Essential elements of anaesthesia practice in ERAS programs.

ABSTRACT

PURPOSE: Enhanced recovery pathways vary amongst institutions but include key components for anesthesiologists, such as haemodynamic optimization, use of short-acting drugs (and monitoring), postoperative nausea and vomiting (PONV) prophylaxis, protective ventilation, and opioid-sparing multimodal analgesia. METHODS: After critical appraisal of the literature, studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies. For each item of the perioperative treatment pathway, available English literature was examined and reviewed. RESULTS: Patients should be permitted to drink clear fluids up to 2 h before anaesthesia and surgery. Oral carbohydrate loading should be used routinely. All patients may have an individualized plan for fluid and haemodynamic management that matches the monitoring needs with patient and surgical risk. Minimizing the side effects of anaesthetics and analgesics using short-acting drugs with careful perioperative monitoring should be encouraged. Protective ventilation with alveolar recruitment maneuvers is required. Preventive use of a combination with 2-3 antiemetics in addition to propofol-based total intravenous anaesthesia (TIVA) is most likely to reduce PONV. While the ideal analgesia regimen remains to be determined, it is clear that a multimodal opioid-sparing analgesic strategy has significant benefits. CONCLUSION: Careful evaluation of single patient and planning of the anesthetic care are mandatory to join the ERAS philosophy. Optimal fluid management, use of short-acting drugs, prevention of PONV, protective ventilation, and multimodal analgesia are the cornerstones of the anaesthesia management within ERAS protocols.