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ERAS - Clinical Practice Updates
With Dr. Mary Brindell & Dr. Kurt Heist · hosted by Dr. Todd Ponsky
Part of
Crohn's Disease 11 items
Chapter 1 of 6 · Fundamentals
Introduction
Introduction to ERAS and Speaker Introductions
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Mary Brindell and Kurt Heist have been pediatric ERAS ambassadors, though this is changing as ERAS expands in pediatric surgery
ERAS is relatively familiar in adult general surgical care
The 16-year-old Crohn's patient was given protein shakes preoperatively for nutritional optimization
The patient came to the operating room drinking high carbohydrate clear liquids on the day of operation
Day surgery nurses gave the patient clear liquids during the afternoon and stopped one hour before the operation
Total IV fluids for the ileocecal resection case were less than 4cc per kilogram per hour
Postoperative multimodal analgesia included Tylenol, Toradol, and Neurontin
The patient was allowed to drink immediately postoperatively and started to snack that night
The patient was hep-locked the following morning and put on a regular diet
Physical therapy walked the patient every two hours starting the morning after surgery
The patient went home the evening after partial colectomy after meeting all preoperative goals
Not all patients go home in one day at Kurt's institution; he had a 10-day colectomy with complications a couple weeks prior
Kurt gave grand rounds to the anesthesia department twice at the beginning of ERAS implementation, with the chair present and supportive
Enhanced recovery after surgery is a multidisciplinary, multimodal, evidence-based way of delivering care to patients
The goals of ERAS are to optimize patient physiology throughout the entire perioperative pathway
ERAS strategies are to decrease operative trauma, inflammatory response, and stress
Typical ERAS tactics include optimizing fluid and analgesia, mobilizing early, and feeding early, which act synergistically when bundled
The whole of ERAS is greater than the sum of its parts
ERAS outcomes include faster healing, earlier discharge, and fewer complications
The adult world has a huge amount published on the benefits of ERAS, including decreased surgical and non-surgical complications
Fast track surgery programs have shown reduced length of stay after surgery
A concern with fast track programs has been increased readmission rates, but ERAS's holistic approach should decrease readmission rates when done well
ERAS is such a massive team approach that it is the ultimate in multidisciplinary change
ERAS implementation has to come from leadership above, where heads of surgery, anesthesia, nursing, and patient relations all meet together
There is no way a surgeon can use ERAS without all the other disciplines being on board and doing ERAS
Kurt's institution collected data for six months on the one-hour NPO time
Data showed that one-hour NPO time did not slow cases down, contrary to institutional anxiety
The neonatal intestinal surgery ERAS protocol was published earlier in 2024
It is exceptionally hard to limit ERAS practice to the subset of patients for which it was initially intended
Once teams get invested in ERAS, they naturally want to start adopting other elements of enhanced recovery after surgery care
Whole recently published a paper about multidisciplinary engagement and its importance in ERAS
Two FAP patients went home in two days after proctocolectomy and colectomy at Kurt's institution a month prior
The adult enhanced recovery group did a study about 10 years ago identifying mobilization and oral intake as the most important parts of the ERAS protocol
About half of ERAS cases were ready to go home physiologically one to two days before they actually agreed to go home because they were afraid
Preoperative optimization period and heavy counseling are important for patient readiness for early discharge
A nurse at Kurt's institution calls patients several times before their operation to go over discharge goals and reassure them
Getting the anesthesiologist to buy into giving the preoperative carbohydrate load is one of the hardest things in obese patients
Over half of bariatric patients are able to go home on the first postoperative day after sleeve gastrectomy with ERAS
After eight years of doing enhanced recovery without aspiration events, Kurt's institution changed NPO times for clear liquids from two hours to one hour for all 43,000 annual procedures as of March 1st
Early in ERAS practice, Kurt's institution did epidurals for a year but it was a disaster because epidurals slowed patients down dramatically
After abandoning epidurals, Kurt's institution switched to QL blocks, rectus sheath blocks, or TAP blocks, which made it easier for patients to ambulate
By giving premeds on the morning of operation or day before and giving a block, then scheduling medications postop, Kurt's institution can do a good job at pain control
Colectomies and craniofacial operations can be done with no narcotics using ERAS protocols
Kurt did ERAS subversively on his own for a few years in Atlanta, collecting his own readmission rates, then presented the data showing it worked
In Atlanta, Epic was involved to put a little ERAS icon on the OR board so everybody knows the patient is on ERAS
A study by Kurt, Mulan, and team at Emory showed that over years with additional ERAS elements adopted, there were decreased intraoperative fluids, decreased intraoperative and postoperative narcotics, and decreased time to getting on a full diet
ERAS in newborns works well for most principles, but feeding immediately is not a great idea for kids with motility problems like imperforate anus
There is a paper in publication in JPS on duodenal atresia repairs and enhanced recovery showing excellent recovery rate without increased return rate