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Key Points

  • image Enhanced recovery after surgery (ERAS) is a paradigm shift in the surgical care of patients. As a multimodal, integrated, evidence-based care pathway, ERAS optimizes patient care in the preoperative, intraoperative, and postoperative setting in order to achieve best patient outcomes. Patients recover faster, experience less physiological stress, enjoy shorter stays in the hospital, and have fewer complications.

  • image Setting appropriate expectations, optimizing nutritional and physical status through prehabilitation, and treating medical comorbidities optimizes patients before surgery.

  • image Achieving normovolemia both intraoperatively and postoperatively is important in order to maintain perfusion without volume overload, as hypervolemia and hypovolemia are both associated with significant complications. Goal-directed therapy approaches maintain normovolemia with zero fluid balance.

  • image Intravenous normal saline administration results in hyperchloremia, which has been associated with increased mortality and morbidity.

  • image As pain is a subjective response and cannot therefore be experienced while unconscious, the use of opioids intraoperatively should generally be avoided in order to minimize the multiorgan system side effects of these medications. Additionally, avoiding intraoperative opioids actually improves postoperative pain scores and reduces the need for postoperative opioids.

  • image Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce postoperative physiological stress and decrease complications associated with surgery as part of a pain management regimen. Multimodal analgesia has been shown to reduce the number of opioids required for analgesia.

  • image The strategies for avoiding postoperative nausea and vomiting include the avoidance of general anesthesia, the use of totally intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and postoperative opioids, and adequate hydration.

  • image Enhanced recovery after surgery care pathways can be applied to numerous types of surgery including colorectal, liver, pancreas, bariatric, gynecologic, and urologic surgery with success.

  • image Traditional Chinese medicine has been practiced for thousands of years and serves as a distinct cultural heritage of China. Its unique theories and methods are still applied widely in the practice of modern medicine, including disease prevention, disease treatment, and perioperative management.

  • image Acupuncture and transcutaneous electroacupuncture can reduce the number of opioids utilized in the perioperative setting. Additionally, acupuncture, transcutaneous electroacupuncture, and some Chinese herb decoctions are effective in the prevention and treatment of postoperative nausea and vomiting.


History and Overview of Enhanced Recovery

As anesthetic techniques, antibiotics, and minimally invasive surgery have improved surgical care over the centuries, further strategies to continue to improve patient outcomes have emerged. A novel perioperative regimen for patients following colon surgery using early oral nutrition, early mobilization, and epidural analgesia was first described in 1995 by Professor Henrik Kehlet from Copenhagen, Denmark in a small group of nine patients.1 He subsequently outlined a more detailed multimodal approach to perioperative care in 1997, reducing length of stay to a median of 2 days following sigmoid resection, and thus, has been described as the founder of enhanced recovery after surgery (ERAS).2,3...

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