Version July 2025
INTRODUCTION —
Multimodal, multidisciplinary protocols have been developed for various types of surgical procedures to achieve enhanced recovery after surgery (ERAS), also known as enhanced recovery pathways (ERPs) or fast-track programs. This topic is an overview of the components (elements) of ERAS protocols and data regarding outcomes after implementation of such programs for major noncardiac surgery such as gastrointestinal, orthopedic, and urologic procedures.
Other topics discuss enhanced recovery after cardiothoracic and gynecologic procedures. (See "Overview of enhanced recovery after cardiothoracic surgery" and "Enhanced recovery after gynecologic surgery: Components and implementation".)
OVERVIEW OF ERAS PROTOCOLS
●Goals – Goals include minimizing surgical stress responses, reducing end-organ dysfunction, providing optimal control of postoperative pain, expediting recovery, decreasing hospital length of stay, and reducing complications.
●Key components – ERAS guidelines and protocols typically include 15 to 20 evidence-based therapeutic interventions (components) to standardize care through integrated preoperative, intraoperative, and postoperative pathways (table 1) [1-3].
Although the relative contribution of individual components to recovery after surgery is unclear, a minimally invasive surgical approach is one of the core elements. Other key components include early postoperative oral intake and early ambulation [4,5], which are influenced by interventions such as opioid-sparing anesthetic techniques and analgesic and antiemetic prophylaxis. Several components have become standard of care. These include preoperative optimization of comorbid conditions, maintenance of normothermia, intraoperative antibiotic prophylaxis, and venous thromboembolism prophylaxis.
●Variability in use of protocols – There is considerable inter-institutional variability in decisions to implement ERAS protocols, as well as variability among surgical subspecialties in their use of specific protocols. Furthermore, use of individual components varies among institutions, subspecialties, and even individual surgeons [1,6,7]. Furthermore, the degree of compliance with each element of an ERAS protocol is usually not reported [1]. These factors impact analysis of data regarding outcomes. (See 'Ensuring compliance' below and 'Outcomes' below.)
PREOPERATIVE STRATEGIES
Patient evaluation and education — Important goals during the preanesthesia consultation include [8]:
●Optimization of comorbid conditions – ERAS programs require optimization of medical comorbidities, including cardiovascular, respiratory, and/or renal disease, as discussed in separate topics:
•(See "Evaluation of cardiac risk prior to noncardiac surgery".)
•(See "Management of cardiac risk for noncardiac surgery".)
•(See "Evaluation of perioperative pulmonary risk".)
•(See "Preoperative evaluation for noncardiac surgery in adults".)
●Prehabilitation (if appropriate) – Consider whether prehabilitation interventions such as smoking cessation, nutritional supplementation, physical exercise programs, interventions to improve cognitive function, and stress reduction are appropriate. For older and frail adult patients, such prehabilitation efforts have shown some benefit [9]. Social and behavioral factors such as illicit drug use and alcohol dependency are also addressed, as necessary.
Specific prehabilitation interventions are discussed separately. (See "Smoking or vaping: Perioperative management" and "Overview of prehabilitation for surgical patients".)
●Patient and family education – Educate the patient and family to set expectations regarding the patient's own role in the recovery process, and to reduce patient anxiety. In particular, preoperative planning for pain management emphasizes realistic expectations regarding postoperative pain relief, and lead to increased patient satisfaction [8,10-12]. Specialty-specific patient and family education (eg, stoma management in colorectal surgery) is also helpful. (See "Approach to the management of acute pain in adults".)
Preoperative fasting — Fasting reduces the risk of aspiration of gastric contents during a general anesthetic by reducing gastric volume and acidity. Guidelines for preoperative fasting vary by geographic area (table 2). Preoperative fasting guidelines established by the American Society of Anesthesiologists (ASA) are based on randomized trials and nonrandomized comparative studies [13,14] (see "Preoperative fasting in adults"):
●Clear liquids – The ASA guidelines recommend fasting for at least two hours from clear liquids and all other intake, including medicines [13,14]. Patients may consume clear liquids, including nonalcoholic beverages such as water, juices without pulp, coffee or tea without milk, and carbohydrate drinks, up until two hours before surgery. This approach to fasting helps avoid symptoms of dehydration, hypoglycemia, and caffeine withdrawal. (See "Preoperative fasting in adults", section on 'Clear liquids'.)
For ERAS protocols, it is critical to minimize the fasting period; thus, we encourage patients to consume clear liquids until two hours prior to surgery to remain hydrated. Typically, we advise patients to drink at least two glasses of water before going to bed the night before surgery and two glasses of water before traveling to the hospital on the morning of surgery. There is no evidence that restriction of the volume of clear liquids is beneficial [15].
●Carbohydrate-rich drink – We do not use complex carbohydrate loading, as the evidence of benefit in the ERAS setting is weak [16]. Rather, patients are given an option to consume a simple carbohydrate drink (eg, apple juice or Gatorade) instead of two glasses of water, but the drink must be consumed at least two hours prior to surgery.
Some ERAS protocols do prescribe a carbohydrate-rich drink two hours prior to surgery. This practice has been suggested as a method to convert the patient from the "fasted" to the "fed" state, reducing postoperative insulin resistance and postoperative weight loss [17]. However, evidence supporting consumption of a carbohydrate-rich drink before elective colon surgery is limited [16-18]. Furthermore, carbohydrate loading is avoided in patients with diabetes mellitus due to concern that hyperglycemia may develop [19].
●Solid foods and milk – The ASA guidelines for solid food and milk are applicable for ERAS protocol [13,14]. (See "Preoperative fasting in adults", section on 'Solid foods'.)
Preoperative medications — Medications typically administered in the preoperative period include:
●Multimodal opioid-sparing analgesic prophylaxis – Multimodal opioid-sparing analgesic medications are typically administered beginning in the preoperative period. As an example, the authors use:
•Acetaminophen – Oral acetaminophen 1 g is administered at least two hours preoperatively if there are no contraindications. Intravenous (IV) acetaminophen 1 g is administered prior to emergence from anesthesia only if the patient did not receive preoperative acetaminophen.
•Oral cyclooxygenase (COX)-2 specific inhibitor – An oral COX-2 inhibitor such as celecoxib 400 mg is administered at least two hours preoperatively if there are no contraindications.
●Antibiotic prophylaxis – When indicated, prophylactic antibiotics should be administered 30 to 60 minutes before the surgical incision. The choice of agents depends on the planned surgical procedure and is discussed in another topic. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
●Venous thromboembolism prophylaxis – For selected procedures, venous thromboembolism prophylaxis (subcutaneous heparin 5000 units) may be administered 30 to 60 minutes before surgery. Mechanical prophylaxis (eg, compression stockings and boots) should also be applied before the induction of general anesthesia. Details are discussed in separate topics:
•(See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
●Agents to be minimized or avoided include:
•Gabapentinoids – Routine use of gabapentinoids is not recommended due to increased risks for excessive postoperative sedation, respiratory depression, delirium, and dizziness. However, gabapentin may be administered if the patient is already receiving this agent as a preoperative prescription [20]. Particular caution is advised in patients >65 years old, those with sleep-disordered breathing (eg, obstructive sleep apnea), or if gabapentin is combined with a benzodiazepine or opioids [21-23]. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
In a 2020 meta-analysis of nearly 25,000 patients participating in 281 trials, gabapentinoids were associated with reductions in pain intensity that were clinically insignificant at 6, 12, 24, and 48 postoperative hours, with no effect by 72 postoperative hours, compared with controls who did not receive gabapentinoids [22]. Also, postoperative nausea and vomiting (PONV) occurred less frequently in patients receiving gabapentinoids (risk ratio [RR] 0.77, 95% CI 0.72-0.82; 17,145 participants). However, a higher incidence of dizziness was noted after gabapentinoid administration (RR 1.25, 95% CI 1.13-1.39; 12,054 participants) [22]. A subsequently published observational study that included 2,848,897 patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) noted that the combined use of midazolam and gabapentinoids was associated with increased risk for postoperative delirium (odds ratio [OR] 1.45, 95% CI 1.38-1.52), falls (OR 1.1, 95% CI 1.07-1.14), and pulmonary complications (OR 1.22, 95% CI 1.18-1.27) [23].
•Benzodiazepines – We avoid routine use of benzodiazepine premedication, particularly if coadministered with opioids [24-26], or a gabapentinoid [23]. Dose-dependent potential adverse effects of benzodiazepines include:
-Risks for postoperative sedation, respiratory depression, amnesia, and cognitive dysfunction [24,26,27] – (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with higher risk'.)
-Increased incidence of pharyngeal dysfunction and discoordinated breathing and swallowing [25,28]. (See "Postoperative airway and pulmonary complications in adults: Management following initial stabilization", section on 'Hypoventilation due to postoperative administration of opioids or sedatives'.)
-Occasional unpredictable paradoxical reactions (eg, irritability, aggressiveness, delirium) [29-31]. (See "Delayed emergence and emergence delirium in adults", section on 'Assessment of causes'.)
However, many anesthesiologists do administer a small intravenous dose of a benzodiazepine, typically midazolam 1 to 2 mg, just before transfer of the patient from the holding area to the operating room. In a retrospective study that included 1,863,996 patients undergoing TKA and 985,471 patients undergoing THA, four of five patients received a benzodiazepine in the preoperative period [32]. Perceived benefits include anxiolysis, sedation, amnesia, and improved patient satisfaction [33], although these benefits are controversial [34].
INTRAOPERATIVE STRATEGIES
Minimally invasive surgery — Minimally invasive techniques are central to ERAS protocols because they decrease inflammatory mediator release, improve pulmonary function, expedite return of bowel function, and reduce length of hospital stay [35-42]. Benefits of minimally invasive surgery are discussed in specialty-specific UpToDate topics.
Anesthetic techniques — Principles for general anesthesia includes:
●Use of short-acting anesthetic and analgesic agents – General anesthesia can be maintained using inhalation agents or total intravenous anesthesia (TIVA) with propofol [43]. We do not routinely use dexmedetomidine due to its prolonged hemodynamic and sedative effects lasting up to four hours and delaying ambulation.
For any technique, it is prudent to use the lowest doses of the selected agents that are necessary to avoid awareness since residual effects of intravenous (IV) hypnotic-sedatives, inhalation anesthetics, opioids, and muscle relaxants can all delay recovery or cause adverse effects. (See "Maintenance of general anesthesia", section on 'Inhalation anesthetic agents and techniques' and "Maintenance of general anesthesia", section on 'Total intravenous anesthesia technique'.)
●Use of short-acting neuromuscular blocking agents (NMBAs) – If a NMBA is used, reduce risk of residual effects by avoiding long-acting agents, monitoring the effects of neuromuscular blockade, administering the smallest dose of an NMBA that provides optimal surgical conditions, and ensuring complete reversal of any residual neuromuscular blockade near the end of the procedure. Dosing of the reversal agent (ie, neostigmine or sugammadex) is based on the degree of residual neuromuscular block at the time the agent is administered. Details regarding use of NMBAs and timing and adequacy of reversal of neuromuscular blockade are found in separate topics:
Analgesic techniques — Multimodal analgesic strategies are used during the intraoperative period, as well as in the preoperative and postoperative periods. (See 'Multimodal management of pain' below and "Approach to the management of acute pain in adults", section on 'Options for managing postoperative analgesia'.)
Other strategies include:
●Reduction of total opioid doses – Institutional efforts to adopt ERAS protocols have reduced opioid consumption across specialties [44]. Postoperative opioid-related adverse events include delayed emergence from anesthesia, postoperative respiratory depression, delirium or cognitive dysfunction, postoperative nausea and vomiting (PONV), urinary retention necessitating bladder catheterization, pruritus, and increased potential for acute tolerance, delayed hyperalgesia, and paradoxical increases in postoperative pain and opioid dosing requirements [45]. (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Prevention and management of adverse opioid effects'.)
Notably, intraoperative tachycardia and hypertension often occur due to causes other than pain. Examples include increased intra-abdominal pressure, absorption of carbon dioxide (CO2), and effects of surgical positioning during laparoscopic surgical procedures. Thus, it is not always appropriate to continue to increase opioid dosing or switch to another opioid to treat hyperdynamic responses.
●Use of short-acting opioids – These include (figure 1 and table 3):
•Infusion of remifentanil, the shortest-acting agent as the opioid component of a TIVA technique. (See "Perioperative uses of intravenous opioids: Specific agents", section on 'Remifentanil'.)
•Administration of bolus doses of fentanyl 25 to 50 mcg during the intraoperative period if indicated to treat responses to noxious stimuli (eg, increased heart rate [HR] and/or blood pressure [BP]). However, we typically limit the dose of fentanyl to ≤1 mcg/kg per hour. If fentanyl requirements exceed this limit, we treat tachycardia and/or hypertension with vasoactive agents such as beta blockers or vasodilators rather than administering additional opioid doses. (See "Perioperative uses of intravenous opioids: Specific agents", section on 'Fentanyl'.)
●Selected use of longer-acting opioids for postoperative pain prophylaxis
•For patients who did not receive a regional anesthetic technique, ERAS protocols include a precalculated dose of a long-acting opioid for most open surgical procedures. We prefer hydromorphone rather than morphine because it provides better analgesia and analgesia relative to respiratory depression [46]. (See "Perioperative uses of intravenous opioids: Specific agents", section on 'Hydromorphone'.)
We use hydromorphone 5 to 10 mcg/kg ideal body weight (IBW), administered approximately 20 minutes prior to the expected time of extubation (typically when the surgeon starts closing the abdomen). This approach does not delay awakening or tracheal extubation [47]. Some clinicians attempt to titrate a long-acting opioid to produce a respiratory rate of approximately 12 to 15 breaths per minute during emergence from anesthesia, but this approach is challenging because of potential residual effects of anesthetic agents and NMBAs.
•Some centers administer the long-acting opioid agent methadone early in the intraoperative period [48]. Theoretical advantages of methadone include a multimodal pharmacodynamic profile that provides superior analgesia and potential attenuation of chronic postsurgical pain. However, evidence supporting routine use in ERAS protocols is lacking, and optimal dosing for methadone remains unclear [49]. (See "Perioperative uses of intravenous opioids: Specific agents", section on 'Methadone'.)
However, long-acting opioids are always used sparingly to minimize opioid-related adverse effects that delay recovery and return to activities of daily living. These adverse effects are exacerbated in patients with comorbidities such as obstructive sleep apnea or liver or kidney dysfunction [48]. (See "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Dosing considerations' and "Perioperative uses of intravenous opioids in adults: General considerations", section on 'Prevention and management of adverse opioid effects'.)
Antiemetic prophylaxis — We routinely use multimodal antiemetic prophylaxis in all patients participating in ERAS protocols to facilitate early recovery. We typically use a combination of:
●IV dexamethasone 8 to 10 mg is administered after induction of anesthesia.
●A 5-hydroxytryptamine type 3 (5-HT3) antagonist such as IV ondansetron 4 mg or palonosetron 0.75 mg administered at the end of the surgical procedure.
●For patients at very high risk of PONV (eg, history of motion sickness, history of previous postoperative PONV, known high opioid requirements for pain relief), we administer an additional antiemetic agent such as preoperative transdermal scopolamine or aprepitant or IV fosaprepitant intraoperatively.
Details regarding use of these agents and additional options to treat PONV are discussed in a separate topic. (See "Postoperative nausea and vomiting", section on 'Adults'.)
Intraoperative fluid management — Intraoperative fluid management is aimed at restoring and maintaining euvolemia. (See "Intraoperative fluid management", section on 'Choosing a fluid management strategy'.)
We typically use a zero-balance fluid therapy approach that minimizes fluid administration for minimally or moderately invasive surgery. We administer a balanced electrolyte solution (eg, Ringer's lactate) at 3 mL/kg/hour. We do not "preload" fluid prior to neuraxial block or induction of general anesthesia, or replace urine output, calculated insensible losses, or nonanatomic "third space" losses [50]. Details are discussed separately. (See "Intraoperative fluid management", section on 'Restrictive (zero-balance) strategy' and "Intraoperative fluid management", section on 'Minimally/moderately invasive surgery'.)
For high-risk patients undergoing major surgical procedures that dictate arterial catheter placement, this approach is supplemented with goal-directed fluid therapy, particularly if significant blood losses >500 mL and/or fluid shifts are expected. With this approach, supplemental crystalloid boluses (typically 200 to 250 mL) are administered based on information derived from invasive dynamic hemodynamic parameters such as manual estimation or automated calculation of variations in systolic blood pressure or pulse pressure in the intra-arterial waveform tracing, or variations in stroke volume. Details are discussed separately. (See "Intraoperative fluid management", section on 'Goal-directed fluid therapy'.)
Evidence suggests that these fluid management strategies (zero-balance or goal-directed approaches) are superior to traditional approaches that use liberal or fixed-volume fluid administration, which can result in use of excessive volumes of crystalloid solution and increased risk for tissue edema. Details are discussed separately. (See "Intraoperative fluid management", section on 'Avoid traditional liberal or fixed-volume approaches'.)
Body temperature control — Core body temperature is routinely monitored at the esophageal or nasopharyngeal site, and warming devices are employed to maintain normothermia (temperature ≥35.5°C). Hypothermia is avoided throughout the perioperative period. Detailed discussion is available in a separate topic. (See "Perioperative temperature management".)
POSTOPERATIVE STRATEGIES
Multimodal management of pain — Postoperative multimodal pain management is patient-specific and procedure-specific, with the goal of minimizing pain during rest and also during early mobilization and physical therapy. Combinations of opioid and nonopioid pharmacologic agents are administered, and local or regional anesthetic techniques are used whenever possible. Details are discussed in a separate topic. (See "Approach to the management of acute pain in adults", section on 'Options for managing postoperative analgesia'.)
Pharmacologic agents — As an example, the authors use the following combination of systemic analgesic agents:
●Opioid analgesics – While the patient is in the post-anesthesia care unit (PACU), pain is treated with intravenous (IV) hydromorphone 0.1 to 0.2 mg (up to 1 mg). An alternative agent is IV morphine 1 to 2 mg doses (up to 10 mg).
After discharge from the PACU, opioid analgesics may include:
•For patients tolerating oral medications, oral oxycodone 5 to 10 mg four times per day as needed for breakthrough pain. For patients unable to take oxycodone, we use tramadol 50 mg four times per day as needed.
•If a patient is unable to take oral medications or has severe pain, small bolus doses of IV hydromorphone (0.5 mg (or morphine 2 to 3 mg) may be administered as needed.
•In rare circumstances, it may be necessary to administer IV opioids via patient-controlled analgesia (PCA) to achieve control of postoperative pain. (See "Approach to the management of acute pain in adults", section on 'Opioids' and "Use of opioids for acute pain in hospitalized patients".)
●Nonopioid analgesics – Combinations of acetaminophen and a nonsteroidal anti-inflammatory drug (NSAID) or a cyclooxygenase (COX)-2 specific inhibitor in multimodal pain management protocols are also administered in patients who have no contraindications. (See "Nonselective NSAIDs: Overview of adverse effects" and "Anesthesia for the patient with liver disease", section on 'Other analgesics'.)
Typical regimens include:
•IV ketorolac 15 to 30 mg (if no contraindications) is usually administered near the end of the surgical procedure. Administration of this NSAID is avoided until the surgical procedure itself has been completed (late during the intraoperative period or in the postoperative period) due to antiplatelet effects that may increase risk of perioperative bleeding. However, COX-2 specific inhibitors spare the COX-1 enzyme and have no antiplatelet effects; thus, these agents may be administered earlier (in the preoperative period) if desired.
•Scheduled doses of oral acetaminophen 1 g four times per day AND
•An oral NSAID (eg, meloxicam 15 mg once per day) or oral COX-2 specific inhibitor (eg, celecoxib 200 mg twice per day) [51-54].
For patients who do not yet tolerate oral liquids, acetaminophen, ibuprofen, and ketorolac are each available in an IV formulation. (See "Nonopioid pharmacotherapy for acute pain in adults".)
Oral or IV preparations of acetaminophen and NSAIDs or COX-2 specific inhibitors are then continued in the postoperative period with regular scheduled dosing. Additional considerations regarding administration of acetaminophen and NSAIDs are discussed in a separate topic. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Acetaminophen' and "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-inflammatory drugs'.)
●Dexamethasone – The authors also use dexamethasone 8 to 10 mg IV as an important component of optimal multimodal analgesia technique [20]. Dexamethasone improves pain relief, prolongs local analgesic blocks, and reduces rebound pain. Safety concerns such as increased surgical site infection, delayed wound healing, and hyperglycemia have not been verified [20,55,56].
Local or regional anesthetic techniques — A local or regional anesthetic technique is often employed as a primary component of a multimodal analgesic regimen [20,51,57,58]. However, evidence regarding any clinical benefit of individual regional techniques is limited, in part due to inadequate reporting of compliance with these and other elements of ERAS protocols [59].
●Local infiltration or surgical field block – Infiltration of the surgical wound with local anesthetic provides excellent analgesia that often outlasts the duration of action of the drug; therefore, this technique is used whenever possible. Details are discussed in a separate topic. (See "Approach to the management of acute pain in adults", section on 'Wound infiltration'.)
●Interfascial plane blocks – Interfascial plane block such as the transversus abdominis plane (TAP) blocks or erector spinae plane blocks provide excellent pain relief after open abdominal surgical procedures, but may not be superior to surgical site infiltration after a laparoscopic procedure with a small incision [57]. (See "Transversus abdominis plane (TAP) blocks procedure guide" and "Erector spinae plane block procedure guide".)
Other blocks include serratus plane block and quadratus lumborum block; details are discussed in separate topics. (See "Thoracic nerve block techniques", section on 'Serratus plane block' and "Quadratus lumborum block procedure guide".)
●Peripheral nerve blocks – Peripheral nerve blocks for the lower extremity (eg, femoral nerve block) are not used commonly due to concern regarding delays in ambulation and recovery. Furthermore, since single injection peripheral nerve blocks have a short duration of action, rebound pain may occur after the block has resolved. However, brachial plexus blocks are still used for selected upper extremity surgery, and popliteal sciatic nerve block are suitable for selected foot and ankle procedures [51]. (See "Approach to the management of acute pain in adults", section on 'Regional anesthesia techniques'.)
●Neuraxial analgesia – We do not use epidural analgesia in ERAS patients undergoing minimally invasive procedures (eg, laparoscopic surgery) because of potential delays in ambulation and hospital discharge due to adverse side effects that may include postural hypotension, need for a urinary catheter, or inadequate muscle strength. In particular, we avoid administration of an intrathecal opioid such as morphine for any ERAS procedure due to high risk for nausea, vomiting, pruritus, urinary retention, and respiratory depression.
Compared with alternative analgesic techniques that provide similar pain relief (eg, interfascial plane blocks), significant additional benefit for pain control is unlikely [51,59].
Management of nausea and vomiting — For patients requiring postoperative rescue antiemetic therapy to treat PONV, we typically administer one or more of the following antiemetics:
●Ondansetron 4 mg IV (no earlier than four hours after an intraoperative ondansetron dose)
●Dimenhydrinate 1 mg/kg IV
●Intramuscular (IM) promethazine 6.25 mg
Details regarding use of these agents and additional options are discussed in a separate topic. (See "Postoperative nausea and vomiting", section on 'Rescue therapy'.)
Postoperative fluid management — Following major abdominal surgery, there is little consensus regarding optimal strategies for fluid management. Before oral intake is allowed, patients typically receive an infusion of a balanced salt solution (eg, Lactated Ringer solution) at 50 mL/hour, with boluses of 100 mL if necessary to treat hemodynamic instability and/or inadequate urine output. Intravenous fluid administration should be discontinued as soon as the patient can tolerate oral liquids. (See "Overview of postoperative fluid therapy in adults".)
Early oral feeding — ERAS programs incorporate resumption of a diet within a few hours after surgery, which can be supplemented with high-calorie drinks to minimize the negative protein balance after surgery. This is in contrast to the traditional approach where oral feedings were withheld until signs of bowel activity (eg, bowel sounds, flatus, bowel movement) were evident. In one study, the presence of bowel sounds, flatus, or bowel movement after major abdominal surgery was not predictive of tolerance of oral intake [60]. Details regarding postoperative nutritional support are discussed separately. (See "Overview of perioperative nutrition support".)
Early mobilization — Early mobilization is a key element of ERAS protocols for all postoperative patients capable of ambulation to reduce risk of postoperative pneumonia and venous thromboembolism [5]. Involving hospital resources such as physical and occupational therapists can help achieve the goal of early mobilization. (See "Overview of the causes of venous thrombosis in adults", section on 'Surgery'.)
Early urinary catheter removal — To aid with early mobilization, urinary catheters should be removed as early as possible, a process that also reduces the incidence of urinary tract infection after surgery. (See "Catheter-associated urinary tract infection in adults", section on 'Catheter management' and "Placement and management of urinary catheters in adults", section on 'Indwelling catheter exchange or removal'.)
ENSURING COMPLIANCE —
Of the 15 to 20 recommended preoperative, intraoperative, and postoperative elements of typical ERAS protocols, studies suggest that these elements are not equally weighted in their influence on postoperative complications and recovery [61]. However, the relative contribution of each individual element is often unknown [1,6,7].
Furthermore, the degree of compliance with each element of an ERAS protocol is usually not reported [1]. One study of 39,482 patients undergoing elective colorectal surgery noted that only 20 percent had full adherence to the ERAS protocol. Patients with full adherence to core ERAS components had lower rates of postoperative complications than those with only partial adherence [62]. Other studies have noted that compliance with postoperative elements (eg, early mobilization, early oral intake) may be the most difficult to achieve, but these elements may be the most strongly associated with optimal recovery once the surgical stress response has occurred [63,64].
OUTCOMES —
Adherence to an ERAS protocol can impact outcomes such as length of hospital stay and postoperative complications [1,8,61,65-71]. Evidence includes:
●A 2024 meta-analysis of randomized trials addressing outcomes after use of ERAS guidelines noted a decrease in hospital length of stay by 1.88 days (95% CI 0.95-2.81 days) compared with no use of an ERAS protocol (74 trials; 9076 participants) [1]. Risk of complications was also decreased with use of an ERAS protocol (risk ratio [RR] 0.71, 95% CI 0.59-0.87), although hospital readmission and mortality risk were not significantly affected. Observational studies have noted similar results [72-78].
●A 2023 observational study also noted that implementation of an ERAS protocol across eight surgical specialties at five hospitals was associated with reduced 30 day, one-year, and two-year mortalities [79].
Specialty-specific ERAS programs have shown similar benefits:
●Colorectal surgery - Use of ERAS protocols is associated with reduced hospital length of stay and morbidity [80,81], faster recovery [82,83], comparable or reduced readmission rate [84,85], and cost savings [86-90] compared with traditional care in both old and young patients [85,91].
●Gynecologic surgery – Use of ERAS protocols for various types of gynecologic surgery is associated with decreased pain, length of stay, use of nursing time, and overall costs, as well as improved patient satisfaction and quality of life. Evidence is discussed in a separate topic. (See "Enhanced recovery after gynecologic surgery: Components and implementation", section on 'Outcomes'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Postoperative nausea and vomiting" and "Society guideline links: Enhanced recovery after surgery".)
SUMMARY AND RECOMMENDATIONS
●Goals and components – Enhanced recovery after surgery (ERAS) protocols include evidence-based therapeutic interventions to standardize care throughout the perioperative period (table 1). Goals include minimizing surgical stress responses, reducing end-organ dysfunction, providing optimal control of postoperative pain, expediting recovery, and reducing hospital length of stay and complications. Key components include minimally invasive surgical approaches, opioid-sparing anesthetic techniques, analgesic and antiemetic prophylaxis, and postoperative early oral intake and ambulation. However, there is considerable inter-institutional and inter-specialty variability in use of any ERAS protocol, as well as variability in selection of specific components and degree of compliance after implementation of a protocol. (See 'Overview of ERAS protocols' above and 'Ensuring compliance' above and 'Outcomes' above.)
●Preoperative strategies
•We strive to optimize comorbid medical conditions, offer prehabilitation efforts (eg, smoking cessation, nutritional supplementation, physical exercise programs, interventions to improve cognitive function, and stress reduction) when appropriate, and educate the patient and family to set expectations regarding the patient's own role in the recovery process. (See 'Patient evaluation and education' above.)
•We strive to minimize the fasting period by encouraging patients to consume clear liquids until two hours prior to surgery to remain hydrated. We do not use complex carbohydrate loading. Guidelines for preoperative fasting are summarized in the table (table 2) and discussed in detail separately. (See 'Preoperative fasting' above and "Preoperative fasting in adults".)
•We use multimodal opioid-sparing analgesics, beginning in the preoperative period. As an example, the authors use oral acetaminophen 1 g administered at least two hours preoperatively (or intravenous [IV] acetaminophen 1 g administered after anesthetic induction), and an oral cyclooxygenase (COX)-2 specific inhibitor such as celecoxib 400 mg administered at least two hours preoperatively if there are not contraindications. (See 'Preoperative medications' above.)
●Intraoperative strategies – Intraoperative strategies in ERAS protocols include:
•Minimally invasive surgical techniques when possible. (See 'Minimally invasive surgery' above.)
•Short-acting anesthetic agents, administering the lowest doses necessary to avoid awareness. We also use the smallest doses of neuromuscular blocking agent (NMBA) that provide optimal surgical conditions, and ensure complete reversal of residual effects. (See 'Anesthetic techniques' above.)
•Short-acting opioids (eg, remifentanil infusion or bolus doses of fentanyl 25 to 50 mcg), and reduce total doses. Longer-acting opioids (eg, hydromorphone 5 to 10 mcg/kg) may be used selectively for postoperative pain prophylaxis. Details are discussed in a separate topic (figure 1 and table 3). (See "Perioperative uses of intravenous opioids: Specific agents".)
•Multimodal antiemetic prophylaxis, typically a combination of IV dexamethasone 8 to 10 mg administered after induction of anesthesia, a 5-hydroxytryptamine type 3 (5-HT3) antagonist such as IV ondansetron 4 mg administered at the end of surgery, and an additional antiemetic (eg, preoperative transdermal scopolamine) if risk of postoperative nausea or vomiting (PONV) is high. Details are discussed above and in a separate topic. (See 'Antiemetic prophylaxis' above and "Postoperative nausea and vomiting", section on 'Adults'.)
•Use of a zero-balance fluid therapy approach that minimizes fluids, with administration of a balanced electrolyte solution at 3 mL/kg/hour for minimally or moderately invasive surgery. For high-risk patients undergoing major surgical procedures that dictate arterial catheter placement, we supplement this approach with goal-directed fluid therapy. Details are discussed above and in a separate topic. (See 'Intraoperative fluid management' above and "Intraoperative fluid management".)
•Use of warming devices to maintain normothermia (temperature ≥35.5°C), as discussed separately. (See "Perioperative temperature management".)
●Postoperative strategies
•We use a multimodal pain management strategy that includes a combination of opioid and nonopioid pharmacologic agents, as well as use of local or regional anesthetic techniques whenever possible. Details are noted above and in a separate topic. (See 'Multimodal management of pain' above and "Approach to the management of acute pain in adults", section on 'Options for managing postoperative analgesia'.)
However, we avoid epidural analgesia to avoid potential delays in ambulation and hospital discharge due to postural hypotension, need for a urinary catheter, or inadequate muscle strength. (See 'Local or regional anesthetic techniques' above.)
•For patients requiring postoperative rescue antiemetic therapy, we administer one or more antiemetic agents (eg, promethazine, ondansetron, dimenhydrinate), as discussed separately. (See "Postoperative nausea and vomiting", section on 'Rescue therapy'.)
•We encourage resumption of a diet within a few hours after surgery, which can be supplemented with high-calorie drinks to minimize postoperative negative protein balance. (See 'Early oral feeding' above.)
•We emphasize early mobilization to reduce risk of postoperative pneumonia and venous thromboembolism. To aid mobilization, we remove urinary catheters as early as possible. (See 'Early mobilization' above and 'Early urinary catheter removal' above.)
