Enhanced Recovery After Surgery (ERAS) in Emergency Abdominal Surgery 

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Background

Enhanced recovery after surgery (ERAS) programs are evidence-based protocols designed to standardize and optimize perioperative medical care. The time available for evaluating, diagnosing, and operating on patients in emergency surgical settings is considerably shorter than that in elective settings. Altered physiology gives rise to varied presentations, resulting in high morbidity and mortality. The ERAS protocol has been well established in elective surgery and has been implicated in all possible gastrointestinal (GI) and non-GI surgical procedures. However, it has not been as well established in emergency surgery.

The components of ERAS may be broadly divided into preadmission, preoperative, intraoperative, and postoperative phases, each of which includes various distinct components (see the image below). In emergency settings, the limited preadmission and preoperative periods pose challenges to the management of ERAS pathways; however, a multidisplinary approach enables the maximum possible implementation of care elements in all phases of an ERAS protocol. [1, 2]

Preoperative, intraoperative, and postoperative co Preoperative, intraoperative, and postoperative components of Enhanced Recovery After Surgery (ERAS). GDFT = goal-directed fluid therapy; MAS = minimal-access surgery; SA = short-acting; SBP = selective bowel preparation.

A number of subspecialties have started implementing ERAS in their patients and have shown improved postoperative outcomes. However, there remains some hesitation to implement ERAS in emergency settings, arising from the expected difficulty of properly executing all of the components of an ERAS protocol, especially the preoperative components (see below).

A better understanding of ERAS principles has led to the publication of many studies reporting on the use of ERAS in emergency settings. [3, 4, 5, 1, 2, 6]  The pioneers in this regard were Gonenc et al, who studied the outcomes of ERAS in patients undergoing laparoscopic repair of a perforated duodenal ulcer. [5] They reported a better outcome in the ERAS group with implementation of only the postoperative components of ERAS. This report was followed by a few other studies that evaluated the applicability and feasibility of ERAS in emergency surgical settings ranging from simple closure of a perforated peptic ulcer to major abdominal operations. [1, 2, 6]

A study by Roulin et al comparing patients who underwent elective colectomy and urgent colectomy found that most of the ERAS elements could be applied to emergency colectomy. [7]  In a retrospective cohort of 370 patients undergoing emergency major abdominal procedures, Wisely et al reported shorter hospital stays and better outcomes in the ERAS group. [6]

Studies from our center on emergency ERAS for perforated duodenal ulcer [1] and emergency small-bowel surgery [2] also established its feasibility and safety and documented its successful implementation. In both studies, there was a significant reduction in the length of hospital stay in the ERAS group with no increase in postoperative complications. In contrast to other studies that used limited intra- and postoperative care elements, the authors maximized the use of ERAS care elements in the study population, including the preoperative components whenever feasible and most of the intraoperative and postoperative components.

Greater awareness, additional trials with larger populations, and further work on identifying and eliminating the factors hindering implementation of ERAS will be the keys to integrating emergency ERAS into day-to-day practice. Every effort should be made to implement as many components of ERAS as possible in the context of an emergency setting.

In this article, we will summarize the various pre-, intra-, and postoperative components of emergency ERAS. We will also briefly discuss discharge criteria, further follow-up, and complications, with a final note on barriers to and limitations of implementation of ERAS protocols in emergency settings.

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Preoperative Components of ERAS

The body goes into a catabolic state during surgery, as various stress hormones and inflammatory mediators are released in response to stress, which in turn leads to insulin resistance. [8, 9] The resistance largely depends on the complexity of the surgical procedure: the more complex the procedure, the greater the resistance, with the greater resistance leading to increased morbidity and prolonged recovery. Hyperglycemia correlates directly with reduction in muscle mass, which leads to infections, cardiovascular events, and poor mobilization. [10] Implementing ERAS care elements reduces surgical stress and aims at maintaining normoglycemia, thereby reducing morbidity.

In a conventional ERAS protocol, the preoperative phase includes various components, such as preadmission counseling, fluid and carbohydrate loading, no prolonged fasting, no or selective bowel preparation, antibiotic prophylaxis, thromboprophylaxis, use of nonopioid analgesics, and no premedication. [11]

Preadmission counseling must be emphasized even in an emergency preoperative setting. For effective management of a patient on an ERAS pathway, the patient, the caregivers, and the family members must all be on board. It is important to highlight the nature and extent of the surgical procedure to be performed, along with the possible complications and the expected length of the hospital stay. [12]

Prewarming of fluids should be recommended, in that it has been shown to reduce postoperative complications (eg, infections). [13] This is carried out by using a warmer device and administering prewarmed intravenous (IV) fluids 2 hours before and after surgery.

Carbohydrate loading and selective bowel preparation, which are preoperative components of ERAS in an elective setting, may not always be feasible in an emergency setting. Carbohydrate loading and reducing the fasting time, when feasible, produce an anabolic state and thereby reduce postoperative thirst, hunger, anxiety, insulin resistance, and protein loss. [9, 13]

Standard mechanical bowel preparation is not generally considered in ERAS protocols, because it is known to cause dehydration and fluid and electrolyte imbalances. [14] It also increases the risk of spillage by liquefying the feces contaminating the operative field. Accordingly, selective bowel preparation is considered when bowel preparation is necessary.

Antibiotic prophylaxis is considered crucial in an emergency setting because of the high risk of postoperative infection, especially in cases of perforation and bowel gangrene. [15]

Thromboprophylaxis is not routinely recommended. [12] When thromboprophylaxis is necessary, low-molecular-weight heparin (LMWH) is preferred to unfractionated heparin (UFH) because it has less of a tendency to induce thrombocytopenia and is more conducive to once-daily dosing.

Patients needing emergency abdominal surgery commonly present with acute abdomen and require potent analgesics postoperatively. In many cases, their pain can be managed with epidural and nonopioid analgesia without resorting to opioids, which are known to prolong postoperative paralytic ileus. [11]  Opioid analgesia can, however, be used as a component of multimodal analgesia for breakthrough pain, as was the case in a study of ERAS in perforated duodenal ulcer from the authors' center. [1] The authors also used nasogastric (NG) tube placement at the time of admission, along with IV fluids, antibiotics, and antacids, as part of preoperative care.

Another study on emergency ERAS from the authors' center focused on emergency small-bowel surgery and used the same components as the previous study, along with ultrasound-guided central venous catheter placement at the time of admission for intraoperative fluid management. [2] The authors have also used IV dexamethasone before induction to reduce surgical stress.

These studies suggest that most of the preoperative components of ERAS—such as preadmission counseling, goal-directed fluid therapy (GDFT), nonopioid analgesics for pain management, antibiotic prophylaxis, and thromboprophylaxis—are indeed feasible in the setting of emergency abdominal surgery.

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Intraoperative Components of ERAS

A surgical stress to the body causes a series of metabolic changes that leads to a cascade of endocrine and inflammatory responses. The magnitude of the responses depends on the extent and nature of the surgical procedure. An ERAS protocol is primarily aimed at reducing the perioperative injury and stress to the body, thereby maintaining the body’s homeostasis. [11] Thus, the components of intraoperative care—including short-acting anesthetic agents, GDFT, normothermia, and the use of minimal-access surgery (MAS)—are important determinants of the ERAS protocol. [11]

Control of pain

Pain is one of the distressing factors after any surgical procedure. It has various adverse effects on the body and can trigger multiorgan dysfunction. It activates the hypothalamic-pituitary-adrenal (HPA) axis, thereby increasing the production of cortisol, which, in turn, leads to anxiety, insomnia and disorientation. Activation of the HPA axis also enhances sympathetic stimulation and increases the levels of antidiuretic hormone (ADH), aldosterone, catecholamines, angiotensin, and prostaglandins in the body, thereby reducing urine output and increasing the need for prolonged catheterization.

The increase in cortisol, glucagon, and catecholamine levels leads to insulin resistance as well. It increases the heart rate and systemic vascular resistance (SVR), thus predisposing the individual to myocardial ischemia. Postoperative pain also leads to restriction of respiratory movements, suppresses the cough reflex, and reduces vital capacity and minute volume. Postoperative atelectasis, pneumonia, and hypoxia may then develop, hindering early mobilization and recovery.

The spinal-level reflexes and hyperactivity of the sympathetic system lead to paralytic ileus. This is a most worrisome complication for a surgeon, in that it impedes early mobilization and enteral feeding; it can also cause muscle spasms and impaired fibrinolysis, thus predisposing the patient to venous thromboembolism (VTE). Nociceptive stimuli can also lead to inflammation, impairing wound healing and predisposing to systemic inflammation. [16, 17]

Managing surgical pain, thereby reducing or minimizing various complications, is one of the key components of ERAS. Opioid analgesics are known to cause prolonged ileus, as well as dependence with long-term use, and are therefore avoided in ERAS protocols. Multimodal analgesia is an effective approach that not only relieves pain but also enhances early enteral feeding, encourages early mobilization, reduces the side effects of opioids, and decreases the systemic inflammation described above, thereby facilitating a quicker recovery. [18]

The primary components of multimodal analgesia include thoracic epidural analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). However, in view of the reservations that have been expressed regarding the use of NSAIDs in patients undergoing bowel anastomoses, transversus abdominis plane (TAP) blocks, spinal anesthesia, and IV lidocaine are currently preferred. [19, 20, 21]

The authors found lumbar epidural anesthesia to be effective in patients with perforated duodenal ulcers and patients undergoing emergency small-bowel surgery on an ERAS protocol. [1, 2] The patients received infusions of 16 mL of 1% lidocaine with 150 μg of epinephrine and short-acting opioids with anesthetic agents such as fentanyl (1 μg/kg) and sevoflurane (0.5-0.7 minimum alveolar concentration).

Maintenance of fluid volume and core temperature

As noted, surgical trauma leads to the release of various inflammatory mediators and catabolic hormones that enhance the retention of fluid and sodium in order to maintain intravascular volume, sustain blood pressure, induce vasoconstriction, and deliver substrates for body metabolism. Body temperature falls in order to reduce oxygen utilization and shunting of blood to vital organs. Hence, maintaining the core body temperature throughout the procedure is crucial. [11]

The release of various inflammatory mediators and the suppression of mitochondrial activity due to surgical trauma leads to altered gut permeability and initiates a hypercoagulable state. [11] The human body has not evolved the capacity to adapt rapidly to such changes. [22, 23]

A hypervolemic state is one of the primary factors leading to prolonged ileus. Maintaining a zero balance intraoperatively is a key component of intraoperative GDFT. [24, 25] Maintenance of a zero balance in an emergency setting is challenging, especially when fasting, hemorrhage, volume losses, and poor oral intake must also be taken into account.

A number of invasive, minimally invasive, and noninvasive techniques are available for monitoring volume status. Euvolemia is maintained by monitoring the pulse rate, arterial blood pressure, urine output, central venous pressure (CVP), end-tidal CO2, stroke volume, and cardiac output. [24, 26] Although urine output has been used as a marker for volume status, it is limited in this regard by its dependence on other factors (eg, prerenal causes of volume depletion and postrenal outflow tract obstruction). [27, 28] However, some studies have reported urine output to be a sensitive marker for volume status. [27]

Commonly used techniques for assessing volume status include the following:

  • Transesophageal echocardiography (TEE), which can measure stroke volume, cardiac output, and CVP [29]
  • Pulmonary artery catheterization, which can measure CVP, mixed venous oxygen saturation (SvO 2), left ventricular end-diastolic pressure and volume, stroke volume, cardiac output, cardiac index, and SVR [29]
  • Arterial waveform analysis–based techniques
  • Esophageal Doppler- and bioimpedance-based technologies [24]

Individualized fluid therapy is warranted for achieving euvolemia prior to surgery. GDFT consists of a continuum of preoperative, intraoperative, and postoperative fluid therapy. Some authors also suggest a zero-balance approach in low-risk surgical procedures. Although there is no established consensus on the parameters and endpoints of GDFT, the following values have been advocated [30] :

  • CVP 8-12 cm H 2O
  • Mean arterial pressure (MAP) 65-90 mm Hg
  • SvO 2 >70%
  • Central venous oxygen saturation (ScvO 2) >65%
  • Urine output >0.5 mL/kg/hr
  • Hematocrit >30%

Many studies have reported better outcomes with GDFT in patients undergoing emergency surgery, as have studies from our center, in which the authors monitored the volume status by measuring CVP by means of an internal jugular vein catheter. [1, 2] There are other studies which have shown no significant outcomes between the GDFT and control group in patients undergoing laparoscopic colorectal surgeries. [31]

Use of minimal-access surgery

MAS is an important determinant of an ERAS protocol, in that it leads to enhanced recovery and an optimal postoperative outcome. Any surgical procedure causes two types of injury, direct and indirect. [11] Direct injury is due to incision and tissue damage from mobilization of tissues and organs; indirect injury sets in with hemorrhage, anesthetic techniques, patient positioning, and creation of pneumoperitoneum with CO2.

In open surgical procedures, reducing the surgical wound by performing a smaller incision involving few dermatomes and myotomes decreases the surgical trauma. [11] Intraoperative bleeding may be controlled by using ultrasonic technology or electrocoagulation.

A much better approach is to perform a laparoscopic procedure whenever feasible. Laparoscopic surgery has the advantage of requiring only small incisions that cause less tissue damage. It is targeted to reduce the stress and injury caused by the surgery to the body. [31] However, the creation of a pneumoperitoneum may have a detrimental effect, particularly when the operation is prolonged. This effect can be counteracted with the help of special ports and neuromuscular blocks. [11]

Lack of infrastructure, unavailability of an appropriately trained surgeon, and a busy emergency operation theater schedule are all potential hindrances to performing emergency laparoscopic surgery on a routine basis. Nevertheless, whenever possible, use of a MAS approach is preferable in an ERAS protocol. The pioneering study on emergency ERAS by Gonenc et al reported successful use of MAS in the management of patients with perforated peptic ulcers. [5] Drain usage should be limited because it impedes early mobilization, thereby prolonging recovery.

A coordinated effort by the surgeon, the anesthesiologist, and the other caregivers in the intraoperative phase of the ERAS protocol is important for successfully translating the benefits of this phase into the postoperative phase.

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Postoperative Components of ERAS

Implementation of the postoperative components of ERAS depends on adequate preoperative and intraoperative care of the patient. These components include management of postoperative pain with nonopioid analgesics and epidural analgesia so as to facilitate early mobilization. Early removal of NG tubes, urinary catheters, and drains and early enteral feeding are important care elements in the postoperative phase. [11]

A study from the authors' center reported a shorter hospital stay (2.83 days) with an adapted ERAS protocol in patients undergoing emergency small-bowel surgery. [2] Postoperative analgesia in the initial hours was achieved by means of NSAIDs and epidural analgesia with bupivacaine infusion for 24 hours. On postoperative day (POD)-0, patients received diclofenac 75 mg IV q12hr; on POD-1, the schedule was changed to SOS (si opus sit; as the occasion requires). On POD-2, patients were switched to acetaminophen 500 mg PO q8hr; this was changed to SOS on POD-3. An IV formulation was used if resumption of enteral feeding was delayed, and opioids were used SOS for management of breakthrough pain.

In another study from the same center, adjuvant medications (eg, metoclopramide 10 mg IV q8hr) were used on POD-0 and POD-1 as prokinetic agents for reducing the gastric emptying time. [1] Proton pump inhibitors (PPIs) were administered, initially IV and later in oral formulations. In addition to postoperative pain management, the authors also employed antibiotic prophylaxis (initially, IV ceftriaxone and metronidazole; subsequently, oral cefixime and metronidazole) for the prevention of surgical-site infections (SSIs).

Ileus and immobilization are the principal factors that delay patient recovery after a surgical procedure. The etiology of postoperative ileus is multifactorial. Risk factors include the following [32] :

  • Elderly male
  • Low serum albumin preoperatively
  • Opioid usage
  • Previous abdominal surgery
  • Airway and vascular disease
  • Prolonged surgery
  • Emergency surgery
  • Sodium and water overload
  • Hemorrhage

Surgery triggers an immune-inflammatory response in the body. The somatic and visceral trauma causes activation of mast cells, monocytes, and macrophages; this, in turn, enhances production of histamine, tumor necrosis factor (TNF)-α, prostanoids, interleukins, and reactive oxygen species. [25] Gut handling, along with surgical trauma, causes sympathetic stimulation; gut handling and anastomosis also interfere with electromechanical coupling. Fluid overload leads to interstitial edema and stretch. Opioid analgesics decrease gut motility, and changes in gut peptides (eg, motilin, vasoactive peptide [VIP], and substance P) occur.

All of these factors ultimately lead to postoperative ileus, thus resulting in nausea, vomiting, distention, and absolute constipation. [11]  In the postoperative phase of ERAS, various measures can be taken to mitigate or prevent these contributing factors. For example, bowel-wall edema is prevented by means of GDFT, and insulin resistance is prevented by means of carbohydrate loading. Surgical stress–induced inflammation and sympathetic drive are counteracted with the help of NSAIDs and epidural analgesics. Laparoscopic surgery reduces tissue trauma, bowel handling, and the inflammatory reaction.

Alvimopan, an opioid antagonist that acts peripherally without crossing the blood-brain barrier, is known to reduce the risk of postoperative ileus. A meta-analysis that included 2195 patients undergoing major abdominal surgery assessed alvimopan against placebo with regard to the development of postoperative ileus. [33] The authors reported that recovery of gut function was 1.3 to 1.5 times quicker with alvimopan.  

Postoperative nausea and vomiting (PONV) is another distressing development after a surgical procedure. The vomiting center, or chemoreceptor trigger zone (CTZ), is triggered by abdominal distention, bowel handling, volume overload, and opioids, and PONV results. [34] A patient's risk for PONV is assessed on the basis of the Apfel score, which includes the following factors [35] :

  • Female sex
  • Nonsmoker
  • History of motion sickness
  • Opioid use

Preoperative risk stratification and prophylactic therapy are recommended in the prevention of PONV.

Until the 1940s, prolonged bed rest was considered a key component of early recovery after surgery. [36] It was believed that prolonged rest provided time for the body to heal, but advances in research eventually proved the opposite. Prolonged bed rest gives rise to multiple complications, including muscle atrophy, bone loss, development of insulin resistance, occurrence of VTE, atelectasis, and pressure injuries. [37] It is also known to cause postoperative fatigue, especially in patients with a malignancy, from the requirement for additional energy to perform a routine physical task.

ERAS pathways focus on eliminating the postoperative fatigue by enhancing early mobilization. [11] This includes early removal of NG tubes, Foley catheters, and drains. Incentive spirometry is performed preoperatively and postoperatively to prevent atelectasis, and prophylactic antithrombotic agents (eg, heparin) are administered in high-risk groups. Early enteral feeding helps prevent muscle wasting and  fatigue.

In a study of ERAS for repair of perforated duodenal ulcers, the average hospital stay was significantly shorter (4.41 days) in the ERAS group with implementation of the postoperative components. [1] Patients were ambulated from POD-0; those with an epidural catheter in place were encouraged to sit for 2 hours and then mobilized after its removal. Urinary catheters were removed once urine output was adequate over the preceding 24 hours (1 mL/kg/hr) without inotropes or diuretics. Drains were removed when output was 100 mL/day or less, irrespective of resumption of oral feeding; NG tubes were removed when output was 300 mL/day or less, irrespective of the presence or absence of bowel sounds.

Early enteral feeding is the key to resolving many of the complications that follow surgery, such as volume overload, loss of muscle and bone mass, postoperative fatigue, and immobilization. Patients can be started on oral feedings at the appearance of the first bowel sounds or the passage of the first flatus and can then gradually progress to a normal diet. [1] If enteral feedings are not tolerated, they can be temporarily withheld and then restarted as early as feasible. In the study mentioned above, [1] most of the patients tolerated oral feedings satisfactorily and experienced an enhanced recovery.

A meta-analysis focusing on ERAS in emergency abdominal surgery (N = 1334) found that ERAS was associated with decreases in length of hospital stay, time to first oral liquid diet, time to first oral solid diet, time to first flatus, and time to first defecation. [38] The authors also reported a significantly lower risk of complications (eg, SSI, paralytic ileus, and pulmonary complications) in patients treated according to ERAS protocols. The 30-day mortality, the need for readmission, and the need for reoperation were similar in ERAS and non-ERAS groups.

As noted, many studies have focused primarily on the postoperative components of ERAS in emergency surgery because these components are easier to implement in this setting. An additional important consideration is the need to obtain further information on outcomes. This can be done through weekly, monthly, or annual surgical audits, where various outcomes (eg, length of hospital stay, morbidity, mortality, and patient compliance with the ERAS protocol) can be discussed in the light of statistical data. Given that emergency ERAS is still evolving and under study, a surgical audit can help bring out its positive and negative aspects, thereby enabling formulation of a protocol that best fits emergency surgery.

Discharge and follow-up

By enhancing patients' recovery, an ERAS protocol prepares them for early discharge. No fixed protocol has yet been established for discharge in emergency ERAS. At the authors' center, discharge criteria have included absence of complications necessitating hospital admission, tolerance of solid diet, pain control with oral analgesics, and ability to mobilize independently (see the image below). [1, 2]

Enhanced Recovery After Surgery (ERAS): discharge Enhanced Recovery After Surgery (ERAS): discharge criteria.

Evaluation of complications and assessment for readmission are carried out through preestablished follow-up of patients after discharge, which provides feedback for any necessary improvements and changes in the existing protocols. Once discharged, patients can be placed on a regimen of oral analgesics on demand, along with with supportive antisecretory PPI therapy if necessary. Effective preoperative and postoperative counseling is necessary to lower readmission rates and reduce repeat patient visits to the hospital after discharge.

A comparison of various studies on ERAS protocols in emergency GI surgery is provided in Table 1 below. [5, 1, 2, 6, 7, 39, 40, 41]

Table-1: Comparison of Studies on ERAS Protocols in Emergency Gastrointestinal Surgery (Open Table in a new window)

Author (y)

Operative Procedure

Study Design

Total No. of Patients

Length of Hospital Stay (d)

Total Postoperative Complications (%)

Need for Readmission (%)

Need for Reexploration

(%)

Roulin et al (2014) [7]

Colonic resection

Prospective cohort

28

8

64

-

-

Lohsiriwat et al (2014) [39]

Colorectal resection

Case control

20* vs 40

5.5* vs 7.5

25* vs 48

Nil

-

Gonenc et al (2014) [5]

Laparoscopic Graham patch repair

RCT

21* vs 26

3.8* vs 6.9

23* vs 26 (P = .804)

19* vs 7 (P = .471)

9* vs 7 (P = .823)

Wisely et al (2015) [6]

Major abdominal surgery

Retrospective cohort

370

8

31; reduced (P = .002)

9 (P = .88)

9 (P = .89)

Mohsina et al (2017) [1]

Simple closure of perforated peptic ulcer

RCT

50* vs 49

5.3* vs 9.7

18* vs 63

Nil

-

Shida et al (2017) [40]

Surgery for obstructed colorectal cancer

Retrospective cohort

80* vs 42

7* vs 10

10* vs 15

1.3* vs 0

0* vs 2.5

Shang et al (2018) [41]

Surgery for obstructed colorectal cancer

Retrospective cohort

318* vs 318

6* vs 9

33.6* vs 45

7.9* vs 8.8

2.5* vs 2.8

Saurabh et al (2020) [2]

Small-bowel surgery

RCT

35* vs 35

8* vs 10

23* vs 37

-

-

* ERAS vs standard care.

RCT = randomized controlled trial.

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Impediments to Application of ERAS in Emergency Settings

ERAS is a multilayered approach that requires strict adherence to the protocol on the part of a multidisciplinary team, as well as good patient compliance. Although there is enough evidence to prove the superiority of ERAS as compared with conventional methods, implementation of ERAS protocols in day-to-day practice faces several barriers and limitations. These barriers may involve the nature of the intervention, the particular institutional setup, various external factors, individual characteristics, and specific implementations. [42]

Because an ERAS protocol is a multistep process that requires multidisciplinary involvement, its implementation becomes a challenge in emergency situations. A good institutional setup that affords access to the necessary resources (eg, availability of MAS in an emergency, a good multidisciplinary team familiar with ERAS components applicable in emergency settings [with a good team leader to coordinate efforts], and a procedure-specific ERAS design) is required for breaking the barriers to implementing emergency ERAS. [43]

Although full functional recovery is the agreed-upon goal, perceptions about what this means may differ. A healthcare worker's determination of the point of full functional recovery might well be different from that of the patient (eg, a sportsperson who considers full recovery the point at which a former routine sports activity can be resumed), and this potential difference is not addressed by the ERAS protocol. In such a situation, an individualized list of do’s and don’t's at the time of discharge might help minimize subsequent visits of the patient to the hospital.

Prehabilitation—that is, functional optimization before surgery in conjunction with rehabilitation (eg, physiotherapy) after surgery—improves patient outcomes but is subject to institutional cost constraints, leading to patient-reported ineffective outcomes. Preimplementation is a major task that must be accomplished through data collection, analysis of previously published papers, and design of a protocol that is suited to the particular institutional setup. The progression of knowledge on the basis of previous work is vital for updating and educating administrators, residents, staff members, patients, and family members toward the goal of successful implementation of ERAS in emergency settings.

Frontline warriors in this effort include administrators, department heads, surgeons, anesthetists, nurses, residents, postanesthesia care unit (PACU) staff, surgical care unit staff, physiotherapists, and nutritionists, all of whom need to be well informed about the guidelines, along with evidence that could improve the adherence rate. In some institutions, a "local hero" (eg, an influential surgeon, anesthetist, or nurse) can be trained to propagate ERAS principles among the other healthcare workers. [44] Following a multidisciplinary approach with good communication among the healthcare workers can also lead to better implementation.

Another way of improving the success rate is to make use of so-called communities of practice in order to bring together like-minded people wanting to gain knowledge in the field of ERAS. [45] A 2009 review assessed the outcomes of educational meetings in implementation of professional practices and found a 6% increase in the compliance rate. [46] Such meetings also serve the purpose of updating healthcare workers on recent changes and updated protocols.

Providing institutionally designed patient education material preoperatively is helpful in preparing the patient for early recovery in the immediate postoperative period. A systematic review of 11 studies reported that patients who received information preoperatively were well prepared for their surgical procedure and their postoperative recovery. [47] These patients also were active participants in their own recovery.

As stated previously, maintaining a weekly or monthly or annual surgical audit and obtaining useful feedback are of paramount importance for evaluating the pitfalls of any protocol. These practices are also useful for identifying and assessing the various barriers to the implementation of an ERAS protocol, as well as helpful in designing a method for overcoming these barriers.

Undoubtedly, there remain major hindrances to the implementation of ERAS in emergency abdominal surgery, where time is critical and saving lives is more important than following any new protocol. Nevertheless, such implementation is achievable with a set of adapted and updated ERAS components.

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