Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs

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Abstract

Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times.

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Most cited references 56

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Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology.

Ian Smith, Peter Kranke, Isabelle Murat … (2011)

This guideline aims to provide an overview of the present knowledge on aspects of perioperative fasting with assessment of the quality of the evidence. A systematic search was conducted in electronic databases to identify trials published between 1950 and late 2009 concerned with preoperative fasting, early resumption of oral intake and the effects of oral carbohydrate mixtures on gastric emptying and postoperative recovery. One study on preoperative fasting which had not been included in previous reviews and a further 13 studies published since the most recent review were identified. The searches also identified 20 potentially relevant studies of oral carbohydrates and 53 on early resumption of oral intake. Publications were classified in terms of their evidence level, scientific validity and clinical relevance. The Scottish Intercollegiate Guidelines Network scoring system for assessing level of evidence and grade of recommendations was used. The key recommendations are that adults and children should be encouraged to drink clear fluids up to 2 h before elective surgery (including caesarean section) and all but one member of the guidelines group consider that tea or coffee with milk added (up to about one fifth of the total volume) are still clear fluids. Solid food should be prohibited for 6 h before elective surgery in adults and children, although patients should not have their operation cancelled or delayed just because they are chewing gum, sucking a boiled sweet or smoking immediately prior to induction of anaesthesia. These recommendations also apply to patients with obesity, gastro-oesophageal reflux and diabetes and pregnant women not in labour. There is insufficient evidence to recommend the routine use of antacids, metoclopramide or H2-receptor antagonists before elective surgery in non-obstetric patients, but an H2-receptor antagonist should be given before elective caesarean section, with an intravenous H2-receptor antagonist given prior to emergency caesarean section, supplemented with 30 ml of 0.3 mol l(-1) sodium citrate if general anaesthesia is planned. Infants should be fed before elective surgery. Breast milk is safe up to 4 h and other milks up to 6 h. Thereafter, clear fluids should be given as in adults. The guidelines also consider the safety and possible benefits of preoperative carbohydrates and offer advice on the postoperative resumption of oral intake.

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Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials

J Kondrup (2003)

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Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.

A. Kurz, D Sessler, R Lenhardt (1996)

Mild perioperative hypothermia, which is common during major surgery, may promote surgical-wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension. Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen. Hypothermia also directly impairs immune function. We tested the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization. Two hundred patients undergoing colorectal surgery were randomly assigned to routine intraoperative thermal care (the hypothermia group) or additional warming (the normothermia group). The patient's anesthetic care was standardized, and they were all given cefamandole and metronidazole. In a double-blind protocol, their wounds were evaluated daily until discharge from the hospital and in the clinic after two weeks; wounds containing culture-positive pus were considered infected. The patients' surgeons remained unaware of the patients' group assignments. The mean (+/- SD) final intraoperative core temperature was 34.7 +/- 0.6 degrees C in the hypothermia group and 36.6 +/- 0.5 degrees C in the normothermia group (P < 0.001) Surgical-wound infections were found in 18 of 96 patients assigned to hypothermia (19 percent) but in only 6 of 104 patients assigned to normothermia (6 percent, P = 0.009). The sutures were removed one day later in the patients assigned to hypothermia than in those assigned to normothermia (P = 0.002), and the duration of hospitalization was prolonged by 2.6 days (approximately 20 percent) in hypothermia group (P = 0.01). Hypothermia itself may delay healing and predispose patients to wound infections. Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations.