Enhanced Recovery After Surgery (ERAS)
Welcome to the APSA Quality and Safety Committee Enhanced Recovery After Surgery (ERAS) page. This page is intended to help anyone who is interested in implementation of an Enhanced Recovery After Surgery (ERAS) program in their hospital. For those interesting in gaining more information on ERAS please refer to the references  and Additional Resources below.
Available toolkit projects are listed below. Many of the approaches described are evidence based - some are not. These approaches have not been approved by APSA.
Sunrise Children’s Hospital
The Sunrise Children’s HospitalEnhanced Recovery After Surgery (ERAS) quality improvement project serves to improve the care of patients receiving both elective and urgent pediatric general surgery by following core ERAS principles. ERAS is a program that has three major pillars with specific strategies: preoperative, perioperative and postoperative. The ERAS bundle includes strategies such as abbreviated preoperative fasting, preoperative coaching and expectation management, intraoperative fluid restriction, opioid sparing analgesia and early mobilization and feeding. These strategies have been demonstrated in the adult and pediatric literature to improve outcomes, reduce hospital length of stay and improve patient and family satisfaction.
- patient and family education handout
- physician and provider education handout
- postoperative patient ERAS checklist
Stakeholders: surgeons, anesthesiologists, pediatricians, preoperative nursing, postanesthesia care unit nursing, perioperative nursing, scrub technicians, administration (COO, CMO, CNO)
Challenges and solutions: get surgeon and anesthesia champions, make repeated efforts to engage staff with the learning process, have multiple venues to access information (grand rounds, nursing education conferences), form a multidisciplinary ERAS team to meet monthly. While other institutions have started small with colorectal surgery, we have applied this more broadly as we do not have sufficient colorectal volume.
Submitted by Erik G. Pearson
ERAS After Gastrointestinal Surgery
Emory/Children’s Healthcare of Atlanta
CHOA developed an Enhanced Recovery Protocol (ERP) for gastrointestinal surgery. This ERP primarily targets older children and adolescents undergoing elective surgery.
Inflammatory bowel disease protocol
Inflammatory bowel disease orderset
Patient engagement checklist
Stakeholders: surgeon led (Heiss, Raval) and multidisciplinary team included anesthesia, pain team, preoperative nursing, postanesthesia care unit nursing, floor nursing, pediatric surgical advanced practice nurse, child life/patient advocates, pharmacy, physical therapy
Challenges and solutions: Having partners in anesthesia and pain management were critical to getting out of the starting blocks.
Submitted by Mehul V. Raval
ERAS After Oncologic Procedures
Children’s Hospital of Philadelphia
CHOP developed an Enhanced Recovery after Surgery (ERAS) protocol for children who undergo total nephrectomy for Wilms tumor. The standard of care for children with Wilms tumor includes total nephrectomy - a major abdominal operation that is nevertheless usually technically straightforward and well tolerated. We use a standardized ERAS protocol for otherwise healthy children who undergo uneventful nephrectomy .
The protocol has evolved gradually over time and is based on standard ERAS guidelines. The details are listed in a separate file in this folder. The basic tenets include
- managing parental expectations
- no nasogastric tube
- clear liquid diet starting the day of surgery
- minimal opiates
- routine ketorolac
- early ambulation.
We also discourage the use of epidural catheters which we have found are unnecessary and prolong hospital stay. We also whenever possible avoid postoperative admission to the pediatric intensive care unit. Using this protocol our typical postoperative length of stay is two to three days without an increase in complications or returns to the emergency department.
Stakeholders: patients, parents, nurses, nurse practitioners, surgeons, anesthesiologists, pain team, residents and fellows.
Challenges and solutions: Ongoing challenges include managing parents’ and nurses’ expectations around criteria for discharge, overcoming years of dogma around the concept of
the postoperative ileus, fluid shifts, optimal pain management strategies, etc., creating ordersets which would make implementation easier but have been difficult to create given our technology environment and Epic build capabilities.
Submitted by Peter Mattei
Additional implementers: Richard Glick
Children’s Hospital Colorado
The Children’s Hospital Colorado developed a Enhanced Recovery After Surgery (ERAS) program for patients following intra-abdominal oncologic procedures. ERAS is an evidence based perioperative protocol to minimize variation between patients undergoing surgery that involves multimodal pain control, minimizing NPO times and standardizing postoperative care . Quality improvement methodologies like Plan, Do, Study, Act (PDSA) cycles are ideal for implementation, allowing one to meet and engage relevant perioperative stakeholders (surgeons, anesthesiologists, perioperative nursing), devise an implementation plan (scheduling, patient and provider education, implementation/adaptation of relevant ERAS implementation tools) and collect data (audit) to feed back to interested parties to optimize care processes. The audit is an important component to verify the team is
doing what is specified in the protocol.
The ERAS protocol process measures approximately 20 perioperative standardized practices. The attached protocol has definitions to meet each high level process measure but it is important that all stakeholders agree on these definitions to maximize buy in.
- patient handout
- patient preoperative checklist
- postoperative orderset
- timeout (used to quickly orient anesthesia, surgery and operating room nursing teams to ERAS intraoperative goals).
Stakeholders: pediatric Surgeons, pediatric Urologists, pediatric anesthesiologists, perioperative nursing (preop, OR, PACU, floor, service nurses), pharmacy
Challenges and solutions: “Buy-in” from providers can be challenging, particularly with those who may practice differently or use existing protocols that differ from the ERAS pathway. Ongoing perioperative provider education and knowledge is always a concern because there are so many providers at many levels who may interact with a patient undergoing surgery.
Submitted by Kyle Rove
ERAS Laparoscopic Cholecystectomy
UPMC Children’s Hospital of Pittsburgh
The Children’s Hospital of Pittsburgh developed an ERAS protocol for pediatric laparoscopic cholecystectomy and general surgery complex abdominal cases that promotes safe and early discharge. Implementation of the protocol was used to standardize preoperative, day of surgery and postoperative care of pediatric patients undergoing elective laparoscopic cholecystectomy. The goals of these clinical pathways are to optimize the clinical care and maximize clinical outcomes.
Particularly to the laparoscopic cholecystectomy clinical pathway, the goal includes minimizing side effects, such as postoperative nausea and vomiting (PONV), adverse events (e.g. severe pain) and decreasing length of stay. The goal is for patients to be consistently ready for discharge on the day of surgery. A significant part of this standardization is to use a multimodal approach that includes regional anesthesia techniques or local anesthetic administration at the laparoscopic instrument sites. The aims are to reduce patients’ pain to an acceptable pain level [Numeric Rating Scale (NRS) pain scores less than 4], improve mobilization, facilitate discharge home on the day of surgery and improve patient/family/nurse satisfaction with their overall clinical care (8 or more).
ERAS protocol for pediatric laparoscopic cholecystectomy
ERAS protocol for pediatric general surgery complex abdominal cases
Stakeholders: surgery, anesthesiology, nursing staff, pain management team, hospital administrators including IT
Challenges and solutions: creating an order set in the EMR has been a challenge. Extending this protocol to younger ages will be revealing as there is very little experience with ERAS in younger kids.
Submitted by Andrew Yeh, Marcus Malek
Enhanced Recovery After Surgery (ERAS) Society Guidelines
Anesthetic Management in ERAS (Up to Date)
- George JA, Koka R, Gan TJ, et al. Review of the enhanced recovery pathway for children: perioperative anesthetic considerations. Can J Anaesth. 2018;65(5):569-577. [PMID:29270915]
- Gibb ACN, Crosby MA, McDiarmid C, et al. Creation of an Enhanced Recovery After Surgery (ERAS) Guideline for neonatal intestinal surgery patients: a knowledge synthesis and consensus generation approach and protocol study. BMJ Open. 2018;8(12):e023651. [PMID:30530586]
- Heiss KF, Raval MV. Patient engagement to enhance recovery for children undergoing surgery. Semin Pediatr Surg. 2018;27(2):86-91. [PMID:29548357]
- Leeds IL, Boss EF, George JA, et al. Preparing enhanced recovery after surgery for implementation in pediatric populations. J Pediatr Surg. 2016;51(12):2126-2129. [PMID:27663124]
- Shinnick JK, Short HL, Heiss KF, et al. Enhancing recovery in pediatric surgery: a review of the literature. J Surg Res. 2016;202(1):165-76. [PMID:27083963]
- Saltzman AF, Warncke JC, Colvin AN, et al. Development of a postoperative care pathway for children with renal tumors. J Pediatr Urol. 2018;14(4):326.e1-326.e6. [PMID:29891188]
- Rove KO, Brockel MA, Saltzman AF, et al. Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations. J Pediatr Urol. 2018;14(3):252.e1-252.e9. [PMID:29398586]
- Rove KO, Edney JC, Brockel MA. Enhanced recovery after surgery in children: Promising, evidence-based multidisciplinary care. Paediatr Anaesth. 2018;28(6):482-492. [PMID:29752858]