Enhanced Recovery After Surgery: A Complete Guide to Optimizing Outcomes

Foreword
Preface
Acknowledgment
Contents
Editors and Contributors
	Editors
	Section Editors
	Contributors
Part I: Introduction
	1: Enhanced Recovery After Surgery: A Paradigm Shift in Perioperative Care
		Introduction
		Effect of Specialization
		Resources for Care
		The Role of Individual Doctors
		The Basics of ERAS®
		Evidence-Based Protocols
		The ERAS Team
		Audit
		Reporting
		Readiness to Change
		The Next Steps in ERAS
		References
	2: Physiology and Pathophysiology of ERAS
		Introduction
		Glucose Metabolism
			Pathophysiology
			Assessment
			Clinical Relevance
		Insulin Metabolism
			Pathophysiology
			Assessment
			Clinical Relevance
		Protein Metabolism
			Pathophysiology
				Bed Rest and Fatigue
				Malnourished Patients
			Assessment of Catabolism
			Clinical Relevance
		Metabolic Attenuation of the Stress Response
			Perioperative Nutrition
			Insulin Therapy
			Minimally Invasive Surgery
			Neural Deafferentation
			Maintenance of Intraoperative Normothermia
			Physical Activity and Mobilization
		Conclusion
		References
	3: Guidelines for Guidelines
		What Are Guidelines?
		Why Is There a Need for Guidelines?
		Who Is an Expert?
		Developing a Guideline
			Scoping the Guideline
			Guideline Development Groups
			Literature Search
			Analyzing Evidence Quality
			Strength of Recommendations
		The Role of Delphi Processes
			What Is a Delphi Process?
		Maintaining Guideline Quality
			The Need to Update Guidelines
			The ERAS® Society Guidelines and Recommendations
		References
Part II: Preoperative Preparation
	4: Preoperative Fasting and Carbohydrate Treatment
		Background
		Perioperative Metabolism and the Role of Insulin Resistance
		Fasting Before Surgery
		Preoperative Oral Carbohydrates
			How Do Preoperative Carbohydrates Work?
				The Metabolic Response to Preoperative Oral Carbohydrates
				Mechanisms Behind Metabolic Effects by Preoperative Oral Carbohydrates
			Effects on Clinical Outcome by Preoperative Oral Carbohydrates
			Preoperative Oral Carbohydrates as a Part of the ERAS Protocol
		Conclusion
		References
	5: Preoperative Patient Education
		Preoperative Education: Rational
		Preoperative Education: By Whom and How?
		Preoperative Education: Delivery Methods
			Face-to-Face Preoperative Education
			Written Information
			Surgery School
			Digital Information
			ERAS Nurse
		Preoperative Educational Content
			Colorectal
			Gynecological Surgery
			Orthopedic
			Thoracic Surgery
			Upper Gastrointestinal Surgery
			Prehabilitation
		Patient’s Opinions
		Conclusion
		References
	6: Perioperative Optimization of Patient Nutritional Status
		Rationale and Scope
		Definitions
			Malnutrition
			Sarcopenia
		Current Assessment of Nutritional Disorders
			Malnutrition Risk Screening
			Sarcopenia Screening
		Epidemiology of Nutritional Disorders in Surgical Patients
		Clinical Significance of Nutritional Disorders in Surgical Patients
			Malnutrition
			Sarcopenia
		Nutritional Intervention in the Preoperative Patient
			Obesity
			Immunonutrition
			Vitamin Supplementation
		Example of Disease-Specific Considerations
			Crohn’s Disease
		Conclusions and Future Directions
		References
	7: Anemia and Blood Management
		Introduction
		Anemia: Incidence and Causes
		Anemia of Chronic Disease
		Anemia: Risks of Complications and Mortality
		Optimal Perioperative Hemoglobin Targets
		Preoperative Interventions to Increase Hemoglobin in Iron Deficiency Anemia
			Oral Iron Therapy
			Intravenous Iron Infusions
			Use of Erythropoietin-Stimulating Agents (ESA)
		Perioperative Blood Management
			Reducing Blood Loss During Surgery and the Postoperative Period
				Surgical and Anesthetic Technique to Reduce Blood Loss
				Red Cell Salvage
				Antifibrinolytics
				Reducing Frequency and Volume of Blood Tests
		Conclusion
		References
	8: Perioperative Smoking and Alcohol Cessation
		Smoking Cessation
			Why, When, Who, and How?
				Smoking: Perioperative Pathophysiologic Changes
				Smoking and Smoking Cessation With and Without Perioperative Interventions: Impact on Clinical Outcomes
				Perioperative Smoking Cessation Interventions: Short- and Long-Term Smoking Cessation Rates
			When and Whose Responsibility?
			How?
				Counseling
				Pharmacotherapy
				Duration and Intensity of Preoperative Smoking Cessation Interventions, Smoking Cessation Rates, and Complications
			Withdrawal Syndrome
		Alcohol Cessation
			Alcohol Abuse and Cessation in the Perioperative Period: Pathophysiologic Changes and Impact on Clinical Outcomes
			Perioperative Alcohol Cessation Strategies
				Counseling
				Pharmacotherapy
		Conclusions and Main Findings
		References
	9: Preoperative Medical Optimization
		Introduction
		Who Should Be Assessed?
		Timing
		Patient Risk Assessment
		Optimization of “Non-modifiable” Factors: Genetics, Age, Gender, and Race
			Genetics
			Age
			Gender and Race
		Optimization of Modifiable Factors
			Anemia
			Nutrition
			Diabetes
			Hypertension
			Cardiovascular Disease
				Atrial Fibrillation
			Pulmonary Conditions and Obstructive Sleep Apnea
			Renal Disease
			Coagulation Disorders and Anticoagulant Use
			Psychological Factors, Chronic Pain, and Opioid Tolerance
			Penicillin Allergy
		The Patient Presenting for Emergent Surgery
		Conclusion
		References
	10: Prehabilitation
		Introduction
		Screening and Assessment
		Elements of Intervention
		Role of Exercise
		Role of Nutrition
		Role of Psychology
			Self-Efficacy
			Sense of Purpose
			Personal Control
			How We Integrate the Above Concepts; Guidelines from the Prehabilitation Platform
		Effective Prehabilitation
		Conclusion
		References
	11: Cognitive Behavior Counseling: Preoperative Preparation in ERAS
		Introduction
		Cognitive Behavioral Therapy
			Integration of CBT Within Prehabilitation Programs
		References
	12: Bowel Preparation: Always, Sometimes, Never?
		Introduction
		Arguments in Favor of Mechanical Bowel Preparation
		Arguments Against the Routine Use of Mechanical Bowel Preparation
		Patient Effects and Considerations
		Surgical Site Infection and Anastomotic Leak Rates
		Mechanical Bowel Preparation Versus No Preparation
		Mechanical Bowel Preparation with Combined Versus Unimodal Antibiotics
		Systemic and Oral Antibiotics Without Mechanical Bowel Preparation
		Site of Resection
		Conclusion
			Summary
		References
	13: Pharmacogenomics in Perioperative Care
		Introduction
		Neuromuscular Blocking Agents
		Local Anesthetic Response
		Inhaled Anesthetics
		Response to Opioids
			Codeine
			Fentanyl
			Hydrocodone
			Methadone
			Tramadol
			Oxycodone and Oxymorphone
			Buprenorphine
		Malignant Hyperthermia
		Benzodiazepine Response
		Nausea and Vomiting
		Cardiovascular/Coagulation Pharmacogenomics
		Summary and Future Directions of Pharmacogenomics
		Conclusion
		References
Part III: Intraoperative Management
	14: Anesthetic Management and the Role of the Anesthesiologist in Reducing Surgical Stress and Improving Recovery
		Introduction and Rationale
		The Surgical Stress Response
		Stress Response Modification: Theory
			Minimal Invasive Surgery
			Opioids
			Neuraxial Blockade
		Stress Response Modification: Modern Approach
			Preoperatively
				Hydration and Nutrition: Carbohydrate Loading
				Prewarming
				Management of Anxiety
			Intraoperative Management
				Appropriate Intravenous Antibiotics
				Avoidance of Hypothermia
				Depth of Anesthesia Monitoring
				Monitoring of Neuromuscular Block (NMB)
				Intravenous Fluid Management
				Analgesia
					Systemic Analgesics
					Local Anesthetics
		Conclusion
		References
	15: Analgesia During Surgery (Medications)
		Introduction
		Pain Pathways in the Context of Analgesia During Anesthesia
		Intraoperative Multimodal Analgesia Management
			Opioid Analgesics
			Non-opioid Additives Within the Context of Multimodal Anesthesia
				Lidocaine
				Ketamine
				Alpha-2 Agonists
				Magnesium
				Beta-Blockers
				Dexamethasone
		Conclusion
		References
	16: Regional Anesthesia Techniques for Abdominal Operations
		Introduction
		Basics: Dermatomes
		Neuraxial Anesthesia
			Spinal Anesthesia
				Anatomy
				Equipment and Technique
				Pros and Cons
				Evidence
			Epidural Anesthesia
				Anatomy
				Equipment and Technique
				Pros and Cons
				Evidence
		Abdominal Wall Blocks
			Paravertebral
			Quadratus Lumborum
				Anatomy
				Equipment and Technique
				Pros and Cons
				Evidence
			Transversus Abdominis Plane
				Anatomy and History of Use (and Misuse)
				Equipment and Technique
				Pros and Cons
				Evidence
			Transversalis Fascia
				Anatomy
				Equipment and Technique
				Pros and Cons
				Evidence
		Conclusion
		References
	17: Prevention of Intraoperative Hypothermia
		Introduction
		Why Patients Lose Heat
		Temperature Distribution
		Temperature Measurement
		Maintaining Normothermia
		Prewarming
		Conclusion
		References
	18: Perioperative Intravenous Fluid Therapy in ERAS Pathways
		Introduction
		Preoperative Fluid Therapy
		Intraoperative Fluid Therapy
		Postoperative Fluid Therapy
		Urine Output
		Types of Fluid
		Conclusion
		References
	19: ERAS and Minimally Invasive Surgical Techniques
		Introduction
		Background to Minimally Invasive Surgery
			Cholecystectomy
			Colorectal Resection
			Upper Gastrointestinal Cancer
			Hepatobiliary
		Enhanced Recovery in the Era of Minimally Invasive Surgery
			LAFA: Perioperative Strategy in Colonic Surgery – Laparoscopy or Fast-Track Multimodal Management Versus Standard Care
			EnROL: A Multicenter Randomized Trial of Conventional Versus Laparoscopic Surgery for Colorectal Cancer Within an Enhanced Recovery Program
		Physiological Consequences of Minimally Invasive Surgery
		Conclusion
		References
	20: Tubes and Drains: Current Updates on Evidence on Their Role Within Recovery
		Introduction
		Nasogastric Tubes
			Esophageal Surgery
			Gastric Surgery
			Liver Surgery
			Colon and Rectal Surgery
		Abdominal Drains
			Pancreatic Surgery
			Gallbladder Surgery
			Bariatric Surgery
			Colorectal Surgery
			Gynecologic Surgery
				Pelvic and/or Para-aortic Lymphadenectomy
				Bowel Resection for Tumor Cytoreduction
				Groin Lymphadenectomy
				Cesarean Delivery
		Conclusion
		References
Part IV: Postoperative Management
	21: Management of Postoperative Nausea and Vomiting (PONV)
		Introduction
		Pharmacological Interventions to Facilitate Enhanced Recovery
		Importance of Effective Antiemetic Prevention and Therapy in Enhanced Recovery
		Basic Pathophysiology of Postoperative Nausea and Vomiting
		Risk Factors
		Basic Measures Against Postoperative Nausea and Vomiting
		Specific Measures of Postoperative Nausea and Vomiting Prophylaxis
			Dexamethasone
			5-HT3 Receptor Antagonists
			Neurokinin-1 Receptor Antagonists (NK-1-RA)
			Butyrophenones
			Metoclopramide
			Dimenhydrinate
			Scopolamine
		Indication for Antiemetic Prophylaxis
		Therapy of Nausea and Vomiting as well as Discomfort After Discharge
		Conclusion
		References
	22: Early Oral Nutrition
		Introduction
		Safety of Early Resumption of Diet
		Evidence in Surgical Subspecialties
			Colorectal Surgery
			Upper Gastrointestinal Surgery
			Pancreatic Surgery
			Hepatic Surgery
		Nutritional Supplementation Strategies
			Postoperative Immunonutrition
			Parenteral Nutritional Supplementation
		Conclusion
		References
	23: Early Ambulation and Physiotherapy After Surgery
		Introduction
		Early Ambulation
			Early Ambulation in Surgical (Nonorthopedic) Pathways
		Avoidable Common Barriers to Early Mobilization
			Early Ambulation in Orthopedic (Hip and Knee Replacement) Surgery
			Early Ambulation and Physiotherapy for ERAS Patients Within the Intensive Care Unit
		Postoperative Physiotherapy
			Postoperative Physiotherapy in General Surgery
			Postoperative Physiotherapy in Orthopedic (Hip and Knee Replacement) Surgery
		Conclusion
		References
	24: Postoperative Multimodal Pain Management
		Introduction
		Acute and Chronic Effects of Postoperative Pain
			Acute Effects of Pain
			Chronic Effects of Pain
		Preventive Analgesia
		Multimodal Pain Management Strategies
		Opioid Analgesia
		Non-opioid Analgesia
			Acetaminophen
			Nonsteroidal Anti-inflammatory Drugs
			Gabapentinoids
			Ketamine
			Tramadol
		Epidural Analgesia
		Spinal Analgesia
		Surgical Site Infiltration and Locoregional Techniques
		Conclusion
		References
	25: Nursing Considerations During Patient Recovery
		Introduction
		Current Evidence
			What Makes the Difference with Standard Care? – A Shift of Activities!
			Clinical Pathways
			Reasons for Non-compliance with the Protocols
			Nursing Workload
		Nurses on the Surgical Ward
			ERAS-Specific Education
			Discharge Planning
		Future and Development
		Conclusion
		References
Part V: Prevention of Postoperative Complications
	26: Long-Term Outcomes Related to ERAS
		Introduction
		The Association Between the Surgical Stress Response and Long-Term Oncological Outcomes
		Overall Effect of ERAS on Oncological Outcomes
			Long-Term Oncological Benefits of ERAS Adherence
			Benefits Based on Reduced Overall Complications
		Individual Component of ERAS and Long-Term Oncological Outcomes
			Minimally Invasive Surgery and Long-Term Oncological Outcomes
			Analgesia in ERAS Protocols and Long-Term Oncological Outcomes
			Antimicrobial Prophylaxis and Mechanical Bowel Preparation
			Perioperative Fluid Management
			Early Oral Intake
		Overall Effect of ERAS on Patient-Reported Outcomes
		Organ-Specific Interventions in an ERAS Setting
			Postoperative Pulmonary Complications
			Myocardial Injury After Non-cardiac Surgery (MINS)
		Conclusion
		References
	27: Postoperative Ileus: Prevention and Treatment
		Introduction
		Definitions
		Pathophysiology
		Risk Factors
		Complications of Ileus
		Management of Postoperative Ileus
		Prevention Strategies
			Perioperative Phase
				Salt and Water Management
				Opioid-Sparing Analgesia
					Midthoracic Epidural Analgesia
					Intravenous Lidocaine
				Surgical Approach
				Nasogastric Tubes
			Postoperative Phase
				Early Oral Feeding
				Prokinetics
				Laxatives
				Chewing Gum
				Nonsteroidal Anti-inflammatory Drugs
				Alvimopan
		Treatment
		Other Future Therapies
		Conclusion
		References
	28: Antibiotic Prophylaxis and Surgical Site Infection Prevention
		Introduction
		Pathogenesis
		Pathogens
		Basic Principles of Prevention
		Control of the Source of Infection
		Use of Appropriate Antibiotics
		Duration of Administration
		Allergy to Antibiotics
		Classification of Surgical Site Infections
			Intra-abdominal Infections
			Specific Organ Infection
			Infection of the Skin and Soft Tissues
			Nosocomial Infection After Surgery
			Sepsis
		Enhanced Recovery After Surgery
		References
	29: Thromboprophylaxis
		Introduction
		Epidemiology and Risk Factors
		Complications of Venous Thromboembolism
		Prevention of Venous Thromboembolism
			Risk Assessment
			Thromboprophylaxis
				Non-pharmacological Treatments
			Pharmacological Treatments
				Unfractionated Heparin and the Low-Molecular-Weight Heparins
				Heparin Alternatives
				Antiplatelet Agents
				Coumarins
				Direct Oral Anticoagulants
				Patients Already Anticoagulated
		ERAS® Society Guidelines
			Some Specialties Currently Not Covered by ERAS® Society Guidelines
				Orthopedic Surgery
				Obstetrics
		The Future
		Conclusion
		References
Part VI: ERAS After Discharge
	30: Functional Recovery at Home and After Discharge
		Introduction
		Functional Recovery
		Patient-Reported Outcomes
		Symptom Burden
		Wearable Technology
		Conclusion
		References
	31: Recovery Within the Cancer Journey
		Introduction
		The RIOT Concept
		Impact of Postoperative Complications and Riot on Oncological Outcomes
			Hepatobiliary Oncology
			Breast Cancer
		Conclusion
		References
	32: Readmission Challenges and Impacts Within ERAS
		Introduction
		The Burden of Postoperative Readmissions
		Discharge and Readmission in the ERAS Era
			Studies that Showed Similar Readmission Rates Between ERAS and Conventional Recovery Groups
				Colorectal Surgery
				Non-colorectal Abdominal Surgery
				Urology
				Transplant
				Thoracic Surgery
				Gynecologic Oncology
			Studies that Showed an Increased Readmission Rate After ERAS Recovery
		Institutional ERAS Readmission Data
		Postoperative Emergency Room Visits Not Requiring Readmission
		Patient and Physician Perspectives
		Predicting and Preventing Readmission
			How Can Modifiable Risk Factors That Can Be Addressed Preoperatively Lead to a Decrease of Readmission Rates?
				Multimodal Prehabilitation
				Focused Preoperative Patient Education
		Conclusion
		References
	33: An Example of a Patient’s Experience in ERAS
		In the Hospital
		After Discharge Experience
		Recommendations
			Upon Diagnosis
			Preparing for Surgery
			At the Hospital Immediately After Surgery
			At Home Post-Surgery
Part VII: Safety and Quality Improvement in ERAS
	34: Measuring Outcomes in ERAS
		Overview
		Measuring ERAS
			Why Do We Need to Measure Outcomes of ERAS?
			Measuring Process Versus Outcomes
		How Are ERAS Outcomes Currently Assessed in the Literature?
		When to Measure ERAS Outcomes?
			Classification of ERAS Outcomes
			Outcomes in the Early Phase of Recovery
				Pain Control
				Gastrointestinal Recovery
				Complications
				Length of Hospital Stay
			Outcomes in the Intermediate Phase of Recovery
				Global Recovery
			Outcomes in the Late Phase of Recovery
				Functional Status
				Pain Control
				Health-Related Quality of Life
				Hospital Readmissions
				Cognitive Function Testing
		Long-Term Impact of ERAS
		Limitations of Measuring Outcomes
		Conclusion
		References
	35: Measurement of Recovery Within ERAS
		What Does It Mean to Recover?
		The Temporal Nature of Recovery
		Measurement of Recovery Within ERAS Programs
		Concept Analyses and the Development of Modern ERAS Recovery Assessment
		Approaches to Recovery Assessment
			Objective Versus Subjective Assessment
			Objective Outcomes
				Clinical Performance Indicators
			Subjective Outcomes
				Patient-Reported Outcomes
				Response Shift and Recall Bias
				Satisfaction
		Quantifying Recovery
			Composite Change Scores
			Dichotomized Recovery Scores
			The Importance of Using the Patient’s Own Baseline as the Comparator
		Contextual Real-Time Recovery: The Future of Modern Recovery Assessment
		The Postoperative Quality of Recovery Scale (PostopQRS)
		Conclusion
		References
	36: Measuring Compliance: Audit and Data Collection
		Introduction
		Conclusion
		References
	37: Success and Failure of ERAS: Prediction Models of Outcomes
		Introduction
		Success and Failure Definitions for ERAS Pathways
		The Role of Complications on Compliance Within an ERAS Protocol
		Identification of Individuals at Risk for Complications
		Predictive Analytics Within ERAS Pathways
		Institutional Experience with Integrated Predictive Analytics to ERAS Pathways (F-ERAS)
		Examples of Integrated Predictive Analytics to ERAS Pathways (F-ERAS)
		Examples of Addition of Items Outside the Core of a Traditional ERAS Pathway
		Prehabilitation Strategies to  Augment ERAS “Success”
		Conclusions and Future Directions
		References
	38: Research Methods in Enhanced Recovery After Surgery
		Introduction
		Preclinical Research
		Descriptive Studies
		Observational Studies
			Bias in Observational Studies
		Clinical Trials
			Quasi-experimental Design
			Experimental Clinical Trials
		Study Outcomes
		Reporting ERAS Research
		Conclusion
		References
	39: Toward a Learning System for ERAS: Embedding Implementation and Learning Evaluation
		Introduction
		Management of Surgical Risk and Quality Improvement
		An Organizing Principle for ERAS Implementation: The Modified Donabedian Model
		The Design Focused Implementation Framework
			Designing the System: The Experience-Based Co-design Approach
			Implementing the Design: The Role of Implementation Research
			Adaptations and Improvement: The Model for Improvement and Implementation
			Continuous Learning from Evaluation
		Implementing ERAS: Some Foundational Considerations for Scale-Up and Sustainability
			Principle 1: Building Trust for Organizational Resilience
			Principle 2: Design Multi-stakeholder Collaboration and Authentic Learning Partnerships
			Principle 3: Select and Train the ERAS Team
			Principle 4: Establish Learning Collaboratives
			Principle 5: Integrate Practices from Human Factors Engineering into ERAS Microsystem Functioning
		Conclusions and Research Recommendations
			Research ERAS Road Map
				Nearer-Term Research Questions
				Longer-Term Research Questions
		References
Part VIII: Specialty-Specific Enhanced Recovery Programs
	40: ERAS in Colorectal Surgery
		Background
		Implementation of ERAS Protocols
		The ERAS Protocol and Number of Interventional Items
		ERAS Items and Their Importance in Optimizing Perioperative Care in Colorectal Surgery
			Preadmission Items
			Preoperative Items
			Intraoperative Items
		Surgical Approach
			Postoperative Items
		Audit and Compliance to the Protocol
		The ERAS Protocol in Colorectal Surgery, Future Perspectives
		References
	41: Enhanced Recovery After Surgery: Recommendations for Esophagectomy
		Introduction
		Preoperative Components
			Multidisciplinary Tumor Board
			Prehabilitation
			Nutrition
		Operative Components
			Timing of Surgery
			Surgical Access
			Lymphadenectomy
			Esophageal Reconstruction
			Surgical Drain, Nasogastric Tube, and Urinary Catheter Placement
			Post-Esophagectomy Nutrition
			Anesthetic Management
		Postoperative Components
			Analgesia
			Mobilization
		Preoperative Components
			Pharmacological Prophylaxis
				Antithrombotic Prophylaxis
				Postoperative Nausea and Vomiting (PONV) Prophylaxis
				Antimicrobial Prophylaxis
			Preoperative Fasting
		Audit
		Conclusion
		References
	42: Enhanced Recovery After Gastrectomy
		Introduction and Methods
			Quality Assessment and Grading
			Procedure-Specific Items Versus General Upper Abdominal Surgery Items
		Results Part 1: Procedure-Specific Items
			Preoperative Nutrition
			Preoperative Oral Pharmaconutrition
			Access: Distal Gastrectomy
			Access: Total Gastrectomy
			Wound Catheters and Transversus Abdominis Plane Block
			Intravenous Analgesia
			Nasogastric/Nasojejunal Decompression
			Perianastomotic Drains
			Early Postoperative Diet and Artificial Nutrition
			Audit
		Results Part 2: General (Not Procedure-Specific) Items
			Preoperative Smoking and Alcohol Consumption
			Preoperative Fasting and Preoperative Treatment with Carbohydrates
			Antithrombotic Prophylaxis
			Antimicrobial Prophylaxis and Skin Preparation
			Epidural Analgesia
			Anesthetic Management
			Postoperative Nausea and Vomiting
			Avoiding Hypothermia
			Postoperative Glycemic Control
			Fluid Balance
		Comments
		References
	43: Bariatric Surgery
		History and Background
		ERAS in Bariatric Surgery
			Preoperative Interventions
				Preoperative Information
				Prehabilitation and Exercise
				Smoking and Alcohol
				Preoperative Weight Loss
				Preoperative Fasting
				Carbohydrate Loading
				Premedication
			Intraoperative Interventions
				Anesthesia
				Fluid Management
				Surgical Technique
				Abdominal Drains and Nasogastric Tube
			Postoperative Interventions
				Thromboprophylaxis
				Postoperative Analgesia
				Nutrition and Substitution of Micronutrients
			Groups of Patients Requiring Specific Considerations
				Diabetes
				Sleep Apnea
		Conclusion and Future Focus of Research
		References
	44: ERAS for Major Urological Procedures: Evidence Synthesis and Recommendations
		ERAS in Urology: Background
			Rationale for Enhanced Recovery Pathways in Urology
			Background and History of the ERAS® Society – Urology Chapter
		Summary of ERAS Guideline for Urological Surgery
			The Preoperative Phase
				Preoperative Counseling
				Preoperative Optimization
				Oral Mechanical Bowel Preparation
				Preoperative Fasting
				Preoperative Carbohydrates Loading
				Preanesthesia Medication
				Thrombosis Prophylaxis
			The Surgical Phase
				Analgesia
				Minimally Invasive Approach
				Resection Site Drainage
				Antimicrobial Prophylaxis and Skin Preparation
				Standard Anesthetic Protocol
				Perioperative Fluid Management
				Preventing Intraoperative Hypothermia
			The Postoperative Phase
				Nasogastric Intubation
				Urinary Drainage
				Prevention of Prolonged Postoperative Ileus
				Prevention of Postoperative Nausea and Vomiting
				Postoperative Analgesia
				Early Mobilization
				Early Oral Diet
				Audit
		Do Guidelines Really Work? Clinical Results in the “After Guidelines” Era (2014–2018)
		Urological Specific Highlights
		Conclusion and Future
		References
	45: ERAS for Breast Reconstruction
		What Is Breast Reconstruction?
		Why Do Women Choose Reconstruction?
		What Types of Breast Reconstruction Are Available?
		Why Do Women Undergoing Breast Reconstruction Need an Enhanced Recovery After Surgery (ERAS) Pathway?
			Recovery Is Unexpectedly Difficult
			Women are Undergoing More Breast Surgery than in the Past
			Postoperative Nausea and Vomiting Risk Is Particularly High in This Patient Population
			Breast Reconstruction Is Almost Always a Series of Operations, Resulting in Multiple Recovery Periods
		What Are the Recommendations in the ERAS© Guideline That Are Unique to Breast Reconstruction?
			Preadmission
			Preoperative
			Intraoperative
			Postoperative
			Post Discharge
		What Has the Research Shown in Terms of Efficacy of ERAS® in Breast Reconstruction?
			Autologous Breast Reconstruction
			Alloplastic Breast Reconstruction
		What Is the Next Frontier of Breast Reconstruction ERAS?
			Consistency
			Better Support at Home
		References
	46: Gynecologic/Oncology Surgery
		Introduction
		ERAS Gynecologic/Oncology Guidelines
		Updates and Areas for Future Inclusion in Guidelines
			Perioperative Nutritional Care
			Venous Thromboembolism Risk in Gynecologic Cancer Surgery
			Preoperative Bowel Preparation: Current Data and Alternative Approaches
			Multimodal Pain Control: Strategy to Reduce Postoperative Opioid Consumption
			Total Intravenous Anesthesia (TIVA)
			Goal-Directed Fluid Therapy (GDFT)
			Surgical Site Infection Reduction Bundles
			Patient-Reported Outcome (PRO) Measures
			Minimally Invasive Surgery
		Conclusion
		References
	47: Enhanced Recovery After Surgery: Cesarean Delivery
		Introduction
		When Do You Start the ERAS Cesarean Delivery Process?
		Optimized Preconception and Antenatal Care Period
			Patient and Family Education
			Antenatal Care Optimization
		Focused Preoperative Period: 30–60 Minutes
			Scheduled or Unscheduled Cesarean Delivery
				Anesthetic Medications
				Antimicrobial Prophylaxis and Vaginal/Abdominal Skin Preparation
		Focused Intraoperative Cesarean Delivery
			Obstetrical Anesthesia Choice
			Maternal and Neonate Hypothermia Prevention
			Surgical Techniques and Abdominal Entry
			Maternal Fluid Management
			Prevention of Uterine Hypotonia: Oxytocin Dose
			Foley Catheter Removal
			Neonatal Immediate Care in the Operating Room
		Focused Postoperative Cesarean Delivery
			Maternal Prevention of Postoperative Nausea and Vomiting
			Prophylaxis Against Maternal Thromboembolism
			Postoperative Analgesia (Multimodal Analgesia)
			Nonsteroidal Anti-inflammatory Drugs
			Acetaminophen
			Opioid Analgesics
			Other Adjuvant Agents
			Oral Nutrition
			Prevention of Postoperative Ileus
			Perioperative Glucose Control
			Early Mobilization and Rehabilitation
		Conclusion
		References
	48: ERAS in Spine Surgery
		Introduction
		Recommendations for Spine Surgery
			Preoperative Period
			Intraoperative Period
			Postoperative Period
		Current Implementation Strategies
		Topics for Future Discussion
		Conclusion
		References
	49: Orthopedic Surgery in Enhanced Recovery After Surgery
		Background and History of ERAS in Orthopedic Surgery
		ERAS in Total Hip Arthroplasty and Total Knee Arthroplasty
			Clinical Outcomes
			Length of Stay, Readmissions, and Complications
			Mortality
			Patient-Reported Measures
			Economics
			Implementation
			The Development of ERAS® Society Guidelines for Hip and Knee Arthroplasty
			Future Directions for Research
		ERAS in Other Orthopedic Procedures
			Fractured Neck of Femur
			Shoulder Arthroplasty
			Ankle Arthroplasty
			Spinal Surgery
		Conclusion
		References
	50: ERAS in Otolaryngology-Head and Neck Surgery
		Background
		What Is ERAS and How Does It Differ from Current Care Pathways in Head and Neck Surgery?
		Current ERAS Guideline for Major Head and Neck Surgery with Free Flap Reconstruction
			Methodology
			Guideline Summary
			Approaches to Implementation
			Application to Practice and Early Results
			Knowledge Gaps
		Organizational Context and Support
		ERAS in Other Areas of Otolaryngology
		Conclusion
		References
	51: Cardiac Surgery ERAS
		Introduction
		Unique Challenges
			Variable Surgical Procedures
			Increased Patient Perioperative Multimorbidity
			Cardiopulmonary Bypass
			Broad Spectrum of Multidisciplinary Care
			Lack of Pre-existing Evidence
		Special ERAS Considerations in the Cardiac Surgical Patient: Preoperative
			Frailty and Prehabilitation
			Glycemic Control and Insulin Infusions
		Special ERAS Considerations in the Cardiac Surgical Patient: Intraoperative
			Bleeding, Coagulation, and Transfusion
			Goal-Directed Fluid Therapy
			Sternal Closure
			Temperature Management
		Special ERAS Considerations in the Cardiac Surgical Patient: Postoperative
			Biomarkers to Reduce Acute Kidney Injury
			Chest Tube Maintenance
			Delirium
			Early Extubation
			Multimodal Analgesia
		Special ERAS Considerations in the Cardiac Surgical Patient: Audit
		Future Directions
		References
	52: Vascular Surgery and ERAS
		Introduction
		Aorta
			Preoperative Counseling, Risk Assessment, and Optimization
				Cardiac Risk Assessment and Optimization
				Anticoagulation
				Tobacco Cessation
				Physical Activity
			Perioperative Pain Control
				Regional Analgesia
				Delirium Screening
			Nutrition Management
				Reduced Preoperative Fasting
				Early Removal of Nasogastric Tubes and Resumption of Postoperative Nutrition
				Promotility Agents
				Nutrition
			Early Postoperative Mobilization
			Intravenous Fluid Management
			Early Drain and Line Removal
		Lower Extremity
			Pain Control
			Mobilization and Prosthetics
		Endovascular
		Conclusion
		References
	53: Thoracic Surgery
		Lung Surgery and ERAS
		Guidelines for ERAS After Lung Surgery
			Smoking Cessation
			Prehabilitation
			Standard Anesthetic Protocol
				One-Lung Ventilation Strategies
				Non-intubated Anesthesia
				Anesthetic Technique
			Regional Anesthesia
				Preemptive Analgesia
				Intraoperative Regional Analgesia
			Perioperative Fluid Management
			Atrial Fibrillation Prevention
			Surgical Technique
				Thoracotomy
				Minimally Invasive Surgery
				Robotic Surgery
			Chest Drain Management
				Number of Chest Tubes
				Application of Suction
				Digital Drainage Systems
				Pleural Fluid Drainage
		Conclusions and Future Directions
		References
	54: Enhanced Recovery in the Ambulatory Surgery Setting
		Introduction
		Preoperative Considerations
		Intraoperative Considerations
		Immediate Postoperative Considerations
		Post-discharge Considerations
		Summary
		References
	55: Enhanced Recovery After Surgery: Emergency Laparotomy
		Introduction
		ERAS and Emergency Laparotomy
			Background to the Development of an ERAS Approach for Emergency Laparotomy
			Management of Physiological Derangement
				Diagnosing and Treating Sepsis
				Early Surgery and Source Control of Sepsis
				The Role of Risk Assessment
				Goal-Directed Fluid Therapy
				Postoperative Management in a Critical Care Bed
				ERAS Approaches with a Focus on Rapid Management of Physiological Derangement and Sepsis and Reliable Delivery of Evidence-Based Care
			Other Significant Considerations in Delivery of an ERAS Approach for Emergency Laparotomy
				The Elderly
				Patient and Family Involvement and Shared Decision-Making
				Emergency General Surgery Service Provision
			A Framework for an Enhanced Recovery Approach to Care of the Patient Undergoing Emergency Laparotomy
				Preoperative Principles
				Intraoperative Care Principles
				Postoperative Management
			Implementation
			Audit and Outcomes
		Conclusion
		References
	56: Liver Surgery
		Introduction
		Fluid Balance and Electrolyte Management
		Postoperative Abdominal Drainage
		Minimally Invasive Approach
		Postoperative Glycemic Control
		Postoperative Nutrition and Early Oral Intake
		Postoperative Nasogastric Intubation
		Analgesia
		Conclusion
		References
	57: Pancreatic Surgery
		Introduction
			Pancreatic Surgery in the Age of ERAS
			Measuring Outcome and Methodological Challenges
		Preoperative Nutrition
		Obstructive Jaundice and Preoperative Biliary Drainage
		Minimally Invasive Techniques in Pancreatic Resection
		Prophylactic Intra-abdominal Drainage
		Nasogastric Drainage
		Postoperative Diet and Artificial Nutrition
		Conclusion
		References
	58: Pediatric Enhanced Recovery After Surgery
		Introduction
		Unique Pediatric Considerations
			Perioperative Analgesia
			Pediatric General Surgery ERAS
			Pediatric Urology ERAS
			Neonatal ERAS
			Pediatric Orthopedic ERAS
		Conclusion
		References
Part IX: Administrative
	59: Department-Wide Implementation of an Enhanced Recovery Pathway: Barriers and Facilitators
		Introduction
		Creating an Enhanced Recovery Pathway
			Obtaining Department Buy-In
			Creating a Leadership Team
				Assigning a Care Pathway Coordinator
				Seeking Patient and Family Involvement
			Developing Content
			Identifying Potential Barriers
		Implementing an Enhanced Recovery Pathway
			Moving into Action
				Communicating and Training the Perioperative Teams
		Evaluating an Enhanced Recovery Pathway
			Sustaining an Established Enhanced Recovery Pathway
		Conclusion
		References
	60: Introducing Enhanced Recovery Programs into Practice: Lessons Learned from the ERAS® Society Implementation Program
		Introduction
		The Complexity of Perioperative Care
		ERAS® Implementation Program (EIP)
			Framework and Contents of the ERAS® Society Implementation Program
				Philosophy and Background of ERAS
				The ERAS Multidisciplinary Team
				Importance of Data Collection and Use of the ERAS® Interactive Audit System (EIAS)
				Change Management
				Feedback on the Clinical Experience Linked to the Protocol
				Sustainability of Results
				Internal Communication for the Success of ERAS
		Key Factors for Success
		Results and Outcomes from Implementation of ERAS
		Conclusion
		References
	61: Enhanced Recovery After Surgery – Making the Business Case: Economics – The Alberta Experience
		Introduction
		The Evidence for ERAS
		Large-Scale Implementation of Multiple ERAS Guidelines
		Barriers and Enablers of ERAS Implementation
		Monitoring Compliance and Outcomes
		Developing a Model for Spread and Scale
		Considering and Preparing a Business Case for ERAS Implementation
		Building the Case for ERAS in Alberta
			ERAS Implementation to Date in Alberta
			Incenting Change and Quality Improvement Through Benefit Sharing
		Conclusion
		References
	62: ERAS® Society and Latin America
		Introduction
			A Global Problem
			The Situation in Latin America
		The Solution Through the ERAS Approach
			From Assumptions to Facts
			From Anecdotal Talk to Effective Communication
			From Standardization to Implementation
		Results from ERAS® LatAm
		Conclusion
			Future Perspectives
		References
	63: ERAS® Society and Asia
		ERAS and ASIA
		Development of ERAS in the Philippines
		Development of ERAS in Singapore
			Lessons Learned from the Singapore Journey
				Redesigning “Established” Workflow
				The “Deconstructed” ERAS Nurse
				Sustaining ERAS in Tan Tock Seng Hospital
				Scaling ERAS in Tan Tock Seng Hospital
		Spreading ERAS in the Region by Tan Tock Seng Hospital and the Medical City
		Future of ERAS in Asia
			Current Status and Challenges of ERAS Implementation in Asia
			Roles of ERAS® Society and Centers of Excellence in Asia
		Conclusion
		References
	64: ERAS for Low- and Middle-Income Countries
		Introduction
		ERAS in Low- and Middle-Income Countries: Barriers, Challenges, and Opportunities
			Access to Healthcare
			Preoperative Evaluation and Optimization
			Discharge Planning
			Cost Implications
			Nutrition
			Human Immunodeficiency Virus
		Proposed First Steps for Low- and Middle-Income Countries
			Preoperative Considerations
			Intraoperative Management
			Postoperative Management
			Data Collection and Management
				Monitoring and Evaluation
		ERAS Guidelines in Low- and Middle-Income Countries
		Conclusion
		References
	65: ERAS Position in the Global Surgical Community
		Introduction
		Enhanced Recovery After Surgery: Position in the Global Surgical Community
			Initial Development of ERAS in Northern Europe
			ERAS in the United Kingdom
			ERAS in Continental Europe
			ERAS in the United States
			ERAS in Other Developed Nations
			ERAS in the Developing Nations of Asia, Africa, and Latin America
		Global Collaboration Efforts
			Role of ERAS in World Health Organization (WHO) Global Surgery 2030
		Conclusion
			Future Direction and Research in the Field
		References
Index