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

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