Enhanced Recovery: Why Is the Patient Still in the Hospital?

Educational Objectives

The goal of this program is to improve patient outcomes through adherence to enhanced recovery after surgery (ERAS) protocols. After hearing and assimilating this program, the clinician will be better able to:

1. Cite data showing shortened length of stay using ERAS pathway.
2. Compare reduction in length of stay using ERAS protocols among various specialties and procedures.
3. Optimize use of iron supplementation in treatment of preoperative anemia.

Summary

Background: enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway aimed at achieving early recovery for patients undergoing major surgery; it promotes evidence-based guidelines across specialties to optimize all stages of the surgical journey; ERAS and enhanced recovery pathways (ERPs) are synonymous

Impact of ERAS on length of stay (LOS): studies from 2006 to 2023 consistently show that ERAS significantly reduces LOS by 1.5 to 2.5 days; these reductions have been observed across various patient groups, including older adults, pediatric patients, and emergency cases, as well as in laparoscopic and open surgeries, and in high- and middle-income settings; more recent research has focused on accelerated enhanced recovery, or “hyper-ERAS,” aiming to discharge patients within 24 hr after major colorectal surgery, further shortening LOS; a 2014 paper emphasized that further randomized controlled trials comparing ERAS to the standard of care in colorectal surgery are unnecessary; the authors highlighted that the focus should now shift towards implementing ERAS protocols globally

Across surgical specialties: in gynecology and gynecologic oncology, a 2024 meta-analysis showed a 1-day reduction; for liver resections, a 2020 meta-analysis reported a 2-day reduction, while a 2019 review found a 2.3-day reduction; orthopedics showed similar results, with a 2023 review of total joint replacement patients reporting reduced stays in 96% of studies; cervical spine surgery studies also showed a 2-day reduction; in cardiac surgery, a 2024 review found shorter intensive care unit and hospital stays, while a 2021 meta-analysis in thoracic surgery showed a 2-day reduction; ERAS has also proven beneficial in urology, plastic surgery, and otolaryngology, consistently reducing LOS after major surgeries

Benefits of ERAS: include few complications, low health care costs, and reduced readmissions; patients experience faster return of bowel function and a significant decrease in opioid use; patient and provider satisfaction improve with ERAS; additionally, ERAS helps conserve blood and blood products and lowers the risk for surgical site infections (SSI)

ERAS for patient blood management: preoperative anemia affects up to 33% of surgical patients, particularly in oncology and vascular, cardiac, and obstetric surgeries; blood transfusions can increase infection risks, LOS, costs, and mortality rates; patient blood management programs aim to improve outcomes by optimizing patients’ blood counts, minimizing surgical blood loss, and supporting conservative transfusion protocols; these programs focus on 3 key pillars, ie, optimizing red blood cell production, minimizing blood loss (from surgery or coagulopathy), and maximizing the patient’s physiologic reserve to handle anemia

Preoperative anemia (POA): a 2019 study identified POA as the primary risk factor for transfusions in total hip and knee replacements and proposed strategies to address it; it suggested increasing hemoglobin through medication, such as oral iron (limited absorption and tolerance), intravenous (IV) iron (which is more effective and better tolerated but requires 2-4 wk), and recombinant human erythropoietin (EPO; costly and less commonly used); intraoperative measures, eg, tranexamic acid (TXA), were recommended to minimize blood loss, while hemostatic agents (eg, tourniquets, drainage devices) were found to be less effective; postoperatively, a restrictive transfusion strategy and iron supplementation were advised

Contribution of orthopedic surgery: a 2019 narrative review highlights that orthopedic surgery accounts for ≈10% of all blood transfusions in the United States (US), with total joint procedures alone representing up to 40% of those transfusions; the authors advocate for establishing minimum hemoglobin standards and suggest delaying procedures if these standards are not met; they emphasize correcting anemia, especially iron deficiency, through appropriate preoperative assessment, ideally 30 to 60 days before surgery

Assessing ERAS guidelines: a 2023 review article examining 15 ERAS guidelines found that in 2018, none of the ERAS guidelines included interventions related to patient blood management’s first and third pillars; however, by 2019, guidelines for colorectal, gynecologic, and thoracic surgeries began to incorporate recommendations related to all 3 pillars of blood management; despite these advancements, the review highlighted that many high-risk surgeries, including cardiac and obstetrics, still lacked clear recommendations for conserving blood products

2023 ERAS Cardiac Society conference: key preoperative recommendations included screening for anemia, managing platelet therapy by holding dual antiplatelet medications when feasible, and treating anemia before surgery; intraoperatively, guidelines emphasized maintaining a low hemoglobin threshold of 6 g/dL and advocated for point-of-care testing to optimize blood management; meticulous surgical techniques, use of antifibrinolytics, blood salvage, and retrograde priming were recommended to minimize hemodilution; postoperatively, a restrictive transfusion threshold of 7.5 g/dL was suggested

Yokoi et al (2024): integrated ERAS pathways with blood conservation strategies in orthopedic patients; the intervention included the treatment of anemic patients with EPO or iron supplements, the administration of TXA through a bolus and infusion, and establishing a transfusion threshold of 8 g/dL; the results indicated a notable 12% reduction in overall transfusions, with an average blood loss decrease of ≈350 mL per patient; the study also reported an increase in the use of TXA and extubation rates in the operating room, with all findings being statistically significant

Use of ERAS to decrease the amount of blood products used: reducing blood product use involves early detection and treatment of anemia using oral or IV iron and potentially delaying surgery to optimize hemoglobin levels; key intraoperative strategies include minimally invasive surgery, use of pharmacologic agents such as TXA, and real-time laboratory data for decision-making; postoperatively, erythropoiesis stimulation, careful fluid management to avoid dilutional anemia, and monitoring for coagulopathy and bleeding are crucial; standardizing transfusion thresholds and enhancing communication among the surgical team can further reduce unnecessary transfusions

Surgical Site Infections

Background: hospital-acquired infections (HAIs) cost the US health care system around $10 billion annually, but progress in addressing them has been limited; one reason is the fragmented approach, where various hospital departments tackle issues in isolation, leading to inefficient efforts and limited success; ERAS protocols, or fast-track protocols, offer a solution by promoting a collaborative, multidisciplinary approach

Grant et al (2017): hypothesized that the implementation of ERAS could not only speed up postoperative recovery but also reduce HAIs; they found that ERAS was significantly associated with a decrease in lung infections, urinary tract infections (UTIs), and SSIs compared with conventional surgical care; when focusing specifically on colorectal surgery, they found that ERAS significantly reduced infections; they attributed this improvement to the use of laparoscopic surgery, pathogen-directed preincision prophylactic antibiotics, and proper surgical site preparation; other recommended strategies included maintaining normothermia, administering preoperative carbohydrates, early removal or avoidance of drains and nasogastric tubes, and promoting early enteral feeding

Impact of SSI in urologic procedures: a 2023 meta-analysis found a significant reduction in infections within the ERAS group, with 6 fewer infections by day 3 and 4 fewer by day 7, compared with traditional care; although these studies included small patient groups (30-50 per study), the decrease in infections was deemed significant; however, the specific interventions contributing to the reduced infection rates were not detailed, and the studies simply noted the use of ERAS protocols; similarly, a 2023 meta-analysis on colorectal surgeries found a significant reduction in both SSIs and overall postoperative complications with ERAS

Practice at University of Texas Southwestern Medical Center: a high rate of SSIs in colorectal surgeries led to efforts aimed at reducing them by 50% over 2 yr; key risk factors identified included not changing trays or gowns during surgery, combination procedures, and delayed patient mobilization, all of which significantly raised infection risk; to address this, the team implemented an SSI bundle within an ERAS protocol; this involved preoperative measures such as using oral antibiotics with bowel preparations, chlorhexidine showers, and standardized antibiotic administration; intraoperatively, they introduced fresh trays and gown changes before wound closure; postoperatively, early mobility was prioritized; in 2020, with 308 surgeries, there were 27 SSIs, leading to 547 hospital days and 81 readmission days; by 2021, after protocol implementation, SSIs dropped to 13 (290 surgeries), with hospital days halved; the improvements were sustained in 2022 with 14 SSIs and fewer hospital days

Readings

Grant MC, Yang D, Wu CL, et al. Impact of enhanced recovery after surgery and fast track surgery pathways on healthcare-associated infections: results from a systematic review and meta-analysis. Ann Surg. 2017;265(1):68-79. doi: 10.1097/SLA.0000000000001703. Erratum in: Ann Surg. 2017;266(6):e123. doi:10.1097/SLA.0000000000002501; Gupta S, Panchal P, Gilotra K, et al. Intravenous iron therapy for patients with preoperative iron deficiency or anaemia undergoing cardiac surgery reduces blood transfusions: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2020;31(2):141-151. doi:10.1093/icvts/ivaa094; Loria CM, Zborek K, Millward JB, et al. Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use. JTCVS Open. 2022;12:280-296. doi:10.1016/j.xjon.2022.08.008; Lu SY, Lai Y, Dalia AA. Implementing a cardiac enhanced recovery after surgery protocol: nuts and bolts. J Cardiothorac Vasc Anesth. 2020;34(11):3104-3112. doi:10.1053/j.jvca.2019.12.022; Moon T, Smith A, Pak T, et al. Preoperative anemia treatment with intravenous iron therapy in patients undergoing abdominal surgery: a systematic review. Adv Ther. 2021;38(3):1447-1469. doi:10.1007/s12325-021-01628-7; Smith TW Jr, Wang X, Singer MA, et al. Enhanced recovery after surgery: a clinical review of implementation across multiple surgical subspecialties. Am J Surg. 2020;219(3):530-534. doi: 10.1016/j.amjsurg.2019.11.009; Yokoi H, Chakravarthy V, Winkleman R, et al. Incorporation of blood and fluid management within an enhanced recovery after surgery protocol in complex spine surgery. Global Spine J. 2024;14(2):639-646. doi:10.1177/21925682221120399.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Street was recorded at the Texas Society of Anesthesiologists 2024 Annual Meeting, held September 5-8, 2022, in San Antonio, TX, and presented by Texas Society of Anesthesiologists. For information on upcoming CME activities from this presenter, please visit tsa.org. Audio Digest thanks the speakers and Texas Society of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

AN664602

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.