Enhanced recovery after surgery programs: Evidence-based practice in perioperative nursing

The enhanced recovery protocol (Enhanced recovery after surgery, ERAS), well-known as the fast-track (FT) protocol, was designed to improve perioperative treatment by optimizing its effectiveness for faster recovery. Traditional perioperative treatment that includes prolonged fasting, decreased mobility, mechanical bowel preparation, use of drainage, and gradual commence of regular nutrition postoperatively, was challenged by ERAS protocols, which were designed by Danish Professor Henrik Kehlet. According to Kehlet, avoiding such perioperative dogmas reduces postoperative hospitalization by minimizing metabolic stress, intravenous fluid overload, and insulin resistance. Postoperative nausea and vomiting, according to patients' experience, can be more stressful than pain.1Wilmore D.W. Kehlet H. Management of patients in fast track surgery.BMJ. 2001; 322: 473-476https://doi.org/10.1136/bmj.322.7ss284.473Crossref PubMed Google ScholarThe most significant aspect of ERAS programs is that they are not designed to get patients faster discharged. It does, however, try to get them ready for shorter hospitalization by ensuring that they are completely capable of returning to daily routine. Patient's education, effective analgesia, and gradual mobilization and consuming normal meals are all part of FT protocols, aiming a faster recovery. ERAS protocols constitute a cornerstone for surgical patients treatment.2Buhrman W.C. Lyman W.B. Kirks R.C. Current state of enhanced recovery after surgery in hepatopancreatobiliary surgery.2018: 1-5https://doi.org/10.1089/lap.2018.0314Crossref Scopus (7) Google ScholarMultiple ERAS programs have been an intriguing topic of multiple systematic reviews in many surgical cases, resulting in reduced postoperative length of stay, fewer complication rates, and lower hospital costs, leading to greater implementation of them. Recent published data have also indicated improved outcomes in major abdominal and cardiovascular operations utilizing comparable methods. However, further studies should be conducted in gastrectomies and esophagectomies.3Bai X. Zhang X. Lu F. et al.The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China.Pancreatology. 2016; : 1-6https://doi.org/10.1016/j.pan.2016.03.018Crossref Scopus (25) Google ScholarThe major goal of this integrated strategy is to reduce the psychological and physiological stress provoked by surgery, with the ultimate goal of lowering tissue catabolism.4Spelt L. Ansari D. Sturesson C. et al.Fast-track programmes for hepatopancreatic resections: where do we stand?.Hpb. 2011; 13: 833-838https://doi.org/10.1111/j.1477-2574.2011.00391.xAbstract Full Text Full Text PDF Scopus (33) Google Scholar This approach appears to enhance postoperative recovery as patient is mobilized and starts liquid diet (water, tea) the day same of the operation and being discharged in seven days.5Kajal K. Gupta A. Behera A. et al.Impact of Enhanced Recovery after Surgery protocol on immediate surgical outcome in elderly patients undergoing pancreaticoduodenectomy.Updates Surg. 2019; https://doi.org/10.1007/s13304-019-00625-4Crossref PubMed Scopus (10) Google Scholar The administration of carbohydrate solutions up to 2 ​h before surgery is recommended as this reduces stomach acidity and dehydration, speeds the restoration of intestinal function, improves postoperative insulin levels, and as a result minimizes gut's best function. Preoperative mechanical bowel preparation has been indicated in previous conducted studies as a useful method for minimizing complications and bacterial burden. Latest evidence implicate that bowel preparation may increase the risk of anastomotic leakage.6Lohsiriwat V. Jitmungngan R. Enhanced recovery after surgery in emergency colorectal surgery: review of literature and current practices.World J Gastrointest Surg. 2019; 11: 41-52https://doi.org/10.4240/wjgs.v11.i2.41Crossref PubMed Google ScholarAs a result, the practice of preparing the gut prior to colon surgery should be further investigated. Simultaneously, stress reduction during surgery is characterized by weakening of the neuro-hormonal response in the operating room, which provides a reasonable basis for improved recovery by reducing the likelihood of organic dysfunction and problems. Consequently, the primary goal should be to undergo the procedure without high stress or pain levels. Many factors affect surgical stress and organic dysfunction, necessitating a well-thought-out and coordinated strategy for stress reduction.7Kehlet H. Wilmore D.W. Evidence-based surgical care and the evolution of fast-track surgery.Ann Surg. 2008; 248: 189-198https://doi.org/10.1097/SLA.0b013e31817f2c1aCrossref PubMed Scopus (1221) Google ScholarERAS protocols, on the other hand, require the formation of a qualified multidisciplinary team focused on evidence-based practice for ERAS recommendations. According to an extensive amount of published data, the protocol's success rates are high, with high patients' satisfaction. Recent studies have shown that successful implementation of the ERAS protocol necessitates the involvement of a multi-inter-disciplinary team, with willing to adapt and understand how protocol works. The dissemination of training materials to patients, the transformation of the postoperative ward into a patient-friendly rehabilitation center, and the use of evidence-based nursing practice in the implementation of these protocols are keys to their success. It has been suggested that clinical care, based on evidence-based medical practice, focuses on the medicalization of patient care and neglecting other aspects of patient's care that are critical to nursing profession's holistic care.The International Council of Nurses and the Canadian Nurses Association both believe that systematic reviews and meta-analyses should be conducted for evidence-based safe nursing practice. The experience of the nurses, as well as the preferences and values of the patients, play a crucial role in the development of these nursing guidelines. Although the role of nurses in the implementation of ERAS programs is mentioned in the international literature, ERAS suggestions based on the critical role of nurses in those programs are not included. Evidence-based practice strong perception and understanding cannot only be quantified, but also requests a part among the recommendations to improve patients’ outcomes. Nowadays, for evidence-based practice, nursing experience and published data for ERAS programs should continue to coexist. The enhanced recovery protocol (Enhanced recovery after surgery, ERAS), well-known as the fast-track (FT) protocol, was designed to improve perioperative treatment by optimizing its effectiveness for faster recovery. Traditional perioperative treatment that includes prolonged fasting, decreased mobility, mechanical bowel preparation, use of drainage, and gradual commence of regular nutrition postoperatively, was challenged by ERAS protocols, which were designed by Danish Professor Henrik Kehlet. According to Kehlet, avoiding such perioperative dogmas reduces postoperative hospitalization by minimizing metabolic stress, intravenous fluid overload, and insulin resistance. Postoperative nausea and vomiting, according to patients' experience, can be more stressful than pain.1Wilmore D.W. Kehlet H. Management of patients in fast track surgery.BMJ. 2001; 322: 473-476https://doi.org/10.1136/bmj.322.7ss284.473Crossref PubMed Google Scholar The most significant aspect of ERAS programs is that they are not designed to get patients faster discharged. It does, however, try to get them ready for shorter hospitalization by ensuring that they are completely capable of returning to daily routine. Patient's education, effective analgesia, and gradual mobilization and consuming normal meals are all part of FT protocols, aiming a faster recovery. ERAS protocols constitute a cornerstone for surgical patients treatment.2Buhrman W.C. Lyman W.B. Kirks R.C. Current state of enhanced recovery after surgery in hepatopancreatobiliary surgery.2018: 1-5https://doi.org/10.1089/lap.2018.0314Crossref Scopus (7) Google Scholar Multiple ERAS programs have been an intriguing topic of multiple systematic reviews in many surgical cases, resulting in reduced postoperative length of stay, fewer complication rates, and lower hospital costs, leading to greater implementation of them. Recent published data have also indicated improved outcomes in major abdominal and cardiovascular operations utilizing comparable methods. However, further studies should be conducted in gastrectomies and esophagectomies.3Bai X. Zhang X. Lu F. et al.The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China.Pancreatology. 2016; : 1-6https://doi.org/10.1016/j.pan.2016.03.018Crossref Scopus (25) Google Scholar The major goal of this integrated strategy is to reduce the psychological and physiological stress provoked by surgery, with the ultimate goal of lowering tissue catabolism.4Spelt L. Ansari D. Sturesson C. et al.Fast-track programmes for hepatopancreatic resections: where do we stand?.Hpb. 2011; 13: 833-838https://doi.org/10.1111/j.1477-2574.2011.00391.xAbstract Full Text Full Text PDF Scopus (33) Google Scholar This approach appears to enhance postoperative recovery as patient is mobilized and starts liquid diet (water, tea) the day same of the operation and being discharged in seven days.5Kajal K. Gupta A. Behera A. et al.Impact of Enhanced Recovery after Surgery protocol on immediate surgical outcome in elderly patients undergoing pancreaticoduodenectomy.Updates Surg. 2019; https://doi.org/10.1007/s13304-019-00625-4Crossref PubMed Scopus (10) Google Scholar The administration of carbohydrate solutions up to 2 ​h before surgery is recommended as this reduces stomach acidity and dehydration, speeds the restoration of intestinal function, improves postoperative insulin levels, and as a result minimizes gut's best function. Preoperative mechanical bowel preparation has been indicated in previous conducted studies as a useful method for minimizing complications and bacterial burden. Latest evidence implicate that bowel preparation may increase the risk of anastomotic leakage.6Lohsiriwat V. Jitmungngan R. Enhanced recovery after surgery in emergency colorectal surgery: review of literature and current practices.World J Gastrointest Surg. 2019; 11: 41-52https://doi.org/10.4240/wjgs.v11.i2.41Crossref PubMed Google Scholar As a result, the practice of preparing the gut prior to colon surgery should be further investigated. Simultaneously, stress reduction during surgery is characterized by weakening of the neuro-hormonal response in the operating room, which provides a reasonable basis for improved recovery by reducing the likelihood of organic dysfunction and problems. Consequently, the primary goal should be to undergo the procedure without high stress or pain levels. Many factors affect surgical stress and organic dysfunction, necessitating a well-thought-out and coordinated strategy for stress reduction.7Kehlet H. Wilmore D.W. Evidence-based surgical care and the evolution of fast-track surgery.Ann Surg. 2008; 248: 189-198https://doi.org/10.1097/SLA.0b013e31817f2c1aCrossref PubMed Scopus (1221) Google Scholar ERAS protocols, on the other hand, require the formation of a qualified multidisciplinary team focused on evidence-based practice for ERAS recommendations. According to an extensive amount of published data, the protocol's success rates are high, with high patients' satisfaction. Recent studies have shown that successful implementation of the ERAS protocol necessitates the involvement of a multi-inter-disciplinary team, with willing to adapt and understand how protocol works. The dissemination of training materials to patients, the transformation of the postoperative ward into a patient-friendly rehabilitation center, and the use of evidence-based nursing practice in the implementation of these protocols are keys to their success. It has been suggested that clinical care, based on evidence-based medical practice, focuses on the medicalization of patient care and neglecting other aspects of patient's care that are critical to nursing profession's holistic care. The International Council of Nurses and the Canadian Nurses Association both believe that systematic reviews and meta-analyses should be conducted for evidence-based safe nursing practice. The experience of the nurses, as well as the preferences and values of the patients, play a crucial role in the development of these nursing guidelines. Although the role of nurses in the implementation of ERAS programs is mentioned in the international literature, ERAS suggestions based on the critical role of nurses in those programs are not included. Evidence-based practice strong perception and understanding cannot only be quantified, but also requests a part among the recommendations to improve patients’ outcomes. Nowadays, for evidence-based practice, nursing experience and published data for ERAS programs should continue to coexist. None declared.