should focus on evidence-based practice
and the skills needed to implement change. This may be made possible by the move to an all
graduate pre-registration education.

15
References

Brady, K., Keller, D., & Delaney, C. (2015). Successful Implementation of an Enhanced
Recovery Pathway: The Nurse’s Role. AORN Journal Volume 102, Issue 5, 469 - 481.

Foss, M. (2016, July 13). Nursing Standard: Enhanced Recovery after Surgery and Implications
for Nurse Education. Retrieved from RCNi:
http://journals.rcni.com/doi/pdfplus/10.7748/ns2011.07.25.45.35.c8625

Joliat, G., Labgaa, I., Hubner, M., Blanc, C., Grisser, A., Schafer, M., & Demartines, N. (2016,
July 30). Cost–Benefit Analysis of the Implementation of an Enhanced Recovery Program
in Liver Surgery. Retrieved from World Journal of Surgery:
https://www.researchgate.net/publication/303889848_Cost-
Benefit_Analysis_of_the_Implementation_of_an_Enhanced_Recovery_Program_in_Liver
_Surgery?enrichId=rgreq-50e131ee958fd1c0243738ecd90d6c61-
XXX&enrichSource=Y292ZXJQYWdlOzMwMzg4OTg0ODtBUzozNzE3NjUyNjA4OT

Kahokehr, A., Sammour, T., Zargar-Shoshtari, K., Thompson, L., & Hill, A. (2016, July 30).
www.theijs.com. Retrieved from International Journal of Surgery:
https://www.researchgate.net/publication/23707153_Implementation_of_ERAS_and_ho
w_to_overcome_the_barriers?enrichId=rgreq-8bbdd378debdd97ac8f6681e7ba72b15-
XXX&enrichSource=Y292ZXJQYWdlOzIzNzA3MTUzO0FTOjEyMDc2ODc1MDk1MjQ0OEAx
NDA1ODA0OTIyMzYx&el=1_x_2

Khan, S., Gatt, M., & Horgan, A. (2009). Issues in Professional Practice: Guidelines for
Implementation of Enhanced Recovery Protocols. 35-43 Lincoln's Inn Fields, London:
Association of Surgeons of Great Britain and Ireland .

Mitchell, M. (2011). The Future of Surgical Nursing and Enhanced Recovery Programmes. British
Journal of Nursing, Vol 20, No 16, 978-984.
Niranjan, N., Bolton, T., & Berry, C. (2016, July 30). Update in Anesthesia: Enhanced recovery
after surgery - current trends in perioperative care. Retrieved from
http://www.anaesthesiologists.org: http://e-safe-
anaesthesia.org/e_library/05/Enhanced_recovery-after-surgery_Update_2010.pdf

Stowers, M., Lemanu, D., Coleman, B., Hill, A., & Munro, J. (2014). Review Article:
Perioperative care in enhanced recovery for total hip and knee arthroplasty. Journal of
Orthopaedic Surgery, 22(3):383-92.

16
 Appendices

APPENDIX A. Successful Implementation of an Enhanced Recovery Pathway: The

Nurse’s Role
APPENDIX B. Enhanced Recovery after Surgery and Implications for Nurse Education
APPENDIX C. The Future of Surgical Nursing and Enhanced Recovery Programmes
APPENDIX D. Letter of Invitation for Interview
APPENDIX E. Interview Response from Dr. Rolando Padilla, Jr.

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APPENDIX A

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APPENDIX B

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APPENDIX C

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 APPENDIX D

Letter of Invitation for Interview

West Visayas State University

GRADUATE SCHOOL
College Of Nursing
La Paz, Iloilo City

August 3, 2016

__________________________________
__________________________________
__________________________________

Dear Sir/Madam:

Greetings!

We, students from West Visayas State University College of Nursing Graduate School will be
having a report on ERAS: Enhanced Recovery After Surgery as part of our requirements in
NEd 501- Current Trends in Nursing.

In line with this, we would like to ask some of your time for an interview regarding the topic
ERAS. The interview would take about 30 minutes – 1 hour on the day which is most convenient
and available for you. We can be reached through mobile number 09463866208.

We hope for your positive response on this request. Thank you so much and may the good Lord
bless you a hundred folds.

Truly yours,

FRANKY F. MUZONES, RN
Team Leader

Noted:

PROF. SHEILA P. BELIRAN

Professor, Current Trends in Nursing

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 APPENDIX E

Interview Response from Dr. Rolando Padilla, Jr.

Barely new, ERAS makes client stay after surgery less versus the traditional. In Iloilo, it is not yet
implemented practice. In neurosurgery, it is not applicable but it is implemented in areas such as
colorectal, gallbladder and urologic surgery.

It was applied by general surgeries. In my experience in general surgery during my residency,

when we prepare patient for colorectal procedure, it takes us 2-3 days to do bowel prep. It is a
question on how a patient can stay for only about 4-5 days in the hospital if ERAS will be applied.
It is difficult for the team to adopt this because they are already comfortable with the set up they
are used to. They have their own pathways / preference they use to follow and it is effective as
far as recovery of their patient is concerned. So why fix things that are not broken? In ERAS, you
should have a separate pathway per procedure. One pathway may not be applicable to the other
or a certain pathway may not be applicable to a certain patient because our treatment to our
patient varies from one patient to the other. Clinical eye is very important and still the best way.
I believe Iloilo is still not ready for this. The hospital set up in the city and province will have the
difficulty to adopt. Some of our set ups here are not ideal. Private hospitals may succeed in the
implementation but it will take time to government hospitals. If this will be introduced, it should
be well disseminated to the different disciplines- to Surgeons, Anesthesiologist, Internist and
Nurses. They have to be open minded in accepting this new trend and proper training has to be
applied for them to be equipped with the knowledge and skills.

In ERAS for example, (abdominal surgery) they encourage early ambulation, no NGT and the use
of epidural analgesia that will lessen the pain of patient during ambulation. They also do proper
pre- operative nutrition like protein and carbohydrates loading due to metabolic reason that will
aid patient’s early recovery. It might be applicable to the first world countries but it is difficult for
the developing ones. It is difficult to monitor the nutrition intake or compliance of the patient. It
will take at least 2 weeks for your patient to be nutritionally ready prior to surgery. However if
you will admit your patient prior to surgery for their nutrition purposes you will also defeat the
purpose of ERAS.

Recommendations:
Pathways should be reviewed. Modifications regarding the nutritional requirement. They have to
tune in their pathways on specific cases, according to patient need and hospital set up.

38