ERAS Society's Guidelines on Perioperative Care: Part 1 - Preoperative Care
9. Preoperative glucose and electrolyte management
The experts recommend,
- “Hyperglycemia and hypoglycemia are risk factors for adverse postoperative outcomes. Pre-operatively, glucose levels should be maintained at 144–180 mg/dL (8–10 mmol/L), a variable rate (sliding scale) insulin infusion should be used judiciously to maintain blood glucose in this range with appropriate monitoring of point of care blood glucose in line with local protocols to avoid hypoglycemia.
- Correction of potassium, magnesium and phosphate prior to surgery should be done using the intravenous route with appropriate monitoring and following local hospital policy. However, it should not delay the patient from being taken to the operating room.”
However, the recommendation level was weak.
10. Preoperative carbohydrate loading
The panel noted, “The increased risk of gastric stasis, intra-abdominal pathology, preoperative use of opioids and generalized practice of using preoperative nasogastric tubes and avoiding oral intake prior to surgery meant we extrapolated evidence of potential harm and this group could not recommend the use of carbohydrate loading”. They also noted that they could not identify any studies on the use or benefit of carbohydrate loading in emergency general surgery.
11. Pre-operative nasogastric intubation
The experts strongly recommend, “Pre-operative nasogastric tube insertion should be considered on an individual basis assessing for the risk of aspiration and gastric distension depending on the pathology and patient factors.”
12. Patient and family education and shared decision making
The experts recommend,
- “Patients and families should have the opportunity to discuss the risk of surgery with a senior physician (this could be the surgeon, anesthesiologist or intensive care physician) prior to surgery. Counseling should be informed by a validated risk score but with the clear understanding that scores have limitations when applied to individual patients. When appropriate, treatment escalation plans and advance care plans should be discussed and documented.
- Clear, concise, written information or decision aids combined with verbal patient education should be provided to the patient and family before surgery if possible.”
The authors concluded, “These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.”
For further information:
https://link.springer.com/article/10.1007/s00268-021-05994-9
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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