ACOG COMMITTEE OPINION

Number 750

Committee on Gynecologic Practice

This document is endorsed by the American Urogynecologic Society. This Committee Opinion was developed by the American College of Obstetricians
and Gynecologists’ Committee on Gynecologic Practice in collaboration with committee member Amanda N. Kallen, MD.

Perioperative Pathways: Enhanced Recovery After

Surgery
ABSTRACT: Gynecologic surgery is very common: hysterectomy alone is one of the most frequently performed
operating room procedures each year. It is well known that surgical stress induces a catabolic state that leads to
increased cardiac demand, relative tissue hypoxia, increased insulin resistance, impaired coagulation profiles, and
altered pulmonary and gastrointestinal function. Enhanced Recovery After Surgery (ERAS) pathways were developed
with the goal of maintaining normal physiology in the perioperative period, thus optimizing patient outcomes without
increasing postoperative complications or readmissions. The basic principles of ERAS include attention to the following:
preoperative counseling and nutritional strategies, including avoidance of prolonged perioperative fasting; perioperative
considerations, including a focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and
maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and
appropriate thromboprophylaxis. Benefits of ERAS pathways include shorter length of stay, decreased postoperative
pain and need for analgesia, more rapid return of bowel function, decreased complication and readmission rates, and
increased patient satisfaction. Implementation of ERAS protocols has not been shown to increase readmission,
mortality, or reoperation rates. These benefits have been replicated across the spectrum of gynecologic surgeries,
including open and minimally invasive approaches and benign and oncologic surgeries. The implementation of the
ERAS program requires collaboration from all members of the surgical team. Enhanced Recovery After Surgery is
a comprehensive program, and data demonstrate success when multiple components of the ERAS pathway are
implemented together. Successful ERAS pathway implementation across the spectrum of gynecologic care has the
potential to improve patient care and health care delivery systems.

Recommendations and Conclusions implementation of a combination of multiple ele-

The American College of Obstetricians and Gynecolo- ments, which when bundled together, form a com-
gists makes the following recommendations and con- prehensive perioperative management program.
clusions regarding the implementation of Enhanced c The basic principles of ERAS include attention to
Recovery After Surgery (ERAS) pathways: the following: preoperative counseling and nutri-
c Enhanced Recovery After Surgery pathways were tional strategies, including avoidance of prolonged
developed with the goal of maintaining normal perioperative fasting; perioperative consid-
physiology in the perioperative period, thus opti- erations, including a focus on regional anesthetic
mizing patient outcomes without increasing post- and nonopioid analgesic approaches, fluid bal-
operative complications or readmissions. ance, and maintenance of normothermia; and
c The goals of decreasing surgical stress and help- promotion of postoperative recovery strategies,
ing the body mitigate the consequences of such including early mobilization and appropriate
stress with ERAS pathways is achieved by the thromboprophylaxis.

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 c Benefits of ERAS pathways include shorter length of pathways for these ERAS or “fast track” programs in
stay, decreased postoperative pain and need for gynecologic surgery.
analgesia, more rapid return of bowel function,
decreased complication and readmission rates, and Background
increased patient satisfaction. Implementation of It is well known that surgical stress induces a catabolic state
ERAS protocols has not been shown to increase that leads to increased cardiac demand, relative tissue
readmission, mortality, or reoperation rates. hypoxia, increased insulin resistance, impaired coagulation
c Institutions considering adoption of ERAS programs profiles, and altered pulmonary and gastrointestinal func-
should carefully examine their own infrastructure tion (3). This response can lead to organ dysfunction with
and patient flow through the preoperative and increased morbidity and delayed surgical recovery (4). The
postoperative phases of care. consequences of delayed postoperative recovery may
include nosocomial infections, development of venous
c In order for an ERAS program to be sustainable, it thromboembolism (VTE), long term diminishment of
should be embedded as a standard model of care in quality of life (5), and increased health care costs.
a health care delivery system. Enhanced Recovery After Surgery pathways were
c Enhanced Recovery After Surgery is a comprehensive developed with the goal of maintaining normal physiology
program, and data demonstrate success when multiple in the perioperative period, thus optimizing patient out-
components of the ERAS pathway are implemented comes without increasing postoperative complications or
readmissions. The goals of decreasing surgical stress and
together.
helping the body mitigate the consequences of such stress
c The use of ERAS pathways should be strongly with ERAS pathways are achieved by the implementation
encouraged within institutions. of a combination of multiple elements, which when
bundled together, form a comprehensive perioperative
management program. Enhanced Recovery After Surgery
Introduction is a comprehensive program, and data demonstrate success
when multiple components of the ERAS pathway are
Gynecologic surgery is very common—hysterectomy implemented together. A meta-analysis of six randomized
alone is one of the most frequently performed operating controlled trials demonstrated that implementation of at
room procedures each year (1). By using evidence-based least 4 of the 17 possible components of the ERAS pathway
protocols for perioperative and postoperative care, sur- in patients undergoing colorectal surgery resulted in
gical stress can be reduced, healing optimized, and the reductions in length of hospital stay (by more than 2 days)
patient experience improved. Traditional components of and complication rates (by nearly 50%) (6–12).
perioperative care include bowel preparation, cessation Colorectal surgery was the first subspecialty to
of oral intake after midnight, liberal use of narcotics, implement ERAS programs. When ERAS pathways have
patient-controlled analgesia use, prolonged bowel and been implemented for benign gynecologic and gyneco-
bed rest, the use of nasogastric tubes or drains, and grad- logic oncology surgeries (using open and minimally
ual reintroduction of feeding. However, many of these invasive approaches), results have been encouraging
commonly implemented interventions are not evidence- (13–19). Benefits of ERAS pathways include shorter
based, and their use frequently does not promote healing length of stay (16, 20, 21), decreased postoperative pain
and recovery (2). With this in mind, ERAS pathways and need for analgesia, more rapid return of bowel func-
were developed with the goal of optimizing patient out- tion, decreased complication and readmission rates, and
comes by introducing interventions that are data sup- increased patient satisfaction (22). Implementation of
ported and have been proved either to decrease ERAS protocols has not been shown to increase read-
surgical stress or help the body mitigate the negative mission, mortality, or reoperation rates (20, 21).
consequences of such stress (2). The basic principles of Multiple studies also have demonstrated significant cost-
ERAS include attention to the following: savings associated with implementation of ERAS pathways.
c Preoperative counseling and nutritional strategies, In one cohort study of 50 patients undergoing vaginal
including avoidance of prolonged perioperative fasting hysterectomy for benign indications with the use of ERAS
c Perioperative considerations, including a focus on pathways (as compared with 50 patients who underwent
regional anesthetic and nonopioid analgesic approaches, vaginal hysterectomy before ERAS implementation), length
fluid balance, and maintenance of normothermia of stay decreased by more than 50% and the percentage of
patients discharged within 24 hours increased fivefold (17).
c Promotion of postoperative recovery strategies, Notably, in this study, preoperative patient education was
including early mobilization and appropriate throm- delivered by a structured “gynecology school” in which pa-
boprophylaxis (Table 1) tients attended an hour-long teaching session (with a maxi-
The purpose of this document is to provide mum of 10 participants) that incorporated audiovisual
education and recommendations regarding perioperative materials and question-and-answer sessions before surgery.

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 Table 1. Components Which May Be Considered in the Design and Implementation of an Enhanced Recovery After
Surgery Program*

Surgical Phase Intervention

Preoperative Components

Education  Dedicated preoperative counseling

Optimization  Recommend tobacco cessation (ideally at least 4 weeks before surgery)

 Recommend alcohol cessation for hazardous drinkers
 Active identification and correction of anemia

Fasting guidelines  May ingest light meal up to 6 hours before procedure; may drink clear liquids up to 2 hours before
procedure; fasting 2 hours before procedure (except indicated preoperative medications)
 Day of surgery: Commercially available carbohydrate loading drink (to be completed at 2 hours before
planned procedure start time)
 Eliminate oral mechanical bowel prep

Intraoperative Components

Analgesia  Before OR entry: consideration of celecoxib 400 mg orally, acetaminophen 1,000 mg orally, and gabapentin
600 mg orally
 Regional anesthesia
 Opioids IV at discretion of the surgical team, supplemented with ketamine, or ketorolac, or
both
 Consideration of transversus abdominis plane block versus local wound infiltration depending on surgical
incision
 For pelvic organ prolapse surgery: Spinal block containing bupivacaine plus hydromorphone (40–100
micrograms); sedation versus light general anesthetic at discretion of the surgical team

Prophylaxis for nausea and  Before incision (6 30 min): consideration of transdermal scopolamine 1.5 mg patch for patients at high
vomiting risk of postoperative nausea or vomiting
 Intraoperative: consideration of dexamethasone 8 mg IV at induction, ondansetron 4 mg IV before
emergence
 Alternative or additional regimens at discretion of anesthesiologist and surgical
team

Fluid optimization  Decrease crystalloid administration

 Increase colloid administration if needed

Thromboprophylaxis  Sequential compression devices

 Consideration of heparin or low-molecular-weight heparin for high-risk patients

Antimicrobial therapy  First-generation cephalosporin or amoxicillin-clavulanic acid within 60 minutes before skin
incisions
 Increase prophylactic antibiotic dosage in obese patients (BMI [calculated as weight in kilograms divided
by height in meters squared] greater than or equal to 30)
 Additional intraoperative doses if heavy blood loss (.1,500 mL) or for lengthy
procedures
 Skin cleansing: Use an alcohol-based agent unless contraindicated
 Vaginal cleansing: Use either 4% chlorhexidine gluconate or povidone-iodine
 Hair clipping (rather than shaving)

Drains/packs  Avoidance of drains and vaginal packs

Temperature  Maintenance of normothermia

Postoperative Considerations

Activity  Evening of surgery: OOB more than 2 hours (including one or more walks and sitting in chair)
 Day after surgery until discharge: OOB more than 8 hours (including four or more walks and sitting in chair)
 Up in chair for all meals

(continued )

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 Table 1. Components Which May Be Considered in the Design and Implementation of an Enhanced
Recovery After Surgery Program* (continued )
Surgical Phase Intervention

Diet  No NG tube (remove at extubation if placed)

 Start regular diet and chewing gum 4 hours after procedure
 Day of surgery: one box liquid nutritional supplement; oral intake at least 800 mL fluid but no more than
2,000 mL by midnight
 Day after surgery until discharge: two boxes liquid nutritional supplement; encourage daily oral intake of
1,500–2,000 mL fluids
 Osmotic diuretics: Senna and docusate sodium; magnesium oxide; magnesium hydroxide as needed
 Maintain blood glucose levels (180–200 mg/dL)

Analgesia  Stepwise, multimodal pain management strategy to minimize opioid administration

 Scheduled ketorolac or scheduled NSAIDs (if unable to take NSAIDs: scheduled tramadol)
 Scheduled acetaminophen (for patients without severe hepatic disease)
 Scheduled gabapentin
 Oral opioids if needed; breakthrough pain: hydromorphone
 IV and PCA regimens only for continued pain despite titration of oral regimen

Fluid optimization  OR fluids discontinued on floor arrival

 Fluids 40 mL/hour until 8 am day after surgery, then discontinued
 Peripheral lock IV at 600 mL oral intake or 8 am day after surgery (whichever first)

Catheters  Removal of urinary catheter within 24 hours

 Assess for removal of drains and vaginal packs

Discharge  Defined discharge pathways (eg, full mobilization, ability to tolerate solids without nausea or vomiting,
oral analgesia)
Abbreviations: BMI, body mass index; IV, intravenous; NG, nasogastric; NSAIDS, nonsteroidal antiinflammatory drugs; OOB, out of bed; OR, operating room; PCA, patient-
controlled analgesia.

*These are suggested considerations only. Discussion and implementation of hospital- and surgery-specific protocols should be discussed.
Data from Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After
Surgery (ERAS[R]) Society recommendations—Part I. Gynecol Oncol 2016;140:313–22; Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for postoperative
care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS[R]) society recommendations—Part II. Gynecol Oncol 2016;140:323–32; Myers K, Hajek P, Hinds C,
McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med 2011;171:983–9; Oppedal K, Møller AM,
Pedersen B, Tønnesen H. Preoperative alcohol cessation prior to elective surgery. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD008343; Chapman JS, Roddy E,
Ueda S, Brooks R, Chen LL, Chen LM. Enhanced recovery pathways for improving outcomes after minimally invasive gynecologic oncology surgery. Obstet Gynecol 2016;128:138–44;
Kalogera E, Bakkum-Gamez JN, Jankowski CJ, Trabuco E, Lovely JK, Dhanorker S, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013;122:319–28; and Kalogera E,
Dowdy SC. Enhanced recovery pathway in gynecologic surgery: improving outcomes through evidence-based medicine. Obstet Gynecol Clin North Am 2016;43:551–73.

Even with the addition of a formal teaching session and Patient-tailored handouts may be helpful in communi-
a newly hired specialist “Enhanced Recovery” nurse, the cating the goals of ERAS and helping patients under-
ERAS protocol was associated with a cost savings of nearly stand the active role they may play in their care.
10% (17). However, differences exist between ERAS proto- Preoperative risk assessment should include identifica-
cols among institutions performing gynecologic surgery; thus, tion of tobacco and alcohol use, overweight status and
there is a need to develop standardized, evidence-based and obesity, anemia, and sleep apnea. These factors should be
specialty-specific guidelines (16, 23). considered when choosing the appropriate preoperative
and postoperative care. The perioperative period is a crit-
Preoperative Enhanced Recovery After ical window of opportunity for surgeons to influence
Surgery Components behavior and encourage smoking cessation. Smoking-
related impairment in wound healing decreases and pul-
Preoperative Management Planning and monary function improves within 4–8 weeks of smoking
Risk Assessment cessation (24). Although the benefits of smoking cessa-
Patient involvement and engagement are key, and tion increase proportionally with the length of cessation,
patient education is associated with improved outcomes and there has been concern about short-term smoking
(6). Counseling should start as early as the initial pre- cessation immediately before surgery, emerging research
operative visit, with an explanation of the rationale suggests that shorter-term perioperative smoking cessa-
behind ERAS and a discussion of patient expectations. tion does not cause harm (25–27). The data

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regarding hazardous drinking is sparser but suggests that which have been shown to adversely affect perioperative
patients who consume 3–4 drinks per day (considered outcomes. In contrast with traditional “nothing by
“hazardous alcohol intake”) may have up to 50% higher mouth” strategies, ERAS pathways avoid dehydration
complication rates (including bleeding, cardiac arrhyth- by reducing the preoperative starvation period and uti-
mias, impaired wound healing, and intensive care unit lizing complex carbohydrate drinks in nondiabetic pa-
admissions) when compared with patients who consume tients. This strategy has been shown to reduce
0–2 drinks per day. Complication rates increase to 200– preoperative thirst and anxiety and reduce postoperative
400% for those who have five or more drinks per day insulin resistance in colorectal surgery, ultimately reduc-
(28). A 2012 Cochrane Review suggested that intensive ing length of stay and improving patient satisfaction (30,
preoperative alcohol cessation interventions could signif- 34, 35). Data from the anesthesia literature have demon-
icantly reduce complication rates (29). strated that intake of clear fluids up until 2 hours before
A discussion regarding planned length of stay is surgery does not increase gastric content, reduce gastric
crucial to ensuring availability of appropriate support fluid pH, or increase complication rates (23). Thus, clear
and managing patient expectations. Patients should be fluids should be allowed up to 2 hours before induction
provided the opportunity to discuss surgical planning of anesthesia and solids up to 6 hours prior. Integration
and pain control with the surgical team and the of a multidisciplinary approach is important to ensure
anesthesia team as desired. Designated nurses specializ- buy-in and compliance with these guidelines from all
ing in ERAS care may be helpful (30). A key strategy for members of the surgical team.
successful implementation of an ERAS program is the Evidence that preoperative mechanical cleansing of
active engagement of all parties. In addition to partner- the bowel improves surgical outcomes is limited. A 2011
ing with the patient, a central component of a successful Cochrane review of 20 randomized trials with 5,805
program is the cooperation of an interdisciplinary team, participants undergoing elective colorectal surgery dem-
including the surgeon, preoperative nurse, anesthesiolo- onstrated no difference in wound infections or anasto-
gist, office nurses, and other important staff (Fig. 1). motic leakage rates between groups of participants who
Appropriate risk stratification is an important received or did not receive mechanical bowel preparation
component of enhancing surgical recovery. The Caprini (36). Although some studies showed that the combina-
VTE risk assessment model and the Rogers score may be tion of oral antibiotics with a mechanical bowel prepa-
used to provide individual risk assessment, although ration regimen reduces rates of infection and
more extensively validated models for specific patient anastomotic leakage (37–39), other data have not dem-
populations are needed (31, 32). Systemic hormone ther- onstrated a significant difference (40). Mechanical bowel
apy and oral contraceptive use have been associated with preparation also has been proposed as a method of
increased risk of VTE; however, the overall risk remains enhancing visualization of the surgical field during lap-
quite low. No trials exist to demonstrate a reduction in aroscopic surgery. However, a randomized controlled
postsurgical VTE with preoperative discontinuation of trial of 146 women assigned to laparoscopic hysterec-
hormone therapy, and this practice should not be rou- tomy either with or without mechanical bowel prepara-
tinely recommended. In women using combined oral tion showed no difference in surgeries rated as “good” or
contraception, prothrombotic clotting factor changes “excellent” visualization (41). Additionally, mechanical
persist 4–6 weeks after discontinuation, and risks associ- bowel preparation is time-consuming, expensive, and
ated with stopping oral contraception a month or more unpleasant for patients. Institutions may individualize
before major surgery should be balanced with the very their approach; data support that in cases of well-
real risk of unintended pregnancy. It is not considered defined location and size of the lesion, shared decision-
necessary to discontinue combination oral contraceptives making between the obstetrician–gynecologist and the
before laparoscopic tubal sterilization or other brief sur- patient is the recommended approach (36).
gical procedures. In current users of oral contraceptives
who have additional risk factors for VTE having major Perioperative Enhanced Recovery After
surgical procedures, heparin prophylaxis should be con- Surgery Components
sidered (33). Lastly, preoperative anemia is associated
Minimizing Infection Risk
with postoperative morbidity and mortality and should
be actively identified and corrected (21). Minimally invasive approaches should be undertaken
whenever possible and incisions kept as small as possible
(30). Patients undergoing hysterectomy, which is classi-
Diet and Bowel Preparation fied as a clean contaminated surgery, should receive
The goal of the preoperative phase of ERAS is for broad-spectrum antibiotics to cover skin, vaginal, and
patients to obtain the energy necessary for the body to enteric bacteria (23, 42). For laparoscopic surgeries that
accommodate the high metabolic demands imposed by do not involve genitourinary or digestive contamination,
surgery. The traditional fasting requirements of surgery no antibiotic prophylaxis is necessary (23). Intravenous
deplete liver glycogen and are associated with impaired antibiotics should be administered within 60 minutes
glucose metabolism and increased insulin resistance, before skin incision. Amoxicillin–clavulanic acid and

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Figure 1. The complex surgical environment. (Modified from Ergina PL, Cook JA, Blazeby JM, Boutron I, Clavien PA, Reeves
BC, et al. Challenges in evaluating surgical innovation. Lancet 2009;374:1097–104.)

cefazolin provide appropriate antibiotic coverage against antiseptics should be used in accordance with their man-
the microbes frequently involved in postoperative in- ufacturer’s instructions. Scrub time (gentle, repeated
fections, although amoxicillin–clavulanic acid is more back-and-forth strokes) for chlorhexidine-alcohol prep-
effective against anaerobes (43). Patients with a severe arations should last for 2 minutes for moist sites (ingui-
b2lactam allergy may be given a combination of clinda- nal fold and vulva) and 30 seconds for dry sites
mycin and gentamycin or a quinolone such as ciprofloxacin (abdomen), and allowed to dry for 3 minutes (46). How-
(23). Health care providers should consult their institu- ever, if using povidone-iodine scrubs for abdominal
tional antibiograms to confirm local susceptibility rates to preparation, recommended scrub time can be as long
the chosen coverage regimen. For lengthy procedures, as 5 minutes (47). The solution should then be removed
additional intraoperative doses of the chosen antibiotic, with a towel and the surgical site painted with a topical
given at intervals of two times the half-life of the drug povidone-iodine solution, which should be allowed to
(measured from the initiation of the preoperative dose, dry for 2 minutes before draping (47). Vaginal cleansing
not from the onset of surgery), are recommended to main- with either 4% chlorhexidine gluconate or povidone-
tain adequate levels throughout the operation (44). Prophy- iodine should be performed before hysterectomy or
lactic antibiotic dosage should be increased in obese vaginal surgery (44). Although currently only
patients (BMI [calculated as weight in kilograms divided povidone-iodine preparations are U.S. Food and Drug
by height in meters squared] greater than or equal to 30) Administration-approved for vaginal surgical-site anti-
and, in surgical cases with excessive blood loss, a second sepsis, solutions of chlorhexidine gluconate with low
dose of the prophylactic antibiotic may be appropriate (44). concentrations of alcohol (eg, 4%) are safe and effective
Although most guidelines do not specifically define “exces- for off-label use as vaginal surgical preparations and may
sive,” data suggest an additional dose of cefazolin when be used as an alternative to iodine-based preparations in
blood loss exceeds 1,500 mL (44). cases of allergy or when preferred by the surgeon. If hair
Perform preoperative surgical site skin preparation removal is needed, electric clipping is preferred to shav-
with an alcohol-based agent unless contraindicated (45). ing (23). Any necessary hair removal should be done
Chlorhexidine-alcohol is an appropriate choice. Skin immediately before the operation (44).

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Pain Management Intraoperative Fluid Balance and Prevention
Opioid use is associated with postoperative nausea and of Hypothermia
vomiting, impairment of bowel function, delayed mobi- Careful attention to intraoperative euvolemia and pre-
lization, and increased pulmonary morbidity, all of vention of hypothermia are important, and close collab-
which can delay recovery and negatively affect patients’ oration between the anesthesia and surgical teams is
perception of the surgical experience. Although there are imperative in order to achieve this goal. Fluid overload
situations in which the judicious use of opioids is appro- may lead to electrolyte abnormalities, peripheral edema
priate to achieve postoperative pain control, the epidemic and impaired mobility, delayed return of bowel function,
of opioid use disorder and drug diversion has focused and pulmonary congestion, whereas hypovolemia may
increased attention on development of alternative, step- result in decreased cardiac output and oxygen delivery.
wise and multimodal, and nonopiate pain management Moreover, even mild hypothermia (a decrease of 1°C
strategies. As an alternative to the administration of from core temperature) stimulates adrenal steroid and
opioids, ketorolac is effective in controlling postoperative catecholamine production and results in increased inci-
pain and does not increase postoperative bleeding (48). dence of wound infections, cardiac arrhythmias, and
Preemptive medication strategies (eg, medications given blood loss (4).
to the patient before surgery), including paracetamol and
acetaminophen, gabapentin, nonsteroidal antiinflamma- Use of Tubes and Drains
tory drugs, and COX-2 inhibitors, have been shown to Surgical drains should be removed as early as possible
decrease total narcotic requirements and improve post- after surgery. The routine use of nasogastric, abdominal,
operative pain and satisfaction scores in women under- and vaginal drains hinders mobilization, increases mor-
going total abdominal hysterectomy (49). bidity, and prolongs hospital stay with limited evidence
Intraoperatively, epidural and spinal anesthesia strate- of benefit (55). Vaginal packing may cause discomfort
gies, when compared with general anesthesia, decrease and limit ambulation, which is important for prevention
overall mortality and postoperative complications, of VTE (30). The judicious use of nasogastric tubes dur-
including VTE, blood loss, pneumonia and respiratory ing surgery (avoiding their use whenever possible) does
depression, myocardial infection, and renal failure (50), not increase anastomotic leaks and, in fact, is associated
although such strategies limit mobilization. However, with decreased pulmonary complications and a trend
epidural and spinal anesthesia strategies are not feasible toward shorter length of stay (30). Removal of the uri-
or appropriate for all surgical procedures. The transver- nary catheter, if used, within 24 hours also shortens hos-
sus abdominis plane block (commonly referred to as pital length of stay by decreasing infection risk (30).
a TAP block), which involves injection of local anesthetic Importantly, women who undergo pelvic surgical proce-
into the transversus abdominis fascial plane, also has dures such as a total laparoscopic hysterectomy or other
been shown to be effective in some studies for reduction long laparoscopic procedures are at risk of postoperative
of postoperative opioid use in patients undergoing lapa- voiding difficulty and should be monitored with postvoid
roscopic surgery, as well as women undergoing total residual checks after discharge, if clinically indicated
abdominal hysterectomy (51, 52). However, other trials (30).
have yielded less promising results. In one randomized
Postoperative Enhanced Recovery After
controlled trial of women undergoing gynecologic lapa-
roscopy, transversus abdominis plane block did not pro-
Surgery Components
vide statistically significant differences in mean Early Mobilization and Thromboprophylaxis
postoperative pain scores (53). Postoperatively, early ambulation (a concept with vary-
The strategy of postoperative minimization of ing definitions but typically encompassing time spent out
opioid use reduces nausea and vomiting, impairment of of bed as early as the day of surgery) is a mainstay of
bowel function, delayed mobilization, and pulmonary management. Mobilization protects against decondition-
morbidity (54). Regimens designed to minimize postop- ing, reduces thromboembolic complications, reduces
erative opioid use also may include the use of scheduled insulin resistance and overall results in shorter hospital
acetaminophen, gabapentin, and nonsteroidal antiin- stays (2). Early ambulation can be promoted by preop-
flammatory drugs. For vaginal hysterectomy, paracervi- erative counseling of the patient, as well as effective step-
cal nerve blocks or intrathecal morphine may be useful. wise, multimodal analgesia regimens that limit reliance
For open general gynecologic surgery, spinal analgesia or on systemic opiates. For patients at risk of VTE, the
thoracic epidural analgesia can be used postoperatively. Caprini score or Rogers score may be used to provide
Wound infiltration with liposomal bupivacaine, a long- further risk stratification (Table 2). Regardless of risk,
acting anesthetic medication effective over 72–96 hours, postoperative thromboprophylaxis in all patients should
also has been proposed as an alternative approach (2); include, in addition to early ambulation, intermittent
although more data are needed on the benefit of its use. pneumatic compression and the use of well-fitted com-
Antiemetics should be incorporated to combat postop- pression stockings and also may incorporate
erative nausea and vomiting. low-molecular-weight heparin. For women undergoing

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laparotomy for abdominal or pelvic malignancies, aged with insulin and regular blood glucose monitoring
extended (28 day) prophylaxis should be provided (54). (54). There are various protocols to achieve glycemic
control, but the data are too limited to recommend one
Nutrition and Fluid Balance specific protocol over another.
Protocols that emphasize early feeding (a return to
regular diet within 24 hours), with use of laxatives as Hospital Discharge
needed, promote the earlier return of bowel function and Hospital discharge should be criteria-based and include
improve patient satisfaction. Postoperative oral fluid assessment for ambulation, adequate pain control with
intake and feeding should begin on the day of surgery, oral analgesics, and tolerance of diet. Written informa-
if possible. Chewing gum reduces the incidence of tion should be provided, including guidelines to notify
postoperative ileus and its use should be considered the surgical team, recovery advice, and emergency
(54). Intravenous fluids should be discontinued within contact information. Flatus is not necessary before
24 hours after surgery because they are rarely needed in discharge. Specific guidelines for patients undergoing
patients able to sustain oral intake. High energy protein same-day discharge should be made available. Patients
drinks may be added to the dietary regimen to ensure with obstructed sleep apnea also warrant specific atten-
protein and calorie intake while oral intake is building. If tion and discharge guidelines given their increased risk of
intravenous fluids must be maintained, total hourly vol- postoperative complications (31). Notably, implementa-
ume should be kept no higher than 1.2 mL/kg to prevent tion of an ERAS program has not been shown to increase
volume overload. Balanced crystalloid solutions, such as readmission rate or work for the primary care provider
Ringer’s lactate, are preferred. The risk of hyperchlore- (30).
mic metabolic acidosis increases with the administration
of large volumes of 0.9% normal saline (54).
A patient’s blood glucose levels should be main- Implementation of Enhanced Recovery
tained between 180 mg/dL and 200 mg/dL (54). Perio- After Surgery Principles
perative hyperglycemia, or blood glucose levels greater Enhanced Recovery After Surgery programs represent
than 180–200 mg/dL, is associated with poor clinical a comprehensive bundle of interventions, and successful
outcomes, including infection, increased length of stay, implementation depends on adaptation of multiple
and postoperative mortality (56). However, the ideal tar- ERAS principles. The implementation of an ERAS pro-
get range remains controversial because of potential gram may require major changes to clinical interventions
adverse events related to hypoglycemia, which itself and supporting clinical systems. Institutions considering
may lead to morbidity (including seizures, brain damage, adoption of ERAS programs should carefully examine
and cardiac arrhythmia). Stricter control may be consid- their own infrastructure and patient flow through the
ered in select patients because maintenance of postoper- preoperative and postoperative phases of care. In order
ative blood glucose levels less than 139 mg/dL has been for an ERAS program to be sustainable, it should be
shown to lower the surgical site infection rate by 35% in embedded as a standard model of care in a healthcare
women with diabetes mellitus and postoperative hyper- delivery system. Factors critical for success include the
glycemia (56). Levels above this range should be man- following:

Table 2. Risk Stratification for Venous Thromboembolism

Patients Undergoing General Surgery,

Patients Undergoing Major General, Thoracic, Including GI, Urological, Vascular, Breast, and
or Vascular Surgery Thyroid Procedures

VTE Risk Rogers Observed Risk of Caprini Observed Risk of

Category Score Symptomatic VTE % Score Symptomatic VTE %

Very low ,7 0.1 0 0

Low 7–10 0.4 1–2 0.7

Moderate .10 1.5 3–4 1.0

High N/A N/A $5 1.9

Abbreviations: GI, gastrointestinal; VTE, venous thromboembolism.

Modified from Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and
prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines [published erratum appears in Chest 2012; 141:1369]. Chest
2012;141 suppl:e227S–77S. Available at: http://journal.chestnet.org/article/S0012-3692(12)60125–1/abstract. Retrieved April 12, 2018.

VOL. 132, NO. 3, SEPTEMBER 2018 Committee Opinion Enhanced Recovery After Surgery e127

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and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
 c Measurement of outcomes and refinement of in- 8. Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P,
terventions based on internal data Tring IC, MacFie J. Randomized clinical trial of multi-
c Involved, engaged clinical leadership at a senior level modal optimization of surgical care in patients undergoing
major colonic resection. Br J Surg 2005;92:1354–62.
c Mutual respect and effective teamwork among
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members of the clinical team who should view pa- Fazio VW. Prospective, randomized, controlled trial
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c An organizational culture that emphasizes safety ambulation and diet and traditional postoperative care
after laparotomy and intestinal resection. Dis Colon Rec-
and quality without fear of risk or blame (30)
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Mitchell CJ. Randomized clinical trial of multimodal opti-
The ERAS principles represent an evidence-based mization and standard perioperative surgical care. Br J Surg
approach to surgical management that challenges tradi- 2003;90:1497–504.
tional surgical management paradigms. The use of ERAS
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