Enhanced recovery after surgery (ERAS) protocols were first developed more than 20 years ago as a way to standardize best practices in general and colorectal surgery (Br J Anaesth. 1997;78:606-617). As reports of improved outcomes, shorter hospital stays, and enhanced patient satisfaction were published, other surgical specialties began to look at ERAS protocols.
Working with the ERAS Society (erassociety.org), Joseph C. Dort, MD, MSc, and otolaryngologist–head and neck surgeon at the Cummings School of Medicine at the University of Calgary in Alberta, and Jeffrey Harris, MD, MHA, an otolaryngologist with the department of surgery at the University of Alberta, Edmonton, put together a multinational consortium that wrote ERAS protocols on perioperative care in major head and neck cancer surgery (JAMA Otolaryngol Head Neck Surg. 2017;143:292–303).
The program not only focused on intraoperative practices; it also included recommendations for preoperative education, nutritional care, antibiotic stewardship, analgesic and anesthetic care, fluid management, pain management, and postoperative care (see “ERAS Protocols for Head and Neck Cancer Surgery,” below).
“One of the benefits of ERAS protocols is that it puts what we were already doing in terms of evidence-based best practices into one document to facilitate cross-specialty communication,” said D. Gregory Farwell, MD, professor and vice chair of the department of otolaryngology, division of head and neck surgery and director of head and neck oncology and microvascular surgery at the University of California Davis in Sacramento and co-author of the ERAS article. “I’ve talked to several colleagues across the country who have found this very valuable; it has given them the evidence-based ammunition to make some pretty significant changes in their institution.”
Since implementing the new head and neck cancer surgery protocols at the University of California Davis, “we are noticing that patients are recovering faster [and] spending much less time in the intensive care units and on ventilators, reinforcing what we have learned about admitting patients straight to the floor, early mobilization, and changing our approach to postoperative care,” said Dr. Farwell.
For Adam Levine, MD, professor of anesthesiology, perioperative and pain medicine, otolaryngology, and pharmacological sciences at the Icahn School of Medicine at Mount Sinai in New York, NY, the true advantage of ERAS protocols is that surgeons, anesthesiologists, and nurses are now on the same page. “We have the same goals and objectives—we talked together and have come up with strategies that can be seamlessly deployed pre-, intra-, and postoperatively,” he said.
Clinical Benefits of ERAS
Patient education. The first item in most ERAS protocols is patient education. It is generally thought that the more information a patient has about what to expect before, during, and after surgery, the better the clinical outcomes.
UC Davis is convinced that patient education is effective in moving the needle on surgical recovery, so they have incorporated a team approach to filling key knowledge gaps. “Our nurse practitioner is more involved in the preoperative communication with the patient and family. We are more aggressive in outlining the expectations for the entire process—from the procedure through recovery—to do an even better job of patient education and preparation,” Dr. Farwell said.
We are noticing that patients are recovering faster [and] spending much less time in the intensive care units and on ventilators, reinforcing what we have learned about admitting patients straight to the floor, early mobilization, and changing our approach to postoperative care. —D. Gregory Farwell, MD
For ambulatory sinus procedures, Satish Govindaraj, MD, associate professor of otolaryngology at the Icahn School of Medicine at Mount Sinai, and colleague Alfred Iloreta, MD, assistant professor of otolaryngology at Icahn, have implemented educational videos that patients can watch from the comfort of their home as they prepare for sinus surgery. In a pilot study, they found that patients who watched the four educational videos and received automated reminders to take medications reported that the videos helped them “better understand their condition and treatment” than patients who received a sham platform (95.7% vs 74.1%, respectively)
(Int Forum Allergy Rhinol [published online ahead of print December 13, 2018; doi: 10.1002/alr.22233].
Preoperative nutrition. ERAS protocols are specifically designed to pre-habilitate patients who are undergoing a major procedure. “They address the functional and biologic benefits of preoperative nutrition and hydration—even mild dehydration impairs mood and neurologic function—and studies have shown that postoperative nausea and vomiting is less in patients who have not fasted prior to surgery,” said Gerald M. Haase, clinical professor of surgery at the University of Colorado School of Medicine in Aurora. (Br J Surg. 2005;92:415–421).
In addition, “preoperative carbohydrate loading has been shown to reduce insulin insensitivity and decrease hyperglycemic risks. Adequate nutrition and preoperative carbohydrate loading reduce hospital stay, infectious complications, and patients’ distress from hunger and anxiety,” Dr. Haase wrote in an editorial in American Journal of Otolaryngology, Head and Neck Medicine and Surgery. In the editorial, he urged otolaryngologist–head and neck surgeons to join the ERAS parade (Am J. Otoalaryngol. 2018;39:652–653).
Pain management. In the era of the opioid abuse epidemic, many institutions are revising their pain management protocols. In the ERAS recommendations, the authors suggest that clinicians rely on a “multimodal approach [to pain management] combining strong opioids, nonopioid analgesics, and peripheral and neuroaxial local anesthetics acting on different sites of the pain pathway.”
However, in a survey of 1,770 members of the American Rhinologic Society, Dr. Govindaraj and colleagues found that the most commonly prescribed pain medications after functional endoscopic sinus surgery were opioids/non-opioid combinations (average of 27 pills) (Int Forum Allergy Rhinol. 2018;8:1199–1203). “What this study demonstrated is that many physicians prescribe a blanket number of opioids based on how they were taught, and do not think about alternative [non-opioid] methods of pain management, such as extra-strength Tylenol or gabapentin, as often as they should.”
In the division of rhinology at Mount Sinai, “we have incorporated a standardized pain management sheet that the surgeon has to fill out about what type of pain medication we want, how many pills we expect to use, and whether we want to incorporate extra-strength Tylenol into that pain regimen,” Dr. Govindaraj said. “We have to better educate patients when they should use stronger opioid medication.”
Dr. Farwell echoed the need to push for safer opioid use. “We’re all well aware of the [risk of misuse and abuse] of opioids, so we’ve become far more aggressive [in using] non-opioid management,” he said. “We’re also conducting research into novel pain regimens, including gabapentin. I think [the opioid crisis has] encouraged a lot of us to look at alternatives to opioids.”
But Dr. Levine worries that in the push to spare opioids, ERAS protocols introduce medications that may not be safe for older patients. As an anesthesiologist at Mt. Sinai, Dr. Levine treats a lot of geriatric patients who are at risk for cognitive decline and delirium. “We really should have ERAS protocols for specific patient populations, as well as for surgical techniques, that account for such risks.
Other Applications in Otolaryngology
Although enhanced recovery protocols are designed for major in-hospital procedures, they can be adopted for many of the ambulatory procedures performed by otolaryngologists, Dr. Govindaraj said. And in many cases, the steps that are needed focus on patient education and optimizing drug therapy, with antibiotic stewardship a prime example.
“The emphasis on antibiotic stewardship is applicable throughout otolaryngology,” Dr. Farwell said. “We [now understand] that antibiotics have been overutilized in the perioperative and therapeutic setting. We are dramatically reducing both the intensity and the duration of our perioperative antibiotics. They are still used for free-flap reconstruction procedures, but we have abandoned their use in routine clean cases.” And that’s a significant improvement, he noted, because “10 years ago, you would [have been] written up if you didn’t prescribe them.”
“I think some of the other protocols, such as hypothermia, early mobilization, [and] reducing the perioperative fluid management, are also applicable across otolaryngology outside of the major free flap surgeries,” he added.
Barriers to ERAS Adoption
According to Dr. Farwell, one of the biggest barriers to the adoption of ERAS protocols is gaps in high-quality data. “Many of these recommendations are based on fairly low-quality evidence, so convincing practitioners to change their approach or their traditional treatment algorithm based on less-than-ideal data is challenging. I think there is an opportunity for us to continue to push ourselves to obtain better data, so that we can strengthen and modify these going forward.”
What concerns Dr. Levine is the protocolization of medicine. “ERAS protocols are guidelines, or guardrails, to give clinicians the sense of the direction they should be moving in to improve patient care, but it does not replace good medical judgement.”
“This is a comprehensive approach to perioperative care, and it really touches on many of our practices. It is imperfect—based on limited data—but I think it encourages surgeons to carefully evaluate each step of the game, so that we can have a cumulative, positive effect on these patients’ outcomes, which provides a better value for our patients,” Dr. Farwell concluded.
Nikki Kean is a freelance medical writer based in New Jersey.