ERAS Collaborative: ERAS Pathway Summary
Pathway Elements
Preoperative elements
1) Preadmission counseling
Recommendation
Rationale
Patients should routinely receive dedicated preoperative
counseling
2) No/selective bowel
preparation
Mechanical bowel preparation should not be used routinely in
colonic surgery.
3) Fluid and carbohydrate
loading
Preoperative oral carbohydrate treatment should be used
routinely. In diabetic patients, carbohydrate treatment can be
given along with the diabetic medication.
4) No prolonged fasting
Clear fluids should be allowed up to 2 h and solids up to 6 h prior
to induction of anesthesia.
Per Ministry of Health guidelines
Routine prophylaxis with intravenous antibiotics should be given
0-60 minutes before initiating colorectal surgery. Additional doses
should be given during prolonged procedures according to the
half-life of the drug used.
Additional doses should be given for operations >4hours.
Diminish patient fear and anxiety, enhance
postoperative recovery, quicken hospital discharge,
encourage patient involvement with care
Adverse effects attributed to dehydration,
distressing for patient, associated with prolonged
ileus after colonic surgery
Reduce preoperative thirst, hunger, and anxiety, as
well as postoperative insulin resistance, less
postoperative losses of nitrogen and protein, better
maintained lean body and muscle strength
See rationale for #3 Fluid and carbohydrate loading
5) Thromboprophylaxis
6) Antibiotic prophylaxis
Intraoperative elements
7) Multi-modal opioidsparing analgesia
8) PONV
9) Maintenance of
normothermia
Created Nov/20/2014
Updated Dec/21/2014
This pathway element has been referred to the Anesthesia
Community of Practice for recommendation. Until a
recommendation is available, please use the following:
The anesthetist should control fluid therapy, analgesia and
haemodynamic changes to reduce the metabolic stress response.
Open surgery: mid-thoracic epidural blocks using local anesthetics
and low dose opioids.
Laparoscopic surgery: spinal analgesia or IV PCA is an alternative
to epidural anesthesia.
A multimodal approach to PONV prophylaxis based on patient
risk should be adopted in all patients undergoing major colorectal
surgery.
Intraoperative maintenance of normothermia with a suitable
warming device and warmed intravenous fluids should be used
Reduce prevalence of DVT in hospitalised patients
Reduce risk of surgical site infections
Minimize need for postoperative intravenous
opiates, allow rapid awakening from anesthesia, and
facilitate early enteral intake and mobilisation on
POD0.
Faster mobilization and return to diet
Reduce rates of wound infection, morbid cardiac
events, and bleeding, also reduced shivering
routinely to keep body temperature 36-38ºC.
10) Avoid salt and water
overload
11) No drains
Post-operative elements
in PAR
12) Chewing gum
13) Urinary drainage
14) Early oral nutrition
15) Early mobilisation
16) Nasogastric intubation
17) Audit
(This temperature range is consistent with Canadian Patient
Safety Initiative Safer Healthcare Now! guidelines.)
This pathway element has been referred to the Anesthesia
Community of Practice for recommendation. Until a
recommendation is available, please use the following:
Patients should receive intraoperative fluids (colloids and
crystalloids) guided by flow measurements to optimise cardiac
output.
(increases oxygen consumption at a critical time)
and pain in hypothermic patients.
Fewer complications caused by fluid overload
Routine drainage is discouraged because it is an unsupported
intervention that probably impairs mobilisation.
Faster independent mobilisation
Chewing gum started in PAR
Removal of catheter by POD2
Postoperative patients should be encouraged to take a full fluid
diet in POD0-1 and diet as tolerated by POD2.
Patient ambulated for any length of time in POD0-1.
Patient ambulated for any length of time at least two times in
POD2.
Prevention of post-operative ileus
Prevent urinary tract infections
Reduce risk of infection and LOS
Postoperative nasogastric tubes should not be used routinely.
Nasogastric tubes inserted during surgery should be removed
before reversal of anesthesia.
For the Collaborative, collect approved minimum data set for
100% of elective colorectal cases.
Reduce rate of fever, atelectasis, and pneumonia
Early return of gut function
Prolonged immobilisation increases the risk of
pneumonia, insulin resistance, and muscle weakness.
A systematic audit is essential to determine clinical
outcome and measure compliance to establish
successful implementation of the care protocol.
Recommendations are based on clinical experience of implementing ERAS in BC sites and evidence found in the literature (primarily, Gustafson et al.
“Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations.” World J Surg
(2013) 37:259-284.
Created Nov/20/2014
Updated Dec/21/2014