Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization

Carol J Peden, Geeta Aggarwal, Robert J Aitken, Iain D Anderson, Nicolai Bang Foss, Zara Cooper, Jugdeep K Dhesi, W Brenton French, Michael C Grant, Folke Hammarqvist, Sarah P Hare, Joaquim M Havens, Daniel N Holena, Martin Hübner, Jeniffer S Kim, Nicholas P Lees, Olle Ljungqvist, Dileep N Lobo, Shahin Mohseni, Carlos A Ordoñez, Nial Quiney, Richard D Urman, Elizabeth Wick, Christopher L Wu, Tonia Young-Fadok, Michael Scott, Carol J Peden, Geeta Aggarwal, Robert J Aitken, Iain D Anderson, Nicolai Bang Foss, Zara Cooper, Jugdeep K Dhesi, W Brenton French, Michael C Grant, Folke Hammarqvist, Sarah P Hare, Joaquim M Havens, Daniel N Holena, Martin Hübner, Jeniffer S Kim, Nicholas P Lees, Olle Ljungqvist, Dileep N Lobo, Shahin Mohseni, Carlos A Ordoñez, Nial Quiney, Richard D Urman, Elizabeth Wick, Christopher L Wu, Tonia Young-Fadok, Michael Scott

Abstract

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds.

Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Conflict of interest statement

Dr. Peden has received consultancy fees from the American College of Surgeons Improving Care and Surgical Recovery program and from the Institute for Healthcare Improvement, and from Merck for unrelated work. Dr. Scott has honoraria from and serves on advisory boards of Baxter, Edwards Lifesciences, Deltex, Trevena, and Merck. He also receives travel reimbursement from these companies. Dr. Lobo has received speaker honoraria for unrelated work from Fresenius Kabi in the last 3 years and is the Scientific Chair of the ERAS® Society. Dr. Wu has nothing to disclose. Dr. Hübner has nothing to disclose. Dr. Lees has nothing to disclose. Dr. Urman has received research funding or fees from Merck, Covidien/Medtronic, AcelRx, Pfizer and Takeda outside the submitted work, as well as federal funding from NIH, AHRQ and NSF. Dr. Aitken has nothing to disclose. Dr. Grant has nothing to disclose. Dr. Hammarqvist has nothing to disclose. Dr. Hare has nothing to disclose. Dr. Havens has research grant funding from Johnson and Johnson outside the submitted work. Dr Ljungqvist is the Chairman of the ERAS® Society, founded and owns stock in Encare AB, and has received honoraria for advice, lecturing including travel support from Nutricia, Fresenius-Kabi, Pharamcosmos, Encare AB, and lecturing honoraria from Medtronic and BBraun outside the related work. Dr Ljungqvist previously held a now expired patent for a preoperative carbohydrate drink. Dr. Ordoñez has nothing to disclose. Dr. Kim has nothing to disclose. Dr. French has nothing to disclose. Dr. Aggarwal has nothing to disclose. Dr. Quiney has nothing to disclose. Dr. Holena has nothing to disclose. Dr. Cooper has nothing to disclose. Dr. Wick has funding from the Agency for Healthcare Research and Quality outside the submitted work. Dr. Bang Foss has nothing to disclose. Dr. Young-Fadok has nothing to disclose. Dr. Mohseni has nothing to disclose. Dr. Dhesi has nothing to disclose.

Figures

Fig. 1
Fig. 1
The hour-1 surviving sepsis campaign bundle of care. From Levy et al. [63]

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