August 12, 2019

What Is an ERAS Protocol?

Healthy woman smiling

What Does ERAS Stand For?

ERAS stands for Enhanced Recovery After Surgery. These protocols are designed to improve the patient’s experience before, during, and after surgery and have increasingly become more common in different surgical specialties during the past 10 years. The end goal is to perform surgery with a rapid recovery and low complication rate – allowing you, the patient, to return to your daily life happy and healthy after surgery.

“I have made an effort to incorporate the tenets of these protocols into the management of both my reconstructive and aesthetic patients during the past few years, Dr. Bajaj says. “As I have implemented them, I have personally observed many of patients recover faster, have less pain, and return to their lives faster – this is the whole reason that I went into plastic surgery – I want to help improve the quality of life for all of my patients.”

Working Together for a Positive Experience

Many individuals are apprehensive about undergoing surgery – that’s completely normal. Many of us have heard multiple stories about how painful the procedure was or how nausea after the anesthesia was unbearable. ERAS protocols are designed to improve, if not eliminate, those negative experiences. These protocols require both of us – the patient and the healthcare team – to work together to ensure that you have a positive experience.

Preparing for Before and After Surgery

Part of the preparation prior to surgery includes educating you, the patient, about what to expect and how to prepare. Research has shown that before surgery, we, as healthcare providers, need to adequately educate and prepare our patients for surgery. Some apprehension is due to the fear of the unknown, so the more you know about what is going to happen, the better you are able to prepare.

Another aspect of preparing for surgery is ensuring that you are in the best physical condition for the upcoming procedure – similar to training for a marathon, you will want to optimize your diet and exercise routine. In addition to optimizing nutrition before surgery, other ERAS recommendations include no-smoking for one month prior to surgery, reaching a BMI of less than 30, and abstaining from alcohol. These steps have been shown through numerous studies to decrease the risks of complications after surgery.

While it may not be possible for everyone to lose weight, we encourage all of our patients to maintain a healthy diet and exercise program prior to surgery. It is also critical that you stop smoking prior to surgery. For more information see our blog on smoking.

ERAS Protocols and the Management of Pain

Prior to and continuing into the operating room, ERAS recommendations include a multi-modal approach to the treatment of postoperative nausea and vomiting and to pain management. This means that prior to surgery you will receive your first dose of medications to treat these two concerns. To help control postoperative nausea and vomiting, we will give you a scopolamine patch prior to surgery. You will receive additional medications to help combat nausea, including steroids and anti-nausea medications, through your IV once you are asleep.

Our approach to pain management is similar. We will start with Tylenol, an anti-inflammatory (Celebrex), and neuro-modulator prior to surgery (Gabapentin). While you are under anesthesia, we will use a long-acting local anesthetic to help numb the surgical area (Marcaine or Exparel). See our blog on pain management.

By starting the pain medication prior to surgery, it helps decrease your body’s response to pain, so that you require less anesthesia and fewer narcotics after surgery. In this manner, you will also have less post-operative nausea and vomiting.

After surgery, you will continue taking Tylenol, the anti-inflammatory, and the Gabapentin. Studies have shown that the combination of these medications is effective in reducing pain and that patients require fewer narcotics.

“Many patients in my practice require minimal to no narcotics with this type of regimen,” Dr. Bajaj says. “By avoiding or minimizing the amount of narcotic that you require, we can decrease or eliminate post-operative nausea/vomiting, constipation, and other side effects of narcotics.”

The combination of reducing nausea and constipation then can allow for you to start eating, walking, and feeling better sooner. By starting a regular diet within the first few hours after surgery, research shows that wound healing is improved and the infection rate is lower. Similarly, by starting to walk after surgery, we can reduce the effects of surgical stress on muscle strength and muscle mass, decrease the risks of developing blood clots in the legs (DVT) or lungs (PE), and decrease the risks of postoperative pneumonia.

“I truly believe that the implementation of ERAS protocols in my practice has helped my patients, Dr. Bajaj says. “I have observed many women who have undergone DIEP flap breast reconstruction require no IV narcotics and go home two days after surgery. Similarly, my aesthetic patients have been able to return to the important job of living their lives sooner and have had a more pleasant surgical experience than they expected.”