ERAS Society's Guidelines on Perioperative Care: Part 1 - Preoperative Care
4. Risk assessment
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.”
ERAS Society Guidelines on Perioperative Care: Part 1 - Preoperative Care
Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. Recently experts of the International ERAS® Society have published their first consensus guidelines for optimal care of patients using an ERAS approach. The guidelines were published in the World Journal of Surgery on March 06, 2021.
The expert panel searched the Pubmed, Cochrane, Embase, and MEDLINE database for for ERAS elements and relevant specific topics. They included a total of 12 elements of preoperative care. They reviewed randomized controlled trials, systematic reviews, meta-analyses and large cohort studies and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate.
Following are the recommendations of the Preoperative Care:
1. Early identification of physiological derangement, and intervention
The expert panel strongly recommend,
- "Resuscitation and correction of underlying physiological derangement should begin immediately and should continue during diagnostic pathways.
- Rapid assessment of the patient for physiological derangement using a validated method such as an Early Warning Scoring (EWS) system should occur. Abnormal scores should trigger rapid escalation to senior personnel in line with pre-established local protocols. While awaiting surgery patients should have regular re-evaluation, with a frequency dictated by local physiological track and trigger protocols."
2. Screen and monitor for sepsis and accompanying physiological derangement
The panel strongly recommend,
- "All patients for emergency laparotomy should be assessed with a validated sepsis score as early in their presentation as possible. This should be repeated at appropriate intervals in line with severity of signs and sepsis risk stratification guidance.
- If SIRS, sepsis or septic shock are diagnosed, or when the underlying surgical pathology makes the patient at high risk of infection or sepsis, such as patients with peritonitis or hollow viscus perforation, treatment should begin immediately in line with the Surviving Sepsis management algorithms including measurement of lactate . Delay to antibiotic administration in patients with sepsis increases mortality.
- Monitoring of blood lactate as a marker of risk and in assessment of physiological response to resuscitation should be considered even in the absence of sepsis."
3. Early imaging, surgery, and source control of sepsis
The team of experts strongly recommend,"Delay to surgery increases mortality in patients with sepsis and septic shock. All patients with septic shock should receive source control with surgery or interventional radiology as soon as possible and within 3 h. For patients with sepsis without septic shock, source control should occur within 6 h."
With regard to Radiological Intervention they stringly recommend to, "Perform a CT scan with IV contrast as soon as possible if indicated. The CT scan should be reviewed by a radiologist immediately. Acquiring a CT scan should not cause a delay to surgery if surgery is very urgent."
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