ERAS Society's Guidelines on Perioperative Care: Part 1 - Preoperative Care

The panel strongly recommend, “A risk score using a validated model should be performed and documented on all patients prior to surgery, and at the end of surgery. The score can be used to guide pathways of care and facilitate discussion between team members and with patients and family on treatment, risks and limitations.”

5. Age-related evaluation of frailty, and cognitive assessment

Concerning Delirium and perioperative neurocognitive disorders, the team strongly recommend,

• “All patients over 65 years of age, and others at high risk, for example patients with cancer, should be assessed for frailty using a validated frailty score.
• Perform a validated simple assessment of cognitive function such as the Mini-Cog® in all patients over 65 years of age if time permits. For patients who are at risk for delirium and postoperative cognitive dysfunction take steps to keep the patient oriented and avoid drugs known to cause harm as defined in the Beers’ criteria.
• All patients over 65 should have regular delirium screening pre and postoperatively with a validated assessment method.
• Patients over 65 years of age should be assessed by a physician with expertise in care of the older patient (geriatrician) pre-operatively and evidence-based elder-friendly practices used. If preoperative assessment is not possible refer for postoperative follow-up.”

6. Reversal of antithrombotic medications
Regarding Anticoagulants (Warfarin, DOACs, Heparin/Enoxaparin), the experts strongly recommend, “Strongly consider reversal of home anticoagulation medications when major surgical intervention is planned. This decision should be based on both the patient’s risk of procedure-related bleeding and the risk of thromboembolism.”
For Platelet inhibitors: (including Aspirin, Clopidogrel, Dipyridamole, Ticagrelor), they recommend, “Consider platelet transfusion in patients taking antiplatelet therapy when the planned procedural bleeding risk is high. In patients with a strong indication for antiplatelets, specialty consultation should be obtained for perioperative co-management of these medications.”

Unlike the recommendation of anticoagulants which was strong, the recommendation for platelet inhibitors was weak.

7. Assessment of venous thromboembolism risk

The expert panel strongly recommend, “Patients should be risk assessed with a validated tool for VTE risk on admission. If pharmaceutical prophylaxis is not possible mechanical prophylaxis should be used. Reassessment should occur daily postoperatively. ”

8. Pre-anesthetic medication—anxiolysis and analgesia

The team of experts strongly recommend,

• “Sedative medication should be avoided preoperatively to avoid the risk of micro-aspiration, hypoventilation and delirium.
• Analgesia should be given to alleviate the patient’s pain and stress.
• Multi modal opioid-sparing analgesia should be titrated to effect to maximize comfort and minimize side-effects.”