ERAS Society's 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."