Summary of 2018 ERAS Society protocol elements and grade of recommendation for elective colorectal surgery27
| Element | Grade of recommendation |
|---|---|
| Preadmission | |
| Information, education, counselling | Strong |
| Preoperative optimization (risk assessment, smoking and alcohol cessation) | Strong |
| Prehabilitation | Weak |
| Preoperative nutritional care (screening and nutrition itself) | Strong |
| Management of anemia (targets, interventions) | Strong |
| Preoperative | |
| Prevention of nausea and vomiting | Strong |
| Preanesthetic medication (anxiolysis and pain) | Strong |
| Antimicrobial prophylaxis and skin preparation | Intravenous antibiotic treatment, chlorhexidine: strong Oral antibiotic treatment, advanced skin decontamination: weak |
| Mechanical bowel preparation | Strong |
| Preoperative fluid and electrolyte therapy to maintain euvolemia | Strong |
| Preoperative fasting and carbohydrate loading up to 2 h before surgery | Strong |
| Intraoperative | |
| Standard Anesthetic Protocol | Strong |
| Intraoperative fluid and electrolyte therapy aimed at near-zero fluid balance; goal-directed fluid therapy in patients at high risk | Strong |
| Prevention of intraoperative hypothermia | Strong |
| Minimally invasive surgical approach (compared to open surgery) | Strong |
| Avoidance of routine use of pelvic and peritoneal drains | Strong |
| Postoperative | |
| Avoidance of nasogastric intubation; if placed, removal before reversal of anesthesia | Strong |
| Avoidance of opioids; use of NSAIDs; apply multimodal analgesia in combination with spinal/epidural or blocks when indicated | Strong |
| Thromboprophylaxis: mechanical prophylaxis until discharge; low-molecular-weight heparin until 28 d postoperatively | Strong |
| Fluid and electrolyte administration aimed at near-zero fluid balance, with avoidance of isotonic crystalloids if giving fluid | Strong |
| Bladder catheterization for 1–3 d acceptable; catheter should be removed routinely after this period | Strong |
| Prevention of postoperative ileus through multimodal strategy | Strong |
| Postoperative avoidance of hyperglycemia with insulin therapy and stress-reducing techniques | Stress-reducing: strong Insulin: strong in ICU, weak on ward |
| Offering of food on day of surgery; offering of immunonutrition (anti-inflammatory supplements such as L-arginine) to malnourished patients | Strong |
| Early mobilization through education and patient encouragement | Strong |
ICU = intensive care unit; NSAID = nonsteroidal anti-inflammatory drug.