Enhanced recovery after surgery: Current research insights and future direction

Table 1 An example of a generic enhanced recovery after surgery protocol

Pre-operative	Intra-operative	Post-operative
Pre-admission counselling	Short acting anaesthetic agents	Mid-thoracic epidural anaesthesia
Fluid and carbohydrate loading	Mid thoracic epidural anaesthesia	No Nasogastric tubes
No prolonged fasting	No drains	Prevention of nausea and vomiting
No/selective bowel preparation	Avoidance of salt and water overload	Avoidance of salt and water overload
Antibiotic prophylaxis	Maintenance of normothermia	Early removal of catheter
Thromboprophylaxis		Early oral nutrition
No Premedication		Early mobilisation
		Non-opioid oral analgesia
		Stimulation of gut motility
		Audit of compliance and outcomes

Table 2 Enhanced recovery after surgery society recommendations for colonic surgery and their evidence level[6]

ERAS element with high/moderate level evidence	ERAS element with low level evidence
Stopping smoking 4 wk prior to surgery	Pre-operative information and counselling
No routine use of bowel preparation	Stopping drinking alcohol 4 wk prior to surgery
Allowing clear fluids up until 2 h before and solids 6 h before anaesthetic induction	Peri-operative oral nutritional supplements and carbohydrate loading
No routine use of sedative premedication	Standard anaesthetic that allows rapid awakening
Routine thromboprophylaxis	Post-operative nausea and vomiting prophylaxis
Antimicrobial prophylaxis and skin preparation	Routine urinary drainage
Balanced intravenous fluids guided by flow measurements	Using stress reducing elements of ERAS to minimise hyperglycaemia
Use of mid thoracic epidural blocks in open surgery	Early mobilisation
Us of spinal analgesia or PCA in laparoscopic surgery
Laparoscopic surgery
No routine use of nasogastric tubes
Maintenance of normothermia
No routine intra-abdominal drains
Early post-operative enteral feeding
Insulin treatment of severe hyperglycaemia in ICU
Use of chewing gum to prevent post-operative ileus

ERAS: Enhanced recovery after surgery; PCA: Patient controlled analgesia; ICU: Intensive care unit.

Table 3 Additional enhanced recovery after surgery elements using sensor technology

Additional ERAS element	What this adds
Pre-operative physical activity monitoring	Measuring patient's baseline function to assess for surgical fitness and to predict support required post operatively
Prehabilitation	Exercise training prescribed to patients to improve their baseline functional capacity, together with nutritional advice and psychological support
Post-operative physical activity monitoring	Providing feedback to clinicians of patient recovery, monitoring compliance with mobilisation recommendations and picking up complications/allowing safer hospital discharge
Activity feedback	Providing motivation to patient to encourage them to mobilise in the initial post-operative phase, thereby reducing complications and enhancing recovery

ERAS: Enhanced recovery after surgery.