ERAS- what is it?

Enhanced recovery after surgery (ERAS) is a multidisciplinary, multimodal approach to improving surgical outcomes by using subspecialty- and procedure-specific evidence-based protocols in the care of surgical patients.

In recent years, “fast track” surgery or enhanced recovery programmes have been developed in many surgical specialties to decrease hospital length of stay (LOS) and decrease perioperative morbidity. Kehlet first introduced the enhanced recovery model in 1997 as a multimodal, evidence-based plan to improve patient care in the perioperative period .

Since then, many ERAS strategies have shown the effectiveness of enhanced recovery programmes in improving patient outcomes. These ERAS programmes have been used successfully in colorectal surgery, radical cystectomies, major pelvic surgery etc. to name a few .

Given the apparent benefits of ERAS programs in other surgical disciplines, it is not surprising that its implementation in spine surgery is becoming increasingly common.Spinal procedures are associated with high amounts of pain, slow return of function, and prolonged hospital stays, among other complications.

What are the components of ERAS?

An ERAS protocol typically contains preoperative, perioperative, and/or postoperative elements that are standardized across all patients undergoing a certain procedure. The implementation of such a protocol is a multidisciplinary effort involving surgery, anaesthesia, nursing, and other disciplines. 

Pre-operative Phase

Patient education

Patients are educated as to what to expect before , during and after the surgery.It can be done in the form of  patient education tip sheets, handouts or even presentations.A standardized education packet can be  given to patients in the clinic prior to surgery. This includes information about the surgery, expectations, support services, management of diabetes, and smoking cessation among other things. At preoperative services, education can be reinforced and patients can undergo a laboratory workup, history and physical prior to surgery.

Prehabilitation

Prehabilitation can be defined as “the process of enhancing the functional capability of an individual in preparation for the surgical intervention”. This process consists of: functional preoperative prehabilitation, nutritional and psychological intervention. Patient reported outcomes such as readiness for surgery and perceived quality of life, were found to be improved by pre-operative neuroscience education and physiotherapy. Patient can be educated again about the procedure and expectations managed.

Alcohol Use

Postoperative morbidity is increased by two- to threefold in alcohol abusers). Preoperative alcohol consumption is associated with an increased risk of postoperative morbidity, general infections, wound complications, pulmonary complications, prolonged stay at the hospital, and admission to intensive care unit. Significant alcohol consumption has been shown to be associated with increased perioperative morbidity. For alcohol abusers,  month of abstinence before surgery is beneficial.

Tobacco use

Smoking is an independent risk factor for non-union in spinal fusion procedures Post-operative infection and wound complications are significantly increased by tobacco consumption. Decreased risk of infection, perioperative respiratory problems, and wound complications have been demonstrated one month after cessation of smoking. Longer periods of cessation of smoking appear to be more effective in reducing the incidence/risk of postoperative complications. There is translational high quality evidence for cessation of smoking at least 4 weeks pre-operatively.

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Preop Risk Assessment and Mitigation

Patient preoperative assessment allows for an opportunity for examination of comorbidities with subsequent identification of fixed and modifiable comorbidities. Modifiable comorbidities may be amenable to improved perioperative management. Chronic conditions such as asthma, chronic obstructive airways disease, diabetes mellitus, anaemia and malnutrition should be optimized prior to surgery. Obese patients having spinal surgery were found to have increased blood loss, prolonged hospital stay and were more likely to develop infection. One year after undergoing spinal fusion, diabetic patients are more likely to have failed the procedure as compared to patients without diabetes. Frailty is an emerging risk assessment tool, however definitions of this clinical entity are heterogenous. Modifiable co-morbidities should be optimized using the preoperative process.

Nutrition

Preoperative malnutrition as defined by hypoalbuminemia, has been shown to be an independent risk factor for increased postoperative complication rates, including cardiorespiratory problems, increased rate of infection and unplanned readmission within 30 days post discharge after elective spinal

There is moderate quality evidence available for performance of risk assessment and screening of nutritional status in patients undergoing spinal surgery. Hence in patients who are prone to malnutrition, albumin levels can be checked as part of pre op work up and correction initiated.

Perioperative phase

 Preoperative fasting and carbohydrate loading

Drinking carbohydrate-rich fluids before elective surgery improves subjective well-being, reduces thirst and hunger and reduces postoperative insulin resistance but has no significant effect on length of postoperative stay and mortality .However, The clinical relevance of administering preoperative carbohydrate loading in patients with diabetes remains to be established.Permitting patients to drink water or clear fluid preoperatively results in significantly lower gastric volumes. International guidelines allow for unrestricted intake of clear fluids up to two hours before elective surgery in patients not considered to have impaired gastric emptying.

In spinal surgical patients without delayed gastric emptying standard fasting implementations can be made. Patients should be allowed to eat up until 6 h and take clear fluids including carbohydrate drinks, up until 2 h before initiation of anaesthesia.

Pre-emptive analgesia

A number of studies found that pre-emptive administration of gabapentin reduced the opioid consumption and pain scores in the postoperative period in spinal patients. Impact of multimodal anti-inflammatory regimes combined with gabapentinoids, is significant in lowering the postoperative pain scores. Multimodal pre-emptive analgesia utilizing individual gabapentinoids and/or non-steroidal anti-inflammatory agents improves pain scores and functional measures in the immediate post-operative period. There is high quality evidence for pre-emptive administration of gabapentinoids in patients undergoing surgery of the spine.

Intraoperative Phase

This includes  Standard Anaesthetic Protocol along with an additional form of anaesthesia like local infiltration or regional anaesthesia like TLIP (Thoracolumbar interfascial plane  blocks) or Erector Spinae blocks at the start of the procedure for lumbar surgeries. TLIP block is a type of interfascial plane block that targets the dorsal rami of the thoracolumbar nerves, in classic TLIP block, the local anaesthetic was injected between the multifidus and longissimus muscles by advancing the needle from lateral to medial side .

TLIP block also reduced the cumulative opioid consumption compared to wound infiltration. In addition to controlling post-operative nausea and vomiting with long acting antiemetics, fluid and blood management with use of tranexamic acid for reducing blood loss and use of cell savers when indicated are also part of the programme.

There is enough evidence that minimally invasive surgical approaches (MIS) improve pain scores, decrease opioid consumption and decrease length of stay, when used within the appropriate clinical context. Hence MIS techniques are recommended when indicated.

Maintenance of normothermia and Goal-directed fluid management may decrease the rate of complications and duration of stay when implemented in the appropriate clinical context.

Post operative Phase

Analgesia

Multimodal analgesia bundles have been incorporated into most care pathways of enhanced recovery in spinal surgery. Simple analgesics such as acetaminophen and NSAIDs are safe and efficacious, particularly in combination. There is high quality evidence for perioperative administration of NSAID’s. Ketamine in both intraoperative and post-operative infusions, reduces pain scores, opioid requirements in the immediate and late post-operative phases. 

VTE prophylaxis

Patients undergoing spinal surgery should have mechanical thromboprophylaxis by well-fitting compression stockings and/or intermittent pneumatic compression until discharge.

Urinary catheter 

Urinary catheter use beyond 48 hours following surgery has been associated with an increase in hospital-acquired urinary tract infections and 30-day mortality. Hence early removal is advised when feasible.

Early Mobilization

Early mobilization is the key component of ERAS. All the preop work up , intraop management are towards achieving the goal of early mobilisation. This enables early removal of catheter and acts as a confidence booster to the patient and physiotherapists alike. There is no clear definition of mobilizing, which may include simple exercise in bed, walking in the room or walking further distances.

Patients should be encouraged to mobilize actively on the day of surgery as guided by clinical condition and surgical concerns. 

ERAS protocols for different types of spine surgery are an effective means of improving patient outcomes, ranging from improved postoperative pain to reduced length of stay without causing increased postoperative complications.This also indirectly reduces overall costs associated with spine surgery.Understanding that a shorter LOS is indicative of faster patient recovery, it’s important that providers are educated and made aware of the evidence-based effects of implementing a multidisciplinary, multimodal approach to patient care for spine surgery like ERAS.

See you soon with some more spine tips in My Spine World. Remember, we got your back !