Implementation of Enhanced Recovery Protocol After Spinal Surgery

Improving Spine Outcomes Through an Enhanced Recovery Protocol After Surgery 

Federico C. Vinas, MD, FAANS, FACS

Medical Director Neurosurgery, Advent Health Daytona Beach

Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based approach to surgical care that focuses on optimizing patient outcomes and speeding up recovery from surgery. ERAS protocols involve a combination of preoperative, intraoperative, and postoperative interventions aimed at reducing surgical stress, maintaining organ function, and promoting early mobilization and discharge. ERAS protocols were introduced more than 20 years ago by Henrik Kehlet, providing the involvement of a multidisciplinary team made up of orthopedic surgeons, nursing staff, anesthesiologists, internists, physiatrists, physiotherapists, and nutritionists. 

Key components of ERAS protocols may include: 

Preoperative optimization: Preoperative ERAS components are defined in this review as interventions that occur any time before the surgery. These elements plan to optimize the patient’s condition prior to surgery. This involves preparing patients for surgery by optimizing their nutrition, hydration, and overall health prior to surgery. Patients may be encouraged to engage in exercise, quit smoking, and follow a specialized diet, all aiming to optimize their preoperative condition. Important interventions of ERAS protocol include patient education and the provision of information associated with a multidisciplinary consultation 

Preemptive pain management: ERAS protocols typically involve the use of multimodal pain management strategies, such as the administration of local anesthetics, nerve blocks, and oral pain medications to be given before surgery. Examples include the use of gabapentin, muscle relaxants, Tylenol, or non-steroidal anti-inflammatory medications. This helps reduce postoperative pain and decrease the need for narcotic medications.  

Perioperative ERAS components refer to all the interventions that occur from surgery until patient transfer to the post-anesthesia care unit. ERAS protocols typically involve the intraoperative administration of local anesthetics, nerve blocks during surgery. This helps reduce postoperative pain and decrease the need for opioid medications. The use of minimally invasive surgical (MIS) techniques are often favored in ERAS protocols as MIS surgery is associated with less tissue trauma, pain, and blood loss compared to traditional open surgeries. Evidence shows that minimally invasive surgical techniques can lead to faster recovery and shorter hospital stays. It is also important to maintain normothermia, normovolemia, and euglycemia, as well as the use of intraoperative, antimicrobial/antibiotic prophylaxis, transfusion control, and avoidance of Foley catheter, whenever possible 

 Postoperative ERAS components are defined as interventions that occur during and after admission to the recovery area. Multimodal analgesia and pain management and early mobilization are important. ERAS protocols emphasize early ambulation and mobilization following surgery to prevent complications such as blood clots, pneumonia, and muscle weakness. Physical therapy and walking programs may be implemented soon after surgery to encourage mobility.  Maintaining proper nutrition and hydration are important aspects of ERAS protocols to support healing and recovery. Patients may be encouraged to resume eating and drinking soon after surgery, and nutritional supplements may be provided as needed. ERAS protocols often involve a coordinated approach to discharge planning (enhanced discharge planning), with the goal of facilitating early discharge and promoting a smooth transition to home or a rehabilitation facility. Maintaining postoperative normothermia, normovolemia, and euglycemia can also help to prevent unwarranted complications.  Postoperative use of antimicrobial/antibiotic prophylaxis should be discontinued 23 hrs after surgery. Other interventions include control of postoperative nausea and vomiting, avoidance of unnecessary transfusions, and removal of Foley catheters as soon as possible.  Patients are typically encouraged to resume normal activities as soon as they are able.  

In conclusion, the goal of ERAS protocols is to improve patient outcomes, enhance the recovery process, and reduce complications following surgery. By implementing a multidisciplinary and evidence-based approach to care, ERAS can help patients achieve faster recovery, reduced pain, and shorter hospital stays after surgery. 

References:

Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br. J. Anaesth. 1997;78:606–617. doi: 10.1093/bja/78.5.606