The ERAS concept: Guidelines for faster recovery

What is the ERAS system all about?

What does ERAS^® stand for?

ERAS is the abbreviation for “enhanced recovery after surgery”.

In April 2018, the European Journal of Cardio-Thoracic Surgery published the ERAS^® post-lung surgery guidelines1. The international authorship consisting of physicians from the UK, Switzerland, Denmark, the US and Canada considered what optimal perioperative management looks like for thoracic surgery patients. The goal was to speed up the healing process and avoid complications. The resulting ERAS^® concept is based on several pillars and looks at the entire patient journey from initial contact to patient discharge.

The significance of the ERAS concept for lung surgery

Surgery represents a stressful situation for any patient. Their bodies react by releasing stress hormones, mediators and cytokines, for example. These can have an unfavourable effect on the healing process. Standardised patient care according to the ERAS^® pathways are intended to ensure that all patients receive optimal treatment both before and after the surgical procedure. In short, the ERAS^® concept aims to decrease organ dysfunction and the overall risk of complications after surgery, while speeding up the healing process. The aim is also to shorten the length of inpatient stay.

To date, studies on the ERAS^® concept have mainly come from the field of colorectal surgery. These have demonstrated that the implementation of ERAS^® has a positive influence on the length of hospital stays. In addition, post-surgical complication rates have decreased.

Based on extensive research results from 1966 to 2017, the authors present in their study a total of 45 specific programme measures that are intended to ensure improved recovery after lung operations, according to the ERAS^® concept. These measures are divided into four time periods and are comprised of the preoperative phase, the admission, the intraoperative phase and the postoperative phase.

In principle, the ERAS^® concept is the comprehensive further development of the Fast Track concepts that were introduced 20 years ago. What is truly new is that, unlike Fast Track, significantly more attention is paid to the preoperative phase. In everyday clinical practice, it is repeatedly demonstrated that there is a strong need and great interest in concepts of this type.

Four tips for chest drainage management according to the ERAS pathway

According to ERAS principles, chest tube management should be approached in an evidence-based way and conservative removal strategies abandoned. This can be achieved with single tubes, no routine suction, the use of digital drainage systems, and removal of tubes even in the presence of relatively high serous pleural fluid outputs.

1. Avoid routine use of external (continuous) suction

According to studies, routine use of external negative pressure does not appear to provide advantages in reducing air leaks or drainage duration. This demonstrates the great advantage of electronically-controlled drainage systems such as Medela’s Thopaz⁺: They only build up intrapleural suction if the previously set sub-atmospheric negative pressure deviates from the measured pressure. Since wall suction limits patient mobility, its routine application should therefore be avoided.

2. Recommendation: Use digital chest drainage systems in lung surgery

Making decisions based on subjective assessments using analogue devices is insufficiently accurate for the ERAS^® system. Since specific limit values require precise measurements, digital systems with objective data displays, including data storage and trend displays, are recommended. In addition, a digital system reduces the drainage time and thus the length of the hospital stay.

3. Remove drains with a drainage volume of 450 ml/24 h

Many institutions only remove the drain at a limit value of 250 ml/24 h. The data shows, however, that there is no clinical difference between ≤450 ml/24 h and 250 ml/24 h. Consequently, after a thoracic surgery the drain can already be removed at ≤450 ml/24 h 24 h so long as there is no evidence of air leak, chyle, pus or active bleeding. The patient can thus be discharged home safely and sooner.

4. Place one drain instead of two after a lung resection

The use of only one drain allows for earlier mobilisation and reduces postoperative pain for the patient without increasing the risk of repeated effusion, thus being fully in line with the ERAS^® pathways. Furthermore, the use of only one drain is associated with a reduction in the amount of fluid drained and a reduced duration of drainage.

From theory to practice: our conclusion on the ERAS concept in lung surgery

A good tip:
The authors of the study emphasise that individual measures may not (or indeed do not) have a measurable effect on their own. Overall, however, they have a positive effect that can be proven scientifically. Good cooperation between doctor and patient is crucial to the treatment's success. The quality of the proven benefit (evidence) and the level of recommendation are also specified for each measure.

In summary, it can be said that The ERAS^® pathways are a comprehensive further development of the Fast Track concepts introduced 20 years ago, with a special focus on the preoperative phase. These concepts are already widely used in colorectal surgery and should now also be increasingly used in lung surgery. The ERAS^® concept measures listed here aim to optimise the healing process for patients after thoracic surgery and ensure a complication-free hospital stay. The patient’s willingness to cooperate is essential here.

Many of the aforementioned ERAS^® recommendations have already been implemented as standard in German surgical clinics for years. Other clinics, in contrast, have not yet given them the desired importance, or such concepts may not be practical for every patient under the circumstances. Ultimately, the goal of all measures used should be to reduce stress in patients' recovery phase post-thoracic surgery as much as possible. Here, the ERAS^® concept offers the potential to identify measures that have so far been deemed insufficient in day-to-day clinical operations and to replace them with new ones.