Enhanced recovery after surgery

8 min read Last updated April 8, 2026

Surgical approach (context: common ERAS index operations)

  • ERAS is a pathway (not an operation); most established in colorectal, also gynaecology, urology, orthopaedics, HPB, upper GI
  • Typical ERAS-favourable surgical strategies
    • Minimally invasive approach where feasible (laparoscopic/robotic) to reduce pain/ileus and facilitate mobilisation
    • Avoid routine drains and nasogastric tubes unless specific indication
    • Meticulous haemostasis; limit tissue handling; maintain normothermia
    • Early removal of urinary catheter (balanced against epidural/urinary retention risk)

Anaesthetic management (typical ERAS case: elective laparoscopic colorectal resection)

  • Type of anaesthesia
    • GA with multimodal opioid-sparing analgesia; consider regional adjuncts (e.g. TAP/rectus sheath/QL block) or thoracic epidural in selected open cases
  • Airway
    • ETT usually (pneumoperitoneum, Trendelenburg, longer duration, aspiration risk); SGA only for short/low-risk procedures where appropriate
  • Duration
    • Typically 2–5 hours depending on procedure/approach/complexity
  • How painful?
    • Moderate–severe (open > laparoscopic). Pain impacts mobilisation, pulmonary complications, ileus and discharge readiness
  • Core intraoperative ERAS aims
    • Maintain euvolaemia, normothermia, normoglycaemia, minimise opioids and PONV, enable early feeding/mobilisation

Definition and principles

  • Standardised, evidence-based, multidisciplinary perioperative care pathway to reduce the stress response and support early return of function
  • Key principles: patient engagement, optimisation, minimally invasive techniques, opioid-sparing analgesia, early mobilisation and nutrition, audit/feedback

Physiological rationale (why ERAS works)

  • Surgery triggers neuroendocrine/inflammatory stress response → insulin resistance, catabolism, fluid shifts, ileus, immune dysfunction
  • ERAS attenuates stress response and prevents iatrogenic harm (excess fluid, hypothermia, prolonged fasting, high-dose opioids, immobility)

Preoperative elements

  • Patient education and shared goals: expected milestones (drinking/eating, mobilisation, analgesia plan, discharge criteria)
  • Optimisation: anaemia management, smoking cessation, alcohol reduction, exercise/prehabilitation, comorbidity optimisation
    • Anaemia: investigate/treat iron deficiency; consider IV iron when time-limited; minimise transfusion where appropriate
  • Fasting and carbohydrate loading
    • Clear fluids up to 2 hours, solids 6 hours (standard guidance; adapt to aspiration risk)
    • Carbohydrate drink (typically evening before and 2–3 h pre-op) may reduce insulin resistance and thirst/anxiety; avoid in delayed gastric emptying/high aspiration risk
  • Thromboprophylaxis planning: mechanical + pharmacological per local policy; coordinate with neuraxial timing
  • PONV risk stratification and plan (multimodal prophylaxis)

Intraoperative elements (anaesthetic focus)

  • Anaesthetic technique: balanced GA with short-acting agents; depth of anaesthesia monitoring may reduce awareness and facilitate titration in selected patients
  • Analgesia: multimodal and opioid-sparing
    • Paracetamol + NSAID/COX-2 inhibitor (if not contraindicated)
    • Regional: TAP/rectus sheath/QL blocks for abdominal surgery; local infiltration; consider epidural for open major abdominal surgery (balance hypotension/urinary retention/mobilisation)
    • Adjuncts: low-dose ketamine (opioid-tolerant), lidocaine infusion (selected centres), magnesium, clonidine/dexmedetomidine (case-dependent)
    • Avoid long-acting opioids where possible; use short-acting opioids titrated to effect; consider PCA only if needed and with clear stop criteria
  • Goal-directed fluid therapy (GDFT) / euvolaemia
    • Avoid both liberal fluids (gut oedema, ileus, impaired anastomotic healing) and excessive restriction (AKI, hypotension)
    • Use dynamic indices/CO monitoring where appropriate; treat hypotension with vasopressors when vasodilation predominates rather than reflex fluid boluses
  • Temperature management: forced-air warming, warmed fluids; aim ≥36°C
  • PONV prophylaxis: multimodal (e.g. dexamethasone + 5-HT3 antagonist ± droperidol/scopolamine) and minimise emetogenic opioids/volatile where feasible
  • Glycaemic control: avoid hyperglycaemia; treat perioperative insulin resistance; monitor in diabetics and major surgery
  • Antimicrobial prophylaxis: correct drug, timing (within 60 min of incision; longer for some agents), redosing if prolonged/major blood loss
  • Ventilation: lung-protective strategies (tidal volume ~6–8 ml/kg PBW, PEEP, recruitment as appropriate), especially laparoscopic/Trendelenburg

Postoperative elements

  • Early oral intake: encourage drinking and feeding as soon as safe; avoid routine NG tubes
  • Early mobilisation: sit out of bed day 0/1, physiotherapy, minimise lines/catheters
  • Analgesia continuation: scheduled non-opioids; regional catheter/blocks where used; minimise opioids to reduce ileus, sedation, PONV
  • PONV rescue plan and hydration strategy; treat hypotension with vasopressors if appropriate rather than excess fluids
  • Remove urinary catheter early; monitor for retention (higher risk with epidural, opioids, pelvic surgery)
  • Thromboprophylaxis continuation and discharge planning; patient-reported outcomes and follow-up

Evidence and outcomes (what to quote in viva)

  • ERAS pathways are associated with reduced length of stay and complications in several surgical populations (notably colorectal); effect depends on compliance with bundle elements
  • Benefits are additive: higher adherence to multiple components correlates with better outcomes
  • Not all elements have equal evidence across all surgeries; local adaptation and continuous audit are core to ERAS

How to implement ERAS safely (systems)

  • Multidisciplinary team: surgeons, anaesthetists, ward nurses, acute pain, physio, dietetics, pharmacy
  • Standardised order sets and protocols: analgesia, antiemetics, fluids, mobilisation, feeding, catheter removal
  • Measurement: compliance dashboards, complications, readmissions, patient experience; iterative improvement (PDSA cycles)
Define Enhanced Recovery After Surgery and outline its key components.

Aim for a definition + structured perioperative bundle (pre-, intra-, post-op).

  • Definition: evidence-based, multidisciplinary perioperative pathway to reduce surgical stress and support early return of function
  • Pre-op: education, optimisation (anaemia, smoking), shortened fasting + carbohydrate drink (selected), VTE plan
  • Intra-op: minimally invasive surgery where possible, multimodal opioid-sparing analgesia, normothermia, GDFT/euvolemia, PONV prophylaxis, glycaemic control
  • Post-op: early feeding, early mobilisation, remove tubes/catheters early, ongoing multimodal analgesia, audit and discharge criteria
Explain the physiological stress response to surgery and how ERAS modifies it.

Link stress response to outcomes (ileus, insulin resistance, catabolism) and show how ERAS reduces triggers/iatrogenic factors.

  • Stress response: sympathetic activation + cortisol/catecholamines/cytokines → insulin resistance, hyperglycaemia, catabolism, sodium/water retention, immune changes
  • Consequences: ileus, impaired mobilisation, infection risk, delayed wound healing, organ dysfunction (e.g. AKI with hypoperfusion)
  • ERAS attenuators: neuraxial/regional analgesia, opioid-sparing, normothermia, euvolaemia, early nutrition, minimally invasive surgery
Discuss perioperative fluid therapy in ERAS. What are the harms of too much and too little fluid?

Expect mention of euvolaemia, GDFT, vasopressors, and complications of fluid imbalance.

  • Goal: euvolaemia with appropriate perfusion pressure and oxygen delivery; avoid routine large “third-space” replacement
  • Excess fluid: gut oedema → ileus, impaired anastomotic healing, pulmonary oedema, impaired mobilisation, longer LOS
  • Under-resuscitation: hypotension/hypoperfusion → AKI, myocardial injury, lactic acidosis; nausea/delayed recovery
  • Approach: balanced crystalloids, consider GDFT (stroke volume/CO monitoring) in major surgery; treat vasodilatory hypotension with vasopressors rather than repeated fluid boluses
Outline an opioid-sparing analgesic plan for laparoscopic colorectal surgery within an ERAS pathway.

A structured multimodal plan with regional options and rescue strategy scores well.

  • Baseline: regular paracetamol + NSAID/COX-2 (if safe); consider gabapentinoids only if local policy and side-effect profile acceptable
  • Regional: bilateral TAP/QL block or rectus sheath (depending on incision sites); surgeon local infiltration
  • Intra-op adjuncts: low-dose ketamine (opioid tolerant), lidocaine infusion (selected), magnesium; short-acting opioid titration
  • Post-op: avoid background opioid infusions; use oral opioids PRN with clear de-escalation; consider PCA only if inadequate control
  • Targets: pain controlled enough to cough, deep breathe, mobilise and eat; minimise sedation and ileus
What is the role of epidural analgesia in ERAS for colorectal surgery? Advantages and disadvantages.

Examiners want balanced selection: open vs laparoscopic, haemodynamics, mobilisation, urinary catheter.

  • Advantages: excellent dynamic analgesia for open surgery; may reduce stress response and opioid requirements; facilitates breathing and mobilisation if well-managed
  • Disadvantages: hypotension → fluids/vasopressors; urinary retention → prolonged catheter; motor block; failure rate; neuraxial anticoagulation constraints; may delay mobilisation/discharge if poorly managed
  • Current practice: many ERAS pathways favour abdominal wall blocks for laparoscopic cases; epidural reserved for open/complex cases or high pain risk
Describe an ERAS approach to preventing postoperative nausea and vomiting (PONV).

Risk assessment + multimodal prophylaxis + rescue + reduce triggers.

  • Risk stratify (patient factors, surgery, anaesthetic) and plan prophylaxis accordingly
  • Reduce triggers: minimise opioids, consider TIVA where appropriate, avoid hypotension and dehydration, ensure adequate analgesia
  • Prophylaxis: combine agents with different mechanisms (e.g. dexamethasone + ondansetron ± droperidol)
  • Rescue: use different class to prophylaxis; reassess causes (opioids, ileus, obstruction, hypotension)
Discuss fasting and carbohydrate loading in ERAS. Who should not receive carbohydrate drinks?

State standard fasting times and contraindications to carb loading.

  • Fasting: typically solids 6 h; clear fluids up to 2 h pre-op (unless aspiration risk)
  • Carbohydrate loading: may reduce insulin resistance and improve comfort; commonly evening before + 2–3 h pre-op
  • Avoid/consider carefully: delayed gastric emptying (e.g. gastroparesis), symptomatic reflux/hiatus hernia with high aspiration risk, bowel obstruction/ileus, emergency surgery, severe obesity with high aspiration risk, uncontrolled diabetes (local policy)
How does ERAS reduce postoperative ileus? List anaesthetic and surgical contributors.

Ileus is a common FRCA discussion point; link to opioids, fluids, mobilisation and minimally invasive surgery.

  • Anaesthetic: opioid-sparing analgesia; avoid excessive fluids (bowel oedema); maintain electrolytes; consider regional techniques; treat PONV to enable feeding
  • Surgical: minimally invasive approach, reduced bowel handling, avoid routine NG tubes, early feeding
  • Post-op: early mobilisation, early oral intake, minimise lines/catheters, manage pain and nausea effectively
A patient on an ERAS pathway is hypotensive in PACU. How do you assess and manage without derailing ERAS?

Structured ABCDE + likely causes (vasodilation, bleeding, hypovolaemia, epidural). Avoid reflex litres of fluid.

  • Assess: ABCDE, surgical bleeding, drain output, Hb/ABG, ECG, urine output, temperature, pain, epidural/regional effects, sepsis risk
  • Treat cause: small fluid bolus if hypovolaemia likely; if vasodilated (anaesthetic/epidural), use vasopressor (metaraminol/phenylephrine) and adjust epidural
  • Avoid: large empiric fluid loading leading to overload/ileus; ensure adequate analgesia and antiemetics to allow mobilisation/feeding
What metrics would you audit to judge whether an ERAS programme is working?

Include compliance and outcomes; examiners like process + outcome measures.

  • Process/compliance: carbohydrate drink given, antibiotic timing, normothermia achieved, fluid balance targets, multimodal analgesia, early mobilisation, early feeding, catheter removal day
  • Outcomes: length of stay, complication rates (infection, ileus, AKI), readmissions, opioid consumption, PONV rates, patient satisfaction/PROMS
  • Balancing measures: unplanned ICU admissions, reoperation, falls, urinary retention, anastomotic leak (surgery-specific)

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