What is the ERAS (Enhanced Recovery After Surgery) protocol?

by admin-blog-kh | May 15, 2025 12:04 pm

Introduction

The ERAS protocol by The Enhanced Recovery After Surgery Society, which is a not-for-profit and international organisation, comprises a multi-disciplinary team of surgeons, nurses, anaesthesiologists, and allied health professionals who have developed evidence-based guidelines for optimising pre-operative patient functional status, enhancing post-operative recovery and reducing post-operative morbidity (development of a temporary or permanent illness or disability after surgery).

This protocol was first developed for colorectal surgery and has been successfully implemented across most major surgeries (cardiac, thoracic, pancreatic[7], breast and many more). The protocol comprises specific guidelines to be followed during the pre-, intra- and post-operative phases, and thus, includes a multi-disciplinary team of healthcare professionals who must cooperate and coordinate with each other and the patients for its successful execution.

Objectives of the ERAS Protocol

• Minimizing surgical stress
• Lowering post-operative pain
• Reducing prolonged hospitalisation
• Reducing post-operative complications
• Enhancing cardiopulmonary function
• Reducing healthcare costs
• Promoting early return of bowel function and normal activity

Key Components of the ERAS Protocol

The ERAS approach has been divided into three phases: pre-operative, intra-operative and post-operative, which are discussed below.

Pre-operative Phase

• Primary care physicians initiate the enhanced recovery process via pre-operative education and counselling to the patients and their families regarding the nature of the surgical procedure, possible complications and length of hospitalisation. They optimise the physical status of the patient by managing their co-morbidities, such as hypertension[8] or diabetes.
• Glycaemic control (maintenance of blood glucose levels within a desirable range) is an important component of the ERAS pathway as peri-operative hyperglycaemia (high blood glucose levels) increases the post-operative risk of infection (glucose is the preferred carbon source of most bacteria, and thus, increases bacterial growth) and cardiovascular morbidity (damages the blood vessels in the heart) in patients with or without diabetes due to the hypermetabolic (increased metabolic rate) stress response (various inflammatory mediators are released) that increases glucose levels and insulin resistance. Glucose levels are maintained between 80 and 180 mg/dL throughout the ERAS protocol, and diabetics are counselled on taking anti-diabetic medicines or insulin the night before or on the day of the surgery.
• Patients are counselled on sleep hygiene and relaxation techniques to reduce anxiety.
• Smoking and alcohol intake must cease 4 weeks before surgery. The patient’s physician can counsel the patient on cessation of smoking[9] and alcohol by recommending cessation aids for smokers and monitoring alcohol withdrawal symptoms and prescribing vitamin B1 supplements (excessive alcohol drinking causes vitamin B1 deficiency).
• Hormone replacement therapy and consumption of oral contraceptive pills must be stopped as the risk of peri-operative venous thromboembolism (blood clot in the veins) increases. Patients must be counselled on alternative birth control methods.
• Most ERAS protocols eliminate the need for bowel preparation as it causes dehydration and fluid imbalance.
• An anti-emetic is prescribed to improve post-operative nausea and reduce vomiting.
• Studies have shown that carbohydrate loading (taking a clear carbohydrate drink) 2 hours before surgery maintains the normal physiological state, enhances insulin sensitivity, reduces thirst, anxiety, hunger and protein loss post-operatively, reduces the length of hospitalisation and lowers post-operative inflammation. Carbohydrate loading is recommended to prevent the body from entering a catabolic state (the body draws the energy from muscles causing muscle pain and fatigue). The ERAS protocol recommends stopping solid food intake 6 hours and clear fluids 2 hours before surgery.
• Administration of an antibiotic 1 hour before skin incision reduces the chance of infection from skin bacteria. Another dose of antibiotic should be given during surgery if the surgery extends beyond 3 hours or blood loss of more than 1 litre.

Intra-operative Phase

• Usage of drains should be eliminated or limited as they can hamper mobilisation and delay recovery.
• During surgery, the patient’s normal body temperature (normothermia) is suppressed and the skin is exposed to cold intravenous fluids and a cold environment, leading to hypothermia (drop in body temperature). Normothermia can be achieved by using warming devices, warm intravenous fluids, warm blankets and increasing the room temperature. This can reduce infection at the surgical site and lower the rate of intra-operative blood loss.
• Maintaining euvolemia (optimal fluid balance) is crucial as excess fluid administration can cause pulmonary or anastomotic (surgery performed to connect blood vessels or portion of the intestines that are originally distant from each other) oedema, whereas less fluid intake can lower cardiac output. Fluid management during surgery is achieved by measuring the urine output. Fluid management enhances an earlier return of bowel function, lowers the risk of urinary tract and surgical site infections and reduces the length of hospital stay.
• A minimally invasive surgical procedure, such as laparoscopic surgery, is preferred in an ERAS protocol as it involves small incisions and lowers tissue damage.

Post-operative Phase

• Early oral feeding increases the return of bowel function and reduces the length of hospitalisation without any complications. Incorporation of clear fluids immediately post-surgery and slowly introducing a standard diet within 24 hours has been recommended in many studies. Chewing gum after surgery has been incorporated into many ERAS protocols as it activates the gastrointestinal system and reduces the time to first bowel movement and the length of hospital stay.
• Early mobilisation reduces the incidence of ileus (delayed bowel movement) and pulmonary and thromboembolic complications, promotes faster organ recovery, and enhances muscle strength. Most ERAS protocols encourage patient mobility within the first 24 hours of surgery. Patient mobility must be encouraged 2 hours before surgery and 6 hours each day afterwards at the hospital. Patient mobilisation is a team effort of the nurses, physiotherapists and the use of healthcare aids (wheelchair, cane or walker).
• Low-molecular-weight heparin, oral anticoagulants or sequential compression devices are recommended intra- and post-operatively for venous thromboembolism prophylaxis. If the patient has a high risk of developing a thromboembolism due to a previous episode or a family history, clinicians can decide to extend the prophylaxis as required.
• The traditional approach for post-operative pain management has been the use of opiate analgesics. However, several adverse effects are observed: nausea, ileus, constipation and drowsiness, which hamper early oral feeding and mobilisation. Most ERAS protocols use nonsteroidal anti-inflammatory drugs and acetaminophen to reduce the administration and side effects of opioids.
• Early urinary catheter removal is recommended to reduce the risk of urinary tract infection[11] and enable early mobilisation.
• Post-operative nausea and vomiting (PONV) should be addressed early and efficiently with anti-emetics as it prevents early mobilisation, the return to normal function and feeding. Narcotics use should be minimised during and after surgery to reduce the risk of PONV.
• The patient is discharged on the following criteria: lack of complications that warrant hospital re-admission, tolerance to solid food, pain management with oral analgesics, and ability to move independently.

Role of anaesthesia management

Anaesthesia management is a crucial part of the ERAS protocol for a smooth transition between pre-, intra- and post-operative phases to improve patient satisfaction.

• Preoperative medication and sedation, including long-acting anxiolytics and opioids, should be avoided as they may delay discharge, while short-acting benzodiazepines should be avoided in the elderly.
• Anaesthetic depth should be monitored by maintaining an end-tidal concentration of 0.7–1.3 MAC or a BIS index between 40 and 60. The goal is to prevent awareness, minimize anaesthetic side effects, and promote rapid awakening and recovery. It is important to avoid overly deep anaesthesia (BIS < 45), particularly in elderly patients.
• The use of deep neuromuscular blockade during laparoscopic surgery remains controversial. Neuromuscular function must be monitored with a peripheral nerve stimulator when using NMBAs to avoid residual paralysis. Long-acting NMBAs should be avoided. A TOF ratio of 0.9 should be achieved to ensure proper muscle recovery and prevent complications.
• The inspired oxygen fraction should be adjusted to maintain normal arterial oxygen levels and saturation. Prolonged exposure to high oxygen concentrations, leading to hyperoxia, should be avoided.
• The role of epidural analgesia in postoperative pain management within the ERAS framework remains a topic of debate. In our practice, we include epidural analgesia in the standard ERAS protocol as part of a multimodal analgesia strategy to reduce opioid use and mitigate the stress response to surgery, both during the intraoperative and postoperative periods.
• PONV is considered a debilitating factor of anaesthesia, leading to prolonged hospitalisation and patient discontent. Prophylactic antibiotics pre- and intra-operatively are effective against PONV. The anaesthesia team should consider certain risk factors, including age, gender and history of PONV and motion sickness to design an approach to reduce PONV. A combination of anti-emetics and a transdermal scopolamine patch have proved effective.

The post-operative recovery of the patient is significantly impacted when the anaesthesia team selects short-acting pre-medications and intravenous anaesthesia or decreased levels of volatile anaesthetics, limiting the use of opioids, maintaining normothermia and euvolemia and administering anti-emetics. The depth of anaesthesia should be monitored to prevent delirium and cognitive dysfunction post-surgery.

How does patient-doctor collaboration contribute to the success of the ERAS protocol?

Patients may not have sufficient medical knowledge, and thus, surgeons play an important role in conveying information in a simple, clear and concise manner to the patient. Patient education is crucial for the success of the ERAS program. Doctors must provide sufficient pre-operative information (face-to-face meetings, videos or books), counselling and support to the patients and their families so that they understand the importance of following the ERAS guidelines in their surgical journey. This will improve the patient’s trust in the ERAS protocol.

Some challenges the surgeons experienced while implementing the ERAS protocol are as follows:

• Traditional surgical practice recommends stopping oral intake from midnight till the morning of surgery. Patients who have undergone traditional surgery previously did not eat anything due to aspiration risk. Some patients could not recollect the pre-operative fasting time, which delayed the surgery.
• Patients need supervision and reminders to eat early after surgery as they would not voluntarily do it.
• Patients believe that it is important to lie in bed for a long time after surgery to avoid pain and improve wound healing. The ERAS team needs to educate patients on the benefits of early mobilisation and its role in recovery.

When patients receive the necessary knowledge and information, they will cooperate and adhere to the ERAS protocol and experience satisfaction, leading to its successful implementation.

Conclusion

The ERAS protocol is an evidence-based approach for peri-operative surgical care to reduce the stress of surgery, length of hospitalisation, and support patients for quick recovery while maintaining normal physiology. As the ERAS protocol begins pre-operatively and continues post-operatively, coordination and cooperation between a multi-disciplinary team of health professionals is crucial for the successful implementation of the protocol.

ERAS protocols are being implemented across many surgical specialities. Strict adherence to all the components of the ERAS protocol reduces complications, improves clinical outcomes and reduces healthcare costs. Compliance with the ERAS protocol is dependent on adequate patient education and effective communication, coordination and cooperation among the staff involved in the different surgical phases and the patients.

When it comes to your health, trust the experts at Kauvery Hospital[12]. With state-of-the-art facilities in Chennai, Hosur, Salem, Tirunelveli, and Trichy, we help you sail through surgery and onto recovery with the help of strategies like the ERAS protocol. Always striving to provide top-notch, personalized healthcare, Kauvery Hospital is dedicated to your recovery and well-being. Come, take the first step towards better health with us today.

Frequently Asked Questions (FAQ) – Enhanced Recovery After Surgery (ERAS) Protocol

What is the ERAS protocol?

The Enhanced Recovery After Surgery (ERAS) protocol is a set of evidence-based guidelines developed by a multidisciplinary team to improve surgical outcomes. It focuses on reducing surgical stress, enhancing post-operative recovery, and minimizing complications through coordinated care before, during, and after surgery.

What are the main goals of the ERAS protocol?

The primary objectives of ERAS are to minimize surgical stress, reduce post-operative pain and complications, shorten hospital stays, improve cardiopulmonary function, lower healthcare costs, and promote a quicker return to normal activity.

Which surgeries use the ERAS protocol?

Although initially developed for colorectal surgery, the ERAS protocol is now widely used across many surgical disciplines, including cardiac, thoracic, pancreatic, breast, and gynaecological surgeries.

Can I eat or drink before surgery under ERAS? 

Yes, unlike traditional fasting, ERAS allows clear fluids up to 2 hours and solid food up to 6 hours before surgery. This approach helps maintain hydration and reduces discomfort pre-surgery.

Where can I receive ERAS-guided care? 

Kauvery Hospital offers ERAS-based surgical care in Chennai, Hosur, Salem, Tirunelveli, and Trichy. With expert teams and advanced facilities, your recovery is guided by internationally accepted protocols and compassionate care.

 

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

Chennai Alwarpet – 044 4000 6000 •  Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4077777 • Trichy – Tennur – 0431 4022555 • Maa Kauvery Trichy – 0431 4077777 • Kauvery Cancer Institute, Trichy – 0431 4077777 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801

Source URL: https://www.kauveryhospital.com/blog/general-surgery/what-is-the-eras-enhanced-recovery-after-surgery-protocol/

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