Enhanced recovery after surgery (ERAS) is a comprehensive multi-disciplinary protocol-based approach with well-defined perioperative interventions. The activity of ERAS begins from the time of preoperative assessment and extends into the postoperative period with the three-fold aim of providing best quality of care, cutting down cost and improving patient satisfaction level. ERAS was the brainchild of Henrik Kehlet and was first started in 1997 for colorectal surgeries, and was later adopted by other surgical specialties. United Kingdom was the first country to publish literature on enhanced recovery for cesarean delivery (ERAC) in 2013.[3–5] ERAS society introduced their guidelines on ERAC in 2018, which was then followed by the consensus guidelines from the Society of Obstetric Anesthesia and Perinatology (SOAP) in 2020.[6–9] Following the seal of approval from ERAS and SOAP, ERAC utilization and research increased, resulting in number of published peer reviewed studies,[10–18] systemic reviews and meta-analysis.[19–23]
Despite a robust literature on ERAC, there is no global consensus on what interventions should formulate an ERAC protocol. None of the published studies applied all the recommended interventions, with few studies focused on implementation methodology utilized to ensure compliance and success of ERAC protocols.
The aim of this narrative review is to discuss the elements and recommendations from ERAS society for cesarean delivery (CD), role of anesthesiologists in the current and emerging ERAC and challenges of ERAC implementation in resource limiting setting.
A comprehensive review of anesthesia and obstetric literature was done by searching database of PubMed and Google Scholar for studies which evaluated the improvement after the introduction of ERAC protocol, systematic reviews, meta-analysis, and editorials. The guidelines and consensus endorsed by ERAS society and SOAP were also appraised for this review.
ERAS society guidelines for Cesarean delivery
The ERAS society has used evidence-based knowledge gained from research based on CD and after critical appraisal and consensus, classified the pathway into a 1) focused pathway and 2) optimized pathway. Focused pathway is initiated from 30-60 minutes before the skin incision, for both scheduled and unscheduled CD, until hospital discharge. Optimized pathway incorporates the provision of antenatal education, identifying and managing maternal comorbidities, and providing immediate neonatal needs at the time of delivery.
The focused pathway is based on three-parts documents; with the first document (part 1) focused on preoperative care beginning 30-60 minutes before the skin incision, for both scheduled and unscheduled CD, second document (part 2) focused on the intraoperative care and the third document (part 3) on the postoperative care until hospital discharge.[6–8] Guidelines for enhanced recovery after CD (focused pathway) with preoperative, intraoperative, and postoperative pathway is summarized in Tables 1-3.
Role of anesthesiologist in the current and emerging ERAC protocol
ERAC uses multidisciplinary approach with inclusion of all stakeholders including anesthesiologists, obstetricians, pediatricians, nurses, pharmacists, patients, and hospital administration. Therefore, successful implementation of ERAC is dependent on institutional support, local infrastructure, and compliance of all supporting systems.
Anesthesiologists play an important role in implementing standardized care to improve maternal outcomes, improve quality of care, and minimize opioid exposure and patient satisfaction. Anesthesiologist involvement in the preoperative, intraoperative, and postoperative period involves the following elements:
Preoperative education/discussion helps to reduce anxiety, manage expectation, and helps in improving compliance with ERAC protocol. Patient engagement in decision-making pertaining to the technique of anesthesia and pain management may start preoperatively with the anesthesiologist. Shared decision-making has shown to improve patient satisfaction and reduce opioid utilization by patients.
Patient nil per oral (NPO) status is a great concern for the anesthesiologist and hence their involvement is of utmost importance. The SOAP and ERAC protocols suggest giving clear juice (16 ounces/500 ml) two hours before surgery. Restricting prolonged NPO and complex carbohydrate (i.e., maltodextrin) loading the evening before and 2-3 hours prior to anesthesia with non-particulate drink can minimize the metabolic stress response, improve postoperative insulin resistance, and lower protein breakdown.
• Technique of Anesthesia:
ERAS guidelines and practice guidelines from American Society of Anesthesiologists from the year 2016 for obstetric anesthesia recommend central neuraxial techniques including spinal, epidural, and combined spinal-epidural for CD. Regional anesthesia is preferred over general anesthesia as it is associated with lower incidence of intraoperative pain, lower incidence of nausea and vomiting, less blood loss, reduced stress response to surgery, and decreased length of stay in hospital.[28,29] While outcomes of both spinal and epidural anesthesia are comparable, spinal anesthesia provides faster onset and results in lower incidence of intraoperative pain.[30,31]
• Management of Perioperative Hypotension:
Even though neuraxial techniques are recommended choice for CD, there are some associated maternal and neonatal complications associated with these techniques. Sympathectomy resulting from neuraxial techniques leads to vasodilation and resulting fall of blood pressure, which is the most commonly encountered side effect. The intensity of hypotension depends on the dose of drug used and the rate of onset of neuraxial block. Spinal-induced hypotension is responsible for symptoms including intraoperative nausea and vomiting and dizziness in mothers and may lead to fetal acidosis secondary to the decrease in the uteroplacental flow.
The most recommended technique for the management of spinal-induced hypotension is fluid therapy and vasopressors. Preloading with both colloid and crystalloid is effective for the prevention of maternal hypotension up to some level.[27,34,35] Current consensus talks more about colloid preload and crystalloid co-loading. However, optimal fluid therapy in terms of the amount of volumes and whether crystalloid or colloid are effective to prevent hypotension is still unclear.
Routine prophylactic use of vasopressors is recommended, as they have shown to be effective against spinal-induced hypotension. Phenylephrine, which is a pure alpha agonist is the vasopressor of choice due to its ability to directly counteract vasodilation. More research-based data from obstetric patients is required to support the use of drugs having mild beta agonist activity like norepinephrine and metaraminol. To avoid hypotension in 90% of parturient undergoing elective CD, investigators recommended the effective norepinephrine bolus dose (ED90) of 6 microgram. Investigators further determined that the estimated dose of phenylephrine 100 mg is equivalent to norepinephrine 8 microgram.[33,37]
• Management of Spinal Anesthesia-Induced Intra and Postoperative Nausea and Vomiting:
Possible causes of spinal anesthesia-induced intra and postoperative nausea and vomiting (PONV) is hyperactivation of the gastro-intestinal tract secondary to sympathetic blockade and activation of vomiting center secondary to hypotension-induced cerebral ischemia. In addition, opioids and some surgical maneuvers like uterine exteriorization and intra-abdominal saline irrigation can also be the contributing factors.[39,40] Maintaining maternal blood pressure by initiating prophylactic vasopressor infusion and fluid loading, decreases the incidence of intraoperative nausea and vomiting and maintains uteroplacental perfusion. It is recommended to combine at least two intravenous anti-emetics having different mode of action.[9,39] It is suggested to use combination of glucocorticoid, D2 receptors antagonists, and 5HT3 antagonists.[9,39]
• Prevention of Hypothermia
Spinal anesthesia can alter thermoregulation for several hours and can cause core body temperature to fall rapidly below36°C. Perioperative hypothermia leadings to increase rate of infection, risk of coagulopathy, myocardial ischemia, and reduced metabolism of drugs among mother, in addition to poor patient satisfaction associated with shivering.
Complications in neonates like hypoglycaemia and respiratory distress syndrome have been linked to neonatal hypothermia secondary to maternal hypothermia.[7,43] Mortality in neonates secondary to hypothermia has been observed in preterm and very low birth weight.[7,43]
ERAS society recommends prevention of perioperative hypothermia by using warming devices. Therefore, use of warming devises for intravenous fluid administration combined with air warming blankets and maintaining operating room temperature to 22°C may decrease the incidence of maternal and neonatal hypothermia.[44–46]
• Multimodal Techniques for Perioperative Pain Management
Multimodal techniques have shown to modify the body physiologic reaction to painful stimuli, consumption of opioid, and chronic opioid use. Multimodal analgesic regime should be considered along with intrathecal opioids which may include non-opioid analgesia and regional techniques.[7–9]
The use of intrathecal opioids prevents intraoperative breakthrough pain and enhances postoperative analgesia. The suggested doses of neuraxial morphine for CD is in the range of 1-3 milligram for epidural technique or 50-150 microgram for intrathecal use via spinal technique. Unless there are contraindication, scheduled non-steroidal anti-inflammatory drugs (NSAIDS), and acetaminophen decrease the need for opioids and its related side effects by 30% to 50% after CD. It is recommended to start scheduled acetaminophen preoperatively or during intraoperative period. NSAIDs in the form of ketorolac 30 mg intravenously can be administered after peritoneal closure, followed by regular NSAIDS at scheduled time interval, e.g., ketorolac can be prescribed in the doses of 15-30 mg six hourly or ibuprofen in the dose of 600 mg six hourly or naproxen in the dose of 500 mg at 12 hourly intervals can be prescribed. As according to FDA approval, the maximum dose of acetaminophen dose is 4000 milligram per 24 hours.
The recommended local anesthetic techniques include both wound infiltration and nerve blocks. Among ultrasound guided nerve blocks transversus abdominis plane (TAP) block and quadratus lumborum block have shown good analgesic effect. Evidence has shown that TAP block has equal efficacy when compared to 100 mg intrathecal morphine for CD in terms of perioperative outcomes like pain scores, requirement of rescue analgesics, incidence of side effects, and satisfaction of patient. The quadratus lumborum block when used as a component of multi-modal analgesic management is found to be effective regional block for postoperative pain control after CD. These nerve block techniques are especially beneficial in circumstances when neuraxial morphine is either not available or cannot be given.
Role of anesthesiologist in postsurgical recovery is now beyond just maintaining low pain scores. It has now progressed from one-dimensional goal to a more holistic multidimensional approach. The goal of providing efficient pain management is not only to reduce parturient suffering but also to improve their functional recovery and the ability to look after their newborns. Anesthesiologists’ role at managing postoperative pain and nausea vomiting will facilitate in achieving key postoperative goal of ERAC, which includes early cessation of NPO and ambulation within the first 24 h.
Measures of postoperative outcome usually focus on morbidity and mortality, which do not necessarily describe the patient’s experience or quality of recovery (QoR) after surgery. Ciechanowicz et al. developed and evaluated an obstetric quality of recovery score (ObsQoR-11) for specific use in parturient who had undergone elective caesarean delivery. As a modified version of the earlier QoR-40 survey, the ObsQoR-11 questionnaire contained items derived from four clinically relevant dimensions of good postoperative quality of recovery, including physical comfort, emotional state, physical independence and care of the newborn, and pain. However, quality of recovery scoring tools validated in developed country may not be valid in developing countries with significant cultural, socio-economic, and linguistic variations. Therefore, Kumar S et al. validated a Hindi version of the ObsQoR-11 for people of developing country like India.
Implementation of ERAC in resource limited setting a challenge!
Robust literature on ERAC including ERAS society guidelines followed by consensus guidelines from Society of Obstetric Anesthesia and Perinatology is indicative of the fact that ERAC has been embraced by many developed countries. However, a lot needs to be ensured before implementation of ERAC in developing countries. Prime barriers mentioned in the literature for introducing ERAC in resource limiting countries are lack of education, huge disparity between rural and urban healthcare setups, failure to recognize early warning signs and inadequate infrastructure, paucity of trained staff for implementation of ERAS protocols, and unavailability of adequate networks and telecommunication facilities.[52,53] All these barriers need support at the government level, however, as rightly mentioned in the editorial published in 2022, the priority of the government in developing country is on reduction of maternal mortality rate. Therefore, implementation of ERAC is not expected to be supported by the government soon.
It is suggested that the approach in developing countries should be at the institutional level by taking all the stake holders on board. Teams including anesthesiologist, obstetrician, nursing, hospital, and patient should be taken on board. Multidisciplinary medical teams at institutional level should try to phase in the intervention strategies of ERAC program. This can start by training the staff and working on patient education. Anesthesiologist being an important part of this team can aim to standardize the perioperative care elements as suggested by ERAS. This can be started by involving patients and their family in the anesthesia plan and pain management, use of regional anesthesia wherever possible, introducing protocols for prevention of post-spinal hypotension, nausea and vomiting, perioperative hypothermia, and use of multimodal analgesia.
The most important modification that can be made in the practice to enhance outcomes and improve quality of care is by implementation of ERAC standardized care. The enhanced recovery protocol after cesarean section should encompass best evidence-based components in perioperative period. A multidisciplinary approach which includes anesthesiologists, obstetricians, pediatricians, nurses, pharmacists, patients, and hospital administration is recommended. Future research is still required to improve recommendations of utilization of ERAC protocol, identify the best procedures and interventions, and assess the most accurate ways to monitor the impact of ERAC. This will help to evaluate the effectiveness of implementation of ERAC protocol and improve the care of women undergoing cesarean delivery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
The authors wish to acknowledge Maheen Fazal for providing support in editing and submission of the manuscript.
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