Enhanced Recover After Surgery (ERAS) for Neuro-oncologic Surgeries

Enhanced Recovery After Surgery (ERAS) was originally conceptualized to decrease morbidity after colorectal surgery and has since been expanded to encompass other abdominopelvic surgeries.  A review article from Journal of Clinical Neuroscience (2015) applied the ERAS concept to elective craniotomies for tumor resections to facilitate hospital discharge for cancer patients, expedite subsequent chemoradiothrapy and improve patient outcome.

The guidelines proposed include:

  1. Pre-operative
    1. Patients should routinely be counselled on what to expect from surgery. (Low, Strong)
    2. Patients should abstain from alcohol and smoking 1 month prior to surgery (Mod, Strong)
    3. Patients should be given enteral nutrition preoperatively. (Mod, Strong)
    4. Patients may benefit from immunonutrition perioperatively. (Mod, Weak)
    5. Patient should be encouraged to load with carbohydrates perioperatively.*  (Low, Strong)

*Perioperative oral CHO loading up to 2 hours prior to surgery has been shown to attenuate insulin resistance and improve subjective feelings of hunger, thirst, and post-operative fatigue compared with fasting.  As CHO beverages are a clear liquid, perioperative CHO loading should be encouraged.

  1. Intra-operative 
    1. Surgeon should minimize scalp shaving. (Mod, Weak)
    2. Cefazolin should be given within 1 hour prior to skin incision.  For patients with MRSA, vancomycin should be initiated 1 hour prior to skin incision. (High, Strong)
    3. Surgeon should utilize scalp in filtration and scalp blocks for craniotomies. (Mod, Strong)
    4. There is no evidence that short-acting anesthetics are superior to longer acting anesthetics, nor TIVA to pure inhalational anesthetics.
    5.  Minimally invasive surgery may improve patient recovery and satisfaction. (Very low, Weak)
  2. Post-operative
    1. Gabapentin / pregabalin / tramadol have side effect profiles that are unfavorable for craniotomy. (Low, Weak)
    2. Low evidence for efficacy of intravenous acetaminophen, but side effect profile is favorable.  (Mod, Strong)
    3. There may be a role for limited dosing of COX-2 inhibitors and flupirtine pending further research.  (Low, Weak)
    4. Routine serotonin receptor antagonists and dexamethasone is recommended for PONV.  (High, Strong)
    5. Aprepitant should be reserved for patients at high risk of PONV due to higher cost and limited effectiveness.  TEAS (transcutaneous electrical acupoint stimulation) requires further study.  (Low, Weak)
    6. Scopolamine and promethazine side effect profiles make them undesirable as first-line nausea meds.  (Low, Weak)
    7. Avoid hypothermia.  (High, Strong)
    8. Remove Foley on posteroperative day 1 or as early as feasible.  (Mod, Strong)
    9. Post-operative TPN not needed except for patients in prolonged comatose state.  (Mod, Strong)
    10. Encourage early mobilization.  (High, Strong)
  3. Others:
    1. Patients should use graduated compression stockings and intermittent pneumatic compression to prevent VTE.  Routine use of anticoagulants is not recommended. (High, Strong)
    2. Audit measure routinely.  (Mod, Strong)

 

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Sample Neurosurgery-ERAS Guideline given to patients from Penn medicine: ERAS Neurosurgery

Reference:

Hagan, K., Bhavsar, S., Raza, S., Arnold, B., Arunkumar, R., Dang, A., Gottumukkala, V., Popat, K., Pratt, G., Rahlfs, T. and Cata, J. (2016). Enhanced recovery after surgery for oncological craniotomies. Journal of Clinical Neuroscience, 24, pp.10-16.

 

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