Enhanced Recovery Protocols
Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow. At Lawton Plastic Surgery they are an integral part of the treatment of every patient.
These programs modify the physiological and psychological responses to surgery, and have been shown to lead to a reduction in complications, improvements in cardiopulmonary function, earlier return of function and earlier resumption of normal activities.
It is well-known that poor nutrition is detrimental to outcomes postoperatively. Inadequate nutrition is an independent risk factor for complications. The importance of nutritional status in patients undergoing plastic surgery is critical. Correction of preoperative nutritional deficiencies is performed at our own Advanced Wound Healing Biology Center that is directly connected to the Clinical Offices and the Fully Certified Surgery Center. A comprehensive evaluation and diet is provided to each patient at their preoperative appointment two weeks prior to surgery.
The stress response is initiated by a variety of physical insults, such as tissue injury, infection, hypovolemia and hypoxia. The ERAS program is aimed at attenuating the body’s response to surgery which is characterized by its catabolic effect.
Autonomic afferent impulses from the area of injury or trauma stimulate the hypothalamus-pituitary-adrenal axis and mediate the body’s subsequent endocrine response. Increased cortisol levels stimulate gluconeogenesis and glyconeogenesis in the liver, with triglyercides being converted to glycerol and fatty acids providing the substrates for gluconeogensis.
Adrenocorticotropic hormone and cortisol production leads to protein catabolism, weight loss, muscle (skeletal and visceral) wasting and nitrogenous loss. There is also a relative lack of insulin and peripheral insulin resistance occurs due to alpha-2-adrenergic inhibition of pancreatic B cells (facilitated by catecholamines) and defects in the insulin receptor/intracellular signaling pathway. Insulin resistance is a major variable influencing wound healing and increased risk of infective complications. Methods which reduce the insulin resistance include adequate pain relief, avoiding a prolonged period when oral intake is interrupted which attenuates postoperative insulin resistance, reduces nitrogen and protein losses, preserves skeletal muscle mass and reduces preoperative thirst, hunger and anxiety.
In addition to preoperative nutritional management, early postoperative nutrition can ameliorate the metabolic response leading to less insulin resistance, lower nitrogen losses and reduce the loss of muscle strength. Nutrition is resumed immediately after surgery. In addition an infusion of antioxidants, anti-inflammatories, vitamins, peptides and mitochondrial stimulants is administered on postoperative day one at the Lawton Advanced Biologics Wound Healing Center.
Enhanced recovery after surgery protocols were initially described in general surgery, but have since been studied in a variety of surgical specialties, including plastic surgery. Despite sound evidence showing significant benefits from ERAS pathways, there are still major difficulties when introducing these evidence-based guidelines into routine practice. Many surgeons state that they have “never heard of ERAS.”
At Lawton Plastic Surgery Advanced Healing Protocols are included in every surgery, and have been shown to improve outcomes, speed recovery, and improve patient comfort in the preoperative and postoperative periods.