What if hospitals could consult a perioperative playbook that, when followed to the letter, would virtually assure that surgical patients would experience less stress, less pain, less time in the hospital, and less recovery time?
While no model of care comes with a guarantee, hospitals are increasingly laser-focused on Enhanced Recovery After Surgery (ERAS) programs, an evidence-based, multimodal and multidisciplinary approach that is revolutionizing the care and outcomes of surgical patients.
Designed to diminish the body’s response to surgical stress and levels of postoperative pain, ERAS protocols are credited with reduced complications, improved outcomes, shorter length of stay (LOS), and faster recoveries.1
In clinical studies, ERAS pathways delivered average savings of up to $5,560 per patient 1,2 and reduced LOS by three to four days on average[3-8]. Enhanced recovery pathways also reduced 30-day readmission rates and costs9,10 and the pace at which patients resumed normal activities. 
The ERAS approach challenges traditional thinking around surgery by embracing evidence-based medicine and best practices. The first ERAS protocol was conceived in 2001 by surgeons from Northern Europe desiring to optimize surgical outcomes. 11 Since then, numerous surgical specialties have adopted enhanced recovery programs, with promising results.
ERAS Priority: Blunt Surgical ‘Stress’ Response
Each ERAS pathway is calibrated to minimize the body’s hemodynamic response to surgical stress. Much like the human ‘fight or flight’ response to duress, the body also reacts to surgical stress. High levels of surgical stress may result in hyperglycemia, hypertension and other adverse events that can prolong recovery time and LOS.
Multiple perioperative factors influence surgical stress, including anesthesia, nutrition, body temperature, hydration, duration of surgery, and so on. Key ERAS stress reduction tactics include optimizing the patient’s nutritional and functional status, limiting pre-operative fasting, individualizing fluid management, favoring opioid-sparing analgesia, opting for minimally invasive surgery, and encouraging early postoperative ambulation and feeding.12
Enhanced recovery pathways designate surgical-specific multidisciplinary protocols for each phase of the perioperative continuum:
- Preadmission: Patient/family education, pain management and recovery planning.
- Preoperative: Limited fasting in favor of light carbohydrate intake; multimodal medications and/or regional blocks.
- Intraoperative: Opioid-sparing analgesics and nerve blocks for management of pain, nausea and vomiting.
- Postoperative: Early nutrition, early mobility, continued multimodal medications, judicious IV fluid management and patient education.
- Post-discharge: Patient monitoring and follow-up with care team.
Patient Monitoring Optimizes ERAS Pillars
As illustrated by this overview, nutrition management, pain management and early mobility—getting the patient up and moving as soon as possible post-surgery—constitute ERAS’s perioperative pillars. Overlaying enhanced recovery pathways with comprehensive patient monitoring can assure a continuous and actionable data stream.
Monitoring Aids in Nutrition Assessment
Just as a proper diet propels athletic performance, ERAS advocates nutritional support during surgery to weaken the patient’s metabolic stress response. Enhanced recovery pathways favor a preoperative carbohydrate load over traditional fasting regimens. Many studies have shown that undergoing surgery in a carbohydrate-fed state versus a fasting state improves patient satisfaction and clinical benefits due to the reduction in postoperative insulin resistance. 13,14
Monitoring and assessing the patient’s nutritional status and energy expenditure during surgery, including inhaled and exhaled gases and cardiac output, helping clinicians in their goals to both blunt surgical stress and ensure adequacy of anesthesia.15
Monitoring Tailors Anesthesia Titration
Anesthesia professionals deliver many enhanced recovery components during the perioperative process. Most importantly, anesthesia teams tailor or ‘titrate’ analgesia and multimodal medications according to ERAS protocols and patient characteristics, monitoring and reacting to patient responses.
Multiple patient monitoring parameters guide anesthesia titration, helping to blunt surgical stress, ensure adequacy of anesthesia and facilitate early mobility:
- Entropy Monitoring The GE Healthcare Entropy module, E-ENTROPY, and accessories are indicated for adult and pediatric patients older than 2 years within a hospital for monitoring the state of the brain by data acquisition of electroencephalograph (EEG) and frontal electromyograph (FEMG) signals. The Entropy algorithm in the host monitor calculates the spectral entropies, Response Entropy (RE) and State Entropy (SE), which are processed EEG and FEMG variables. The Entropy measurement is to be used as an adjunct to other physiological parameters. In adult patients, Response Entropy (RE) and State Entropy (SE) may be used as an aid in monitoring the effects of certain anesthetic agents, which may help the user titrate anesthetic drugs according to the individual needs of adult patients. Furthermore, in adults, the use of Entropy parameters may be associated with a reduction of anesthetic use and faster emergence from anesthesia.
- Neuromuscular Transmission (NMT) monitoring guides the anesthesia team in the management of neuromuscular blocks during surgery, which relax muscles and keep patients immobile. NMT-guided anesthesia measures the level of neuromuscular block by stimulating and evaluating the patient’s nerve-muscle response. NMT monitoring supports ERAS by predicting recovery more accurately and, depending on the stimulation method, may decrease residual post-operative paralysis, often a factor in extended post-anesthesia care unit (PACU) stays.16
Telemetry and Wireless Monitoring Supports Early Mobility
Early initiation of physical activities post-surgery such as walking and light weight-bearing is associated with better gastrointestinal function, improved body composition, oral intake and successful outcome of ERAS. 21 However, patient monitoring of newly ambulatory patients remains paramount during the crucial hours following surgery.
Enter Telemetry and wireless monitoring, which supports continuous, comfortable and quality transmission of vital patient data while permitting the patient to ambulate freely. Telemetry systems are compact, portable transmitters that securely and wirelessly send the patient’s clinical data to a central monitoring location. As the newly mobile patient derives the benefits of being up and out of bed, the care team can monitor their heart rhythm, heart rate, oxygen level and other parameters and immediately respond to any irregularities.
Considering an ERAS perioperative playbook? Incorporate a patient monitoring strategy to amplify nutrition assessment, anesthesia management and early mobility efforts with continuous and essential feedback on patient status.
- Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet. 2003;362:1921–8. Accessed May 14, 2019.
- Schmidt et al., Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy. Ann Thorac Surg 2016;102:931–9. Accessed April 2, 2019.
- Chipollini, J. et al., Cost Impact Analysis of Enhanced Recovery after Surgery Protocol Implementation in a Radical Cystectomy Cohort of Patients. The Journal of Urology 2017; 197(4), e414-e415. doi:10.1016/j.juro.2017.02.991. Accessed April 2, 2019.
- Wick EC, Galante DJ, Hobson DB, et al. Organizational Culture Changes Result in Improvement in Patient-centered Outcomes. Implementation of an Integrated Recovery Pathway for Surgical Patients. J Am Coll Surg 2015;221:669e677. Accessed April 2, 2019.
- Thiele et al., Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. J Am Coll Surg 2015;220:430e443. Accessed April 2, 2019.
- Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052e1061. Accessed April 3, 2019.
- Archibald LH, Ott MJ, Gale CM, et al. Enhanced Recovery after Colon Surgery in a Community Hospital System. Dis Colon Rectum 2011;54:840e845. Accessed April 2, 2019.
- Kariv Y, Delaney CP, Senagore AJ, et al. Clinical Outcomes and Cost Analysis of a “Fast Track” Postoperative Care Pathway for Ileal Pouch-anal Snastomosis: A Case Control Study. Dis Colon Rectum 2007;50:137e146. Accessed April 4, 2019.
- Stephen AE, Berger DL. Shortened Length of Stay and Hospital Cost Reduction with Implementation of an Accelerated Clinical Care Pathway after Elective Colon Resection. Surgery 2003;133: 277e282. Accessed April 3, 2019.
- Schmidt et al., Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy Ann Thorac Surg 2016;102:931–9. Accessed April 3, 2019.
- Semerjian, A., et al. (2017). pd67-11 Enhanced Recovery after Radical Cystectomy Reduces Cost and Length of Stay: The Johns Hopkins Experience. The Journal of Urology 2017; 197(4), e1280-e1281. doi:10.1016/j.juro.2017.02.2987. Accessed April 3, 2019.
- Chelsia Gillis, R.D., M.Sc.; Francesco Carli, M.D., M.Phil. Promoting Perioperative Metabolic and Nutritional Care, Anesthesiology, December 2015. Accessed April 3, 2019.
- Jessica K Brown, M.D., Karanbir Singh, M.D., Razvan Dumitru, C.R.N.A., D.N.P., Edward Chan, M.D., and Min P. Kim, M.D. The Benefits of Enhanced Recovery After Surgery Programs and Their Application in Cardiothoracic Surgery. Methodist Debakey Cardiovasc J. 2018 Apr-Jun; 14(2): 77–88.doi: 10.14797/mdcj-14-2-77. Accessed April 3, 2019.
- Ljungqvist O. Modulating postoperative insulin resistance by preoperative carbohydrate loading. Best Pract Res Clin Anaesthesiol. 2009. December; 23 4: 401– 9. Accessed April 3, 2019.
- Awad S, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr. 2013. February; 32 1: 34– 44. Accessed April 3, 2019.
- Karcz M, Papadakos PJ. Respiratory complications in the postanesthesia care unit: A review of pathophysiological mechanisms. Can J Respir Ther. 2013;49(4):21–29.
- Mark S. Siobal, BS, RRT, FAARC. Jami E. Baltz, RD, CNSC. Guide to the Nutritional Assessment and Treatment of the Critically Ill Patient. 2013, American Association for Respiratory Care. Accessed April 4, 2019.
- Chen X, Thee C, Gruenewald M, Wnent J, Illies C, Hoecker J, Hanss R, Steinfath M, Bein B. Comparison of surgical stress index-guided analgesia with standard clinical practice during routine general anesthesia: a pilot study. Anesthesiology. 2010; 112(5):1175-83. doi: 10.1097/ALN.0b013e3181d3d641. Accessed April 4, 2019.
- Vakkuri A, Yli-Hankala A, Sandin R, Mustola S, Høymork S, Nyblom S, Talja P, Sampson T, van Gils M, Viertiö-Oja H.Spectral entropy monitoring is associated with reduced propofol use and faster emergence in propofol-nitrous oxide-alfentanil anesthesia. Anesthesiology. 2005 Aug;103(2):274-9. Accessed March 30, 2019.
- Aimé I, Verroust N, Masson-Lefoll C, Taylor G, Laloë PA, Liu N, Fischler M. Does monitoring bispectral index or spectral entropy reduce sevoflurane use? Anesthesia & Analgesia. 103(6):1469-1477, DEC 2006. Accessed March 30, 2019.
- Tarek El Hor, M.D.; Philippe Van Der Linden, M.D., Ph.D.; Stephan De Hert, M.D., Ph.D.; Christian Mélot, M.D., Ph.D, M.Sc Biostat; Javad Bidgoli, M.D. Impact of Entropy Monitoring on Volatile Anesthetic Uptake. Anesthesiology, April 2013. Accessed March 30, 2019.
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