Guidelines for Enhanced Recovery After Lung Surgery (ERAS)
1 Department of Thoracic Surgery, Lakeridge Health Oshawa and The Durham Regional Cancer Center, Oshawa ON, Canada
Enhanced Recovery After Surgery, or ERAS, can be considered an evidence-based treatment paradigm for all surgical patients. It’s fundamental tenets are the development and systematic implementation of evidence-based perioperative care protocols. The goal of which is to optimize patient outcomes, decreased morbidity and decrease length of stay. There has been considerable interest in the development of these protocols for nearly two decades with Colorectal Surgery being one of the original champions of the paradigm. There is an abundance of data linking ERAS protocols with improved patient outcomes. This is borne out in many meta-analyses albeit with a significant amount of heterogeneity in the data. “Fast Track” protocols in lung surgery have been described by many authors and more recently a large review by the ESTS and ERAS societies synthesized some of this data into a highly-effective and streamlined recommendations. Continued efforts are needed to generate high level data examining each facet of perioperative care, to solidify any lessons derived there-from.
The following are evidence-based perioperative care recommendations endorsed by the CATS best practice committee for an Enhanced Recovery After Surgery (ERAS) pathway in patients undergoing major pulmonary resection. These recommendations are in line with the recommendations described by the ESTS and ERAS societies however recommendations for which data was less clear, or not relevant in the Canadian clinical context, were modified or excluded. Where possible the data were independently reviewed for quality and relevance, particularly in areas known to have a paucity of quality data. As this document in itself is not based on an exhaustive systematic review of the literature therefore the strength of evidence and grades of recommendation will not be mentioned.
- Patients should be screened preoperatively for nutritional status and weight loss
- Oral nutritional supplements should be given to malnourished patients
- Smoking cessation should strongly be encouraged including the use of smoking cessation programs
- Cessation greater than 4 weeks pre-op is associated lower post operative pulmonary complications
Alcohol dependency management
- Alcohol consumption (in alcohol abusers) should be avoided for at least 4 weeks before surgery
- Patients with COPD should have their pulmonary function medically optimized by a multidisciplinary team that includes a respirologist
Preoperative fasting and carbohydrate treatment
- Clear fluids should be allowed up until 2 h before the induction of anaesthesia and solids until 6 h before induction of anaesthesia
- Oral carbohydrate loading reduces postoperative insulin resistance and can be considered (data is extrapolated from abdominal surgery population)
- Routine administration of sedatives to reduce anxiety preoperatively should be avoided
Venous thromboembolism prophylaxis
- Patients undergoing major lung resection should be treated with pharmacological and mechanical VTE prophylaxis
- Patients at high risk of VTE may be considered for extended prophylaxis with LMWH for up to 4 weeks although data are lacking in the Thoracic patient population and trials are forthcoming
Antibiotic prophylaxis and skin preparation
- Routine intravenous antibiotics should be administered within 60 min of, but prior to, the skin incision
- Hair clipping is recommended if hair removal is required
- Chlorhexidine–alcohol is preferred to povidone-iodine solution for skin preparation
Preventing intraoperative hypothermia
- Maintenance of normothermia with convective active warming devices should be used perioperatively
- Continuous measurement of core temperature for efficacy and compliance is recommended
Standard anaesthetic protocol
- Lung-protective strategies should be used during one-lung ventilation
- A combination of regional and general anaesthetic techniques should be used
- Short-acting volatile or intravenous anaesthetics, or their combination, are equivalent choices
- A multimodal pharmacological approach for PONV prophylaxis is indicated in patients at moderate risk or high risk
Regional anaesthesia and pain relief
- Regional anaesthesia (ie intercostal nerve block, paravertebral block or pleural catheter) is recommended with the aim of reducing postoperative opioid use
- Paravertebral blockade provides equivalent analgesia to epidural anaesthesia
- A combination of acetaminophen and NSAIDs should be administered regularly to all patients unless contraindications exist
- Ketamine should be considered for patients with pre-existing chronic pain
- Dexamethasone may be administered to prevent PONV and reduce pain
Perioperative fluid management
- Very restrictive or liberal fluid regimes should be avoided in favour of euvolemia
- Balanced crystalloids are the intravenous fluid of choice and are preferred to 0.9% saline High Strong
- Intravenous fluids should be discontinued as soon as possible and replaced with oral fluids and diet
Atrial fibrillation prevention
- Patients taking b-blockers preoperatively should continue to take them in the postoperative period
- Magnesium supplementation may be considered in magnesium deplete patients
Surgical technique: thoracotomy
- If a thoracotomy is required, a muscle-sparing technique should be performed
- Intercostal muscle- and nerve-sparing techniques are recommended
- Reapproximation of the ribs during thoracotomy closure should spare the inferior intercostal nerve
Surgical technique: minimally invasive surgery
- A VATS approach for lung resection is recommended for early-stage lung cancer
- Minimally invasive techniques are feasible in more advanced disease (post-neoadjuvant, sleeve resections) but their use should be limited to surgeons with experience in such techniques
Chest drain management
- The routine application of external suction should be avoided Low Strong
- Chest tubes should be removed even if the daily serous effusion is of high volume (up to 450 ml/24 h)
- A single tube should be used instead of 2 after anatomical lung resection
- In patients with normal preoperative renal function, a transurethral catheter should not be routinely placed for the sole purpose of monitoring urine output
- It is reasonable to place a transurethral catheter in patients with thoracic epidural anaesthesia
Early mobilization and adjuncts to physiotherapy
- Patients should be mobilized within 24 h of surgery Low Strong
- Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ et al. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg 2018;155:1843–52.
- Cerfolio RJ, Pickens A, Bass C, Katholi C. Fast-tracking pulmonary resec- tions. J Thorac Cardiovasc Surg 2001;122:318–24.
- Das-Neves-Pereira JC, Bagan P, Coimbra-Israel AP, Grimaillof-Junior A, Cesar-Lopez G, Milanez-de-Campos JR et al. Fast-track rehabilitation for lung cancer lobectomy: a five-year experience. Eur J Cardiothorac Surg 2009;36:383–91; discussion 391.
- Muehling BM, Halter GL, Schelzig H, Meierhenrich R, Steffen P, Sunder- Plassmann L et al. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Eur J Cardiothorac Surg 2008;34:174–80.
- Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189–98
- Navarro LH, Bloomstone JA, Auler JO, Cannesson M, Rocca GD, Gan TJ et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med 2015;4:3.
- Fiore JF, Bejjani J, Conrad K, Niculiseanu P, Landry T, Lee L et al. Systematic review of the influence of enhanced recovery pathways in elective lung resection. J Thorac Cardiovasc Surg 2016;151:708–15.e6.
- Bjerregaard LS, Jensen K, Petersen RH, Hansen HJ. Early chest tube re- moval after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. Eur J Cardiothorac Surg 2014;45:241–6.
- Frendl G, Sodickson AC, Chung MK, Waldo AL, Gersh BJ, Tisdale JE et al. 2014 AATS guidelines for the prevention and management of periopera- tive atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014;148:e153–93.
- Li S, Zhou K, Che G, Yang M, Su J, Shen C et al. Enhanced recovery pro- grams in lung cancer surgery: systematic review and meta-analysis of randomized controlled trials. Cancer Manag Res 2017;9:657–70
- Zaouter C, Ouattara A. How long is a transurethral catheter necessary in patients undergoing thoracotomy and receiving thoracic epidural analgesia? Literature review. J Cardiothorac Vasc Anesth 2015;29: 496–501.
- Allen MS, Blackmon SH, Nichols FC, Cassivi SD, Harmsen WS, Lechtenberg B et al. Optimal timing of urinary catheter removal after thoracic operations: a randomized controlled study. Ann Thorac Surg 2016;102:925–30.