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Enhanced recovery after major surgery protocols are evidence-based, multimodal approaches used to facilitate recovery after major surgical procedures in the preoperative, intraoperative, and postoperative periods. Anesthesia management plays a key role in providing standardized care and achieving earlier recovery. This activity reviews the role of the anesthesia team in improving recovery and care of patients after major surgical procedures such as major gastrointestinal surgery, urological surgery, gynecological surgery, thoracic surgery, orthopedic surgery, and breast surgery. Objectives: Summarize current literature covering the enhanced recovery after major surgery protocol. Review the multifactorial approach of enhanced recovery after major surgery protocols in the perioperative period. Identify the role of the anesthesiologist in the enhanced recovery after major surgery pathways. Explain the benefits and challenges of the implementation of the enhanced recovery after major surgery system. Access free multiple choice questions on this topic.

Enhanced recovery after surgery (ERAS) pathways were first implemented at the start of the 21st century. For the past 2 decades, ERAS protocols have successfully improved perioperative mortality and morbidity, reduced length of hospital stay, decreased complications, and expedited recovery after major surgeries. This protocol is a multimodal approach that was instituted to enhance recovery postoperatively. These pathways are evidence-based guidelines applied at every stage of the perioperative period, including the preoperative, intraoperative, postoperative, and rehabilitation periods. ERAS protocols were initially implemented with colorectal surgeries and have since expanded to most major surgical procedures.[1] These protocols have been studied and carried out in various areas such as colorectal, thoracic, cardiac, urologic surgery, spine, neurosurgery, vascular, orthopedic, pancreatic, gynecological, and breast surgery. ERAS protocols have been shown to alter physiological and psychological responses to surgery. The basis of implementing ERAS pathways resides in the maintenance of patients' preoperative physiologic and psychologic responses by reducing the stress response throughout the perioperative period.[2] While surgeries may differ in their requirements and their impact on the patient, ERAS protocol is a structured, multimodal, multidisciplinary, fast-track approach that provides evidence-based standardized management to patients undergoing different types of surgeries.[3] Coordination is required between members of the perioperative period to ensure the successful implementation of ERAS protocols, including the surgical team, anesthesia team, nursing staff, and preoperative, intraoperative, and postoperative personnel. The anesthesiologist is a key member of this team, optimizing the patient in the preoperative period, monitoring the patient in the intraoperative period to ensure hemodynamic stability, adequate depth of anesthesia, and analgesia, and ensuring optimal postoperative care. The anesthesiologist plays the most critical role in managing ERAS pathways, serving as the bridge between the preoperative, intraoperative, and postoperative periods.

Successful implementation of ERAS protocols requires collaboration, communication, and teamwork between medical personnel in the three different perioperative periods, including the patient, who plays a vital role in understanding and thereby facilitating the pathway. Adherence to the ERAS protocols allows for a seamless transition of the preoperative patient to when the patient is ready for discharge from surgery, whether on the same day or a few days later. The anesthesiologist plays an essential role in facilitating the implementation of the protocols because they are key decision-makers in the factors that can be debilitating to the progression of recovery from surgery.

Perioperative nurses and medical personnel play a vital role in the implementation of the ERAS protocols. Successful implementation of the protocols requires a good understanding of the ERAS pathways and knowing the implications.[20] Due to the multifaceted nature of the pathways, there needs to be communication and collaboration between members of the preoperative team with the intraoperative team and the intraoperative team with the postoperative team. This can be facilitated through hand-offs when information is communicated regarding the patient, their history, the surgery they are having, and the interventions that have been done in each period.

The ERAS system, due to its relatively new venture into the healthcare system, requires systemic auditing to improve outcomes continually. Auditing will identify pitfalls in communication, and issues with collaboration between teams, and improve compliance and adherence to ERAS protocols. However, due to the multidisciplinary approach of this pathway and the many medical personnel involved, it can serve as an impediment to implementation. The team members of the ERAS system include physicians, pre-admission testing staff, nurses, dieticians, physiotherapists, occupational therapists, and social workers. This entire cohort needs to be familiar with ERAS principles and must be willing to implement them. This requires changing their mindset from the traditional view of postoperative care to one that is evidence-based and collaborative.