Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland

Abstract

Introduction
The ERAS protocol is a set of international guidelines established to expedite patients’ discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients’ return to home at earlier rates than traditional practice.

Methods
A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively.

Results
In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin.

Conclusion
UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.

Full text

Vol.:(0123456789)
Irish Journal of Medical Science (1971 -)
https://doi.org/10.1007/s11845-024-03731-4
ORIGINAL ARTICLE
Assessment ofpre‑, peri‑, andpost‑surgical practices forelective
colorectal patients inamodel 4 hospital inIreland
GavinDavidO’Connor1,2 · RóisínTaplin1· ClodaghMurphy1
Received: 15 May 2024 / Accepted: 30 May 2024
© The Author(s) 2024
Abstract
Introduction The ERAS protocol is a set of international guidelines established to expedite patients’ discharge after colo-
rectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function
allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few,
and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients’ return to
home at earlier rates than traditional practice.
Methods A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in
a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed
about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively.
Results In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements
of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within
24h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative
antibiotics use of preoperative gabapentin.
Conclusion UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improve-
ment required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary
team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.
Keywords Anaesthesia· colorectal surgery· enhanced recovery after surgery· ERAS
Introduction
Enhanced Recovery After Surgery Protocol
Enhanced recovery after surgery (ERAS) is a protocol devel-
oped in 1997 with the aim of expediting discharges in patients
undergoing colorectal surgery [1]. The ERAS protocol outlines
a variety of measures that should be taken throughout a patients’
surgical stay, including at the first meeting in the preoperative
phase [2]. The protocol includes preoperative, perioperative and
postoperative measures to be followed, with the primary objec-
tive of getting patients fit for discharge, without compromising
patient care. The ERAS protocol aims to promptly treat, and
prevent, common postoperative complications that increase
morbidity, mortality, or length of stay in patients. Such compli-
cations include, but are not limited to postoperative nausea and
vomiting (PONV), deep vein thrombosis (DVT), pulmonary
embolism (PE), ileus, fluid overload and pain [2]. The ERAS
protocol is often viewed as the gold standard in terms of patient
care for those undergoing elective colorectal surgery.
The ERAS protocol is a large set of guidelines, and requires
the collaboration of a multidisciplinary team. Preoperative
measures include adequate preoperative assessment, patient
education, nutritional assessment, and preoperative carbohy-
drate drinks. Perioperative factors include preoperative anti-
biotics, PONV prophylaxis, nerve blocks, and adequate fluid
replacement. Postoperative factors include early mobilisation,
early return to eating and drinking, removal of catheters and
the use of prophylactic anticoagulants [2]. These are a wide
set of recommendations to be incorporated that require the
collaboration of surgeons, anaesthesiologists, nursing staff,
physiotherapists and dieticians, among others, to perform.
* Gavin David O’Connor
gavin9300@gmail.com
1 University Hospital Limerick, Limerick, Ireland
2 University College Cork, Cork, Ireland

Irish Journal of Medical Science (1971 -)
Inpatient stay aftercolorectal surgery
Colorectal surgery is common, with over 600,000 operations
occurring in the United States per year [3]. It can be per-
formed for a variety of aetiology, including colorectal cancer
resection. The patient demographic undergoing colorectal sur-
gery are often over 65years of age with multiple comorbidi-
ties [4]. Median length of stay (LOS) of patients undergoing
elective colorectal surgery has been reported in some studies
to be 14days [5]. With such a large number of patients under-
going colorectal surgery each year, and a significant inpatient
stay, factors which can expedite a patients’ return to function
and discharge are very valuable both in terms of their experi-
ence, and financial savings to the patient and hospital.
The ERAS protocol has been shown through a variety of
research to enhance early discharge, whilst not increasing
30-day readmission rates [6–11]. It has been suggested that
the 30-day readmission rates can decrease from 19% pre-
ERAS to 12% after ERAS [9]. Strong data has been published
that greater compliance to the ERAS protocol decreases a
patients’ LOS [7–9, 12],and reduces postoperative complica-
tions and readmissions from 59.2% pre-ERAS to 34.1% post-
ERAS [12]. Compliance can improve greatly over time as
institutions continue to implement ERAS into their practice
[7]. With all of these benefits in mind, we wanted to assess to
current compliance of the ERAS protocol in UHL in patients
undergoing elective colorectal surgery in 2023.
Study aims
To assess the pre-, peri-, and post-surgical practices for
patients undergoing elective colorectal surgery in a mode 4
hospital in Ireland in 2023.
Study objectives
Primary objective: Comparing the current pre-, peri-, and
post-surgical practices for patients undergoing colorectal
surgery in University Hospital Limerick with the enhanced
recovery after surgery protocol.
Methods
Study design andparticipants
This study is a prospective cohort study of all patients in Uni-
versity Hospital Limerick, Ireland who underwent elective
colorectal surgery from February to September in 2023. The
theatre lists of the colorectal surgeons was accessed during
the study period to identify patients who were having elective
colorectal surgery for inclusion in our study. Inclusion criteria
included patients who were over the age of 18, undergoing
elective colorectal surgery, who were not admitted to a critical
care bed (ICU or HDU) postoperatively, who were an inpatient
day 4 postoperatively, had capacity to consent to be in a study,
and consented to participate in the study. Exclusion criteria
included patients under the age of 18, not undergoing elective
colorectal surgery, admitted to a critical care bed postopera-
tively, no longer an inpatient, lacking capacity, or declined to
participate in the study. In total, 33 patients agreed to partici-
pate in the study, who granted the investigators access to their
medical charts, and filled out a short questionnaire.
Study measures
Variables to be collected were taken from the ERAS guideline
to assess the care provided to patients in UHL in compari-
son to the standards set out in the ERAS guideline. Variables
collected included age, sex, name of procedure, anti-emetics
used, MUST score, preoperative weight, preoperative nutri-
tional drink provided, date of surgery, postoperative weight,
weight change, PONV, date of discharge, length of stay, post-
operative complications, preoperative antibiotics, prophylactic
antibiotics, intraoperative fluid type, pre-operative gabapentin,
time of first oral intake, diet day 0 to day 3, day of first bowel
motion, DVT prophylaxis, physiotherapy interaction, elective
nasogastric tube use, attendance at preoperative assessment
clinic and fasting status prior to the operation. Satisfactory
adherence to the ERAS protocol was defined as compliance of
70% or greater in accordance with published literature.
Ethical approval
Ethical approval to conduct this study was sought from the
Ethics Committee in University Hospital Limerick on 23rd
of September, 2022. Ethical approval was granted on 29th
of November 2022.
Data analysis
All of the data collected was entered into IBM SPSS ver-
sion 22.0 for Windows (SPSS, Chicago, Illinois, USA) for
analysis. Continuous variables were analysed using descrip-
tive statistics to calculate the mean, median, range and 95%
confidence intervals. Categorical variables were analysed
using frequency tables.
Results
Study cohort
The total sample size was 33 patients with a male predomi-
nance (Table1). The median age for patients included in the

Irish Journal of Medical Science (1971 -)
study was 70years, mean age was 66.03 (standard deviation,
11.92, range 35 to 84): 65.2 for men and 67.4 for women.
Length of stay ranged from 6 to 22days with a mean of 11
(SD 3.886, median 10).
Compliance preoperatively
In this study, 100% of patients attended the preoperative
assessment clinic (POAC). During this clinic, 100% of
patients were supplied with fasting guidelines for food and
water to follow before their surgery, and had their starting
weight documented. The Malnutrition Universal Screening
Tool (MUST) was used on 72.7% of patients. Only 24.2% of
patients drank any water on the morning of surgery, despite
the guidelines saying that they must only fast for water 2h
prior to surgery. Preoperative gabapentin was used in 48.4%
of patients (Table2).
Compliance perioperatively
Laparoscopic surgery techniques were used on 97% of
patients who underwent elective colorectal surgery in UHL.
No patient had a nasogastric tube leaving the operating thea-
tre. Single anti-emetics were used in 78.8% of patients, with
21.2% of patients receiving dual anti-emetics. Granisetron
was used in 69.7% of patients. CSL was the IV fluid used in
75.8% of cases (Table3).
Postoperative compliance
Patients were mobilising with a physiotherapist within 24h
after surgery in 100% of cases in this study. Low molecular
weight heparin (LMWH) was initiated in 51.5% of patients
on day 0 and 100% of cases on day 1 postoperative for DVT
prophylaxis. Antibiotic prophylaxis was continued for 24-h in
90.1% of patients. Postoperative complications were recorded
in 57.6% of patients, including 30.3% of patients experiencing
an ileus, 12.1% of patients being treated for a lower respiratory
tract infection (LRTI). Surgical site infections were recorded in
2 patients, with 1 patient experiencing notable pain, 1 patient
requiring a postoperative blood transfusion, and 1 patient expe-
riencing a surgical complication. In our study, mean LOS for
patients with an ileus was 13.13days (range 9 to 22days, SD
4.155) compared to 10.22 in those without an ileus (range 6 to
18days, SD 3.58). No patients experienced a DVT or PE. In this
study, 33.3% of patients had oral intake on the same day after
their surgery, whilst 93.9% had oral intake day 1 postoperatively,
and 100% having oral intake day 2 postoperatively. Postoperative
weights were only recorded in 48.5% of patients. First bowel
motion had a mean of 2.76days (SD 1.953) (Table4).
Table 1 Patient Demographic
Data shown as % of all patients or mean ± standard deviation
Cohort Result
Age (years) 66 ± 11.92
Female, n (%) 13 (39.4)
Length of stay 10.97 ± 3.886
Table 2 Preoperative criteria of ERAS protocol
Data shown as % of all patients; POAC, Preoperative assessment
clinic;MUST, Malnutrition Universal Screening Tool
Preoperative criteria Total, n (%)
Attended POAC 33 (100)
MUST score 24 (72.7)
Water morning of surgery 8 (24.2)
Preoperative gabapentin 16 (48.4)
Preoperative nutrition drink usage 32 (97)
Fasting guidelines supplied 33 (100)
Preoperative weight documented 33 (100)
Table 3 Perioperative criteria of the ERAS protocol
Data shown as % of all patients;CSL, Compund Sodium Lactate
Perioperative criteria Total, n (%)
Laparascopic surgery 32 (97)
Nasogastric Tube leaving theatre 0 (0)
Granisetron 23 (69.7)
Single anti-emetic 26 (78.8)
Dual anti-emetic 7 (21.2)
CSL 25 (75.8)
Table 4 Postoperative criteria of the ERAS protocol
Data shown as % of all patients; LMWH, Low Molecular Weight
Heparin; LRTI, Lower Respiratory Tract Infection; DVT, Deep Vein
Thrombosis; PE, Pulmonary Embolism
Postoperative criteria Total, n (%)
Physiotherapy within 24h 33 (100)
LMWH day 0 17 (51.5)
LMWH day 1 33 (100)
24-h prophylactic antibiotics 30 (90.1)
Complications 19 (57.6)
Ileus 10 (30.3)
LRTI 4 (12.1)
DVT/PE 0 (0)
Post-operative weight 16 (48.5)
Eating day 0 11 (33.3)
Eating day 1 31 (93.9)
Eating day 2 33 (100)

Irish Journal of Medical Science (1971 -)
Discussion
In terms of preoperative aspects of the ERAS protocol, our
adherence in the hospital was satisfactory at over 70% for
almost all aspects. All patients had attended the preopera-
tive assessment clinic, where they were reviewed by the sur-
gical team and preoperative assessment nurses. This is an
important clinic to get patients optimised for surgery [13].
Potential issues in relation to the surgery and anaesthetic
are highlighted at this clinic. Decisions are made if patients
require extra preoperative tests, such as chest x-rays or
echocardiograms. Some patients require the review of spe-
cialists prior to surgery, should they have heart, lung, kidney
or endocrinological co-morbidities. Potentially complicated
patients are highlighted to the anaesthetic team at this clinic,
who may guide and request specific investigations so that a
safe anaesthetic can be performed [14].
At this clinic, many tasks were carried out. Practical tasks
such a routine preoperative bloods and ECGs were per-
formed, weights were measured and documented, guidelines
were given with regard to which medications to withhold
the day of surgery and the days before, along with fasting
guidelines for food and water preoperatively. A nutritional
drink was also supplied, which is a carbohydrate rich drink
shown to improve blood sugar control postoperatively, and
may also reduce PONV [15]. The MUST score was also
measured and documented to highlight patients who are
malnourished and may benefit from the review of a dieti-
tian. Malnourishment has been associated with decreased
healing potential and increased postoperative complications
and LOS [13]. All of these factors had a satisfactory com-
pliance of over 70%. Whilst patients had been given fasting
guidelines not to drink water 2-h before their operation, over
75% of patients did not drink any water on the morning of
surgery. This is likely out of fear of cancellation or delaying
their surgery, despite being permitted in the guidelines. Pre-
operative gabapentin loading is used as an adjunct to control
postoperative pain [16]. It was used in only 48% of patients
in our study.
With respect to intraoperative factors investigated, adher-
ence to the ERAS protocol was satisfactory for numerous
aspects. Laparoscopic surgery was used in 97% of cases.
This has been shown repeatedly in studies to aid recov-
ery after colorectal surgery, and reduce the LOS [9, 10].
The benefits of laparoscopic surgery versus open surgery
are numerous when performed by a skilled and competent
operator and include reduced pain, earlier mobilisation,
reduced complications and reduced LOS [11, 17]. Open
surgery and stoma formation however have been associ-
ated with increased LOS after elective colorectal surgery
[6]. Other features of the ERAS protocol associated with
decreased LOS included intraoperative warming, early
cessation of IVF and early removal of catheters and NG
tubes [18], although conflicting research has been published
with respect to laparoscopic surgery and fluid restrictive
strategies [11].
Intraoperative NG placement is common during colo-
rectal surgery for a number of reasons. Nasogastric tubes
can be placed to drain stomach contents reducing the risk
of aspiration, which can be particularly useful when lapa-
roscopic techniques are being utilised [19]. NGs have also
been used to prevent a build-up of pressure in the bowel
causing distension which can lead to wound dehiscence and
anastomotic leakage [20, 21]. The ERAS protocol encour-
ages the removal of these NGs in theatre, using them for the
minimal amount of time clinically indicated. In this study, no
patient left theatre with a nasogastric tube. This has impor-
tant benefits in terms of enhancing patient comfort, whilst
also encouraging oral intake [21].
Compound sodium lactate (CSL), also known as Hart-
mann’s solution, is the preferred crystalloid of choice for
maintenance fluids and resuscitation fluids intraoperatively
in the majority of patients, as described by the ERAS pro-
tocol. CSL is a more physiologic fluid with respect to its
electrolyte content, and reduces the risk of hypernatraemia
and hyperchloraemic metabolic acidosis which can be seen
with 0.9% normal saline [22]. Normal saline may be pre-
ferred in specific circumstances, such as patients who are
hyponatraemic or hypochloraemic [23, 24]. Adherence to
this policy was over 75% in this study, highlighting how CSL
has become the fluid of choice intraoperatively.
Anti-emetics are important intraoperatively to help
prevent PONV. PONV is a debilitating condition associ-
ated with anaesthetic gases and drugs, and can lead to an
increased inpatient stay due to reducing PO intake and lead-
ing to complications such as AKI (acute kidney injury) and
surgical dehiscence [25]. Anti-emetics were given intraoper-
atively to all patients in this study. Single agent anti-emetics
were used in 79% of patients, with 21% of patients receiving
dual anti-emetics. Granisetron is the preferred anti-emetic
of choice as it is advantageous over ondansetron due to its
longer duration of action requiring it to be dosed only once
a day versus three times a day in the case of ondansetron
[26]. Granisetron was used in 69.7% of patients which was
just below the satisfactory level. Dual agent anti-emetics
included dexamethasone. Dexamethasone has side-effects
such as increasing postoperative blood sugars, peptic ulcers,
impaired wound healing, infection and surgical dehiscence
[27]. Reasons that anaesthetists may have opted to omit dex-
amethasone are numerous and include male patients who
have reduced incidences of PONV according to the Apfel
score, and therefore would not require dual anti-emetics
[28], elderly patients who may be more sensitive to the side-
effects of dexamethasone, and patients with type 2 diabetes

Irish Journal of Medical Science (1971 -)
in whom elevated glucose levels postoperatively would be
undesirable [27].
Prophylactic antibiotics are an important element of the
ERAS protocol, and are also included in the WHO safe
surgery checklist [29]. They should be administered within
60min before skin incision to ensure they reach a desirable
plasma concentration in the tissue before contamination with
bacteria occurs as the skin is pierced [29]. Co-amoxiclav is
the antibiotic of choice in our hospital in patients who are
not penicillin allergic undergoing elective colorectal surgery.
Postoperative elements of the ERAS protocol were inves-
tigated extensively in this study. The discharge criteria for
patients after elective colorectal surgery usually involve
ensuring pain is adequately controlled, patients can mobilise
independently or are back at baseline, patients can tolerate
adequate oral intake, and normal bowel and bladder func-
tion have returned [30]. All of this should be accomplished
without any complications before discharge.
In our hospital, patients are seen within 24-h of surgery
by physiotherapists in 100% of cases. Physiotherapists are
essential members of the multidisciplinary team. They ben-
efit the care of patients by encouraging mobilisation in a safe
manner after surgery which can decrease the risk of DVT
and PE, whilst also providing breathing exercises to prevent
complications such as atelectasis [31].
LMWH is used routinely in hospital to help prevent DVTs
and PEs, which are known postoperative complications, usu-
ally associated with decreased mobility among other risk
factors [32]. LMWH was administered on the same day as
the surgery (day 0) in 52% of patients, with 100% of patients
receiving LMWH by day 1 postoperatively. No patient had
a DVT or PE in this study.
Antibiotic prophylaxis is an important element to prevent
postoperative complications such as surgical site infections
[33]. To prevent these complications, antibiotics should be
administered for 24-h postoperatively, before being discon-
tinued, unless there is a clinical reason to continue antibiot-
ics for longer. Antibiotic prophylaxis in accordance with this
policy was administered in 90% of patients.
Increased compliance with the ERAS protocol has been
correlated with a decrease in complications postoperatively,
and a reduced LOS [12]. Increased compliance has been
associated with a decreased LOS [7–9], reduced postopera-
tive complications and readmissions [12]. Enhanced ERAS
compliance has also been found to reduce perioperative
complications from 56% before the implementation of an
ERAS protocol, to 9.4% [8]. With respect to postoperative
complications in our institution, these were documented to
have occurred in 58% of patients. Complications included
ileus in 30% of patients, with 6% of patients having a surgi-
cal site infection, 12% having a LRTI, 3% requiring postop-
erative blood transfusions, 3% having significant pain, and
3% suffering from a intraoperative complication. Prolonged
postoperative ileus has been reported to occur in 16.6% of
patients, but has been reduced in patients who had early
feeding, mechanical bowel preparation, early mobilisation,
and who had laparoscopic surgery [34]. LOS in patients who
had an ileus was 13days compared to 9.5days in those with-
out [34]. In our study, mean LOS for patients with an ileus
was 13.13days compared to 10.22 in those without an ileus.
ERAS has been shown to reduce the time to bowel function
to 2.5days from 4.1days [35]. Our study had similar results
with a mean time to bowel opening of 2.76days.
Early commencement of oral intake is a key step in the
ERAS protocol [36]. Previously, patients were routinely
fasted after surgery, in an attempt to prevent complications
such as postoperative ileus or dehiscence. Newer studies
have disputed this practice however, and early exposure to
oral intake postoperatively is associated with faster return
to bowel function and regular eating habits, whilst reducing
the risk of postoperative ileus among other complications
[34]. In our study, 33% of patients were allowed oral intake
on the same day of surgery, with 94% of patients allowed
to eat day 1 postoperatively, and 100% allowed to eat day 2
postoperatively. Local policy in the hospital encourages the
stepwise progression of oral intake after colorectal surgery.
Sips of water are first to be introduced, followed by jelly
and a high protein, fortified ice-cream to aid patients who
are malnourished, whilst also providing key ingredients that
aid tissue repair and recovery postoperatively [37]. Coffee is
another element of the ERAS protocol that has been found to
be beneficial in patients undergoing colorectal surgery, to aid
the return to normal bowel function [37]. Jelly sweets and
chewing gum are also encouraged to aid the return to normal
bowel function [38, 39]. Following from this, tea and toast
are introduced, followed by soft food such as yoghurt, eggs
and potato, before commencing to a normal diet.
Whilst preoperative weight was measured in 100% of
patients, postoperative weights were only measured in 49%.
Postoperative weights are recommended to be taken to
assess for fluid balance, with an excessive positive balance
being associated with poorer outcomes such as postopera-
tive ileus rates, and prolonged length of hospital stay [40].
The ERAS protocol has been associated significantly with
existing research to decrease the LOS after elective colorec-
tal surgery [6–9]. It has been shown that the use of the ERAS
protocol does not increase 30-day readmission rates [6–8,
10, 11],whilst re-admission rates have been suggested to
fall from 19% pre-ERAS to 12% post-ERAS [9]. Strong data
has been published to suggests that greater compliance to
the ERAS protocol can decrease a patients’ LOS [7–9, 12],
and reduces postoperative complications and readmissions
from 59.2% pre-ERAS to 34.1% post-ERAS [12]. Compli-
ance can improve greatly over time as institutions continue
to implement ERAS into their practice [7]. Mean LOS in
patients undergoing elective colorectal surgery under the

Irish Journal of Medical Science (1971 -)
ERAS protocol has been suggested to be 4days [11]. Our
study had a much higher mean LOS of 11 with a median
of 10. This was possibly due to the varying local protocol
with regard to discharge criteria, along with the data collec-
tion methods which involved consenting patients who were
inpatients on day 4 postoperatively. This method may have
missed patients who were discharged prior to day 4, whilst
also selecting patients who had suffered a postoperative
complication at a rate that was potentially disproportional
to the true incidence rate.
Limitations
Ethical approval in this study only allowed patients to be
approached to be informed of the study on day 3 before sign-
ing a consent form on day 4. This may have introduced bias
into our study by having healthy, uncomplicated patients
discharged before day 4 of their hospital stay. This may also
have introduced bias as patients who underwent more exten-
sive surgery, which naturally has a greater risk of complica-
tions, may be over represented in our study cohort, along
with any patient who underwent minor surgery but suffered
a postoperative complication. This may explain why our
complication rate is at 58% after the implementation of the
ERAS protocol, and our prolonged LOS. Patients filled out a
questionnaire on day 4 of their inpatient stay. Some patients
may have had difficulty remembering their oral diets and
bowel movements in the days prior to this questionnaire,
which may introduce recall bias. No author approached any
patient that they were directly involved in the care of during
this project.
Future research
Future research based on this project should look at the vari-
ous elements of the ERAS protocol that were not investi-
gated in this project. Such elements may include the use of
intraoperative blocks, such epidural catheters or transver-
sus abdominis plane (TAP) blocks, the use of opiates and
other analgesics postoperatively, and the impact of limit-
ing opiate exposure whilst delivering analgesia on patient
outcome postoperatively. Preoperative bowel prep is a topic
that is suggested by the ERAS protocol to be omitted, but
new research may suggest its use in clinical practice. More
research on preoperative bowel prep may be required to
address this topic and its possible incorporation into the
ERAS protocol. Further research should investigate the
efficacy of the ERAS protocol on a patient cohort who are
not undergoing elective colorectal surgery, such as elective
breast, urology, orthopaedic, or emergency surgery, to see if
the same principles and benefits are transferrable.
Conclusion
UHL has a satisfactory compliance of over 70% with a large
variety of elements of the ERAS protocol. UHL has a suc-
cessful POAC for patients undergoing elective colorectal
surgery, with 100% of patients attending this clinic. Areas
of improvement in UHL with regard to the ERAS protocol
include preoperative gabapentin usage and postoperative
antibiotic prophylaxis. No patient left theatre with an NG
tube in-situ. Over 94% of patients were receiving oral intake
by day 1 postoperatively, with 100% of patients mobilising
with a physiotherapist day 1 postoperatively, and receiving
LMWH prophylaxis. With the collective effort of the multi-
disciplinary team, along with education, the ERAS protocol
can successfully be applied and implemented in a model 4
hospital in Ireland.
Acknowledgements I would like to thank the UHL ethics commit-
tee for granting permission for this research project to take place. I
would like to thank the consultant surgeons who made their patients
accessible to be approached to be included in this study. I would like
to thank the nursing staff on the wards who were accommodating in
allowing this prospective chart review to take place. I would like to
thank every patient who agreed to take part in this research study.
Finally, I would like to sincerely thank my supervisor Clodagh Murphy
and co-investigator Dr Róisín Taplin for their time in designing this
project, collecting and analysing the data for inclusion in this thesis.
Funding Open Access funding provided by the IReL Consortium.
Data availability Raw data if desired can be requested by contacting
the lead author directly by email.
Open Access This article is licensed under a Creative Commons Attri-
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References
1. Kehlet H (1997) Multimodal Approach to control postoperative
pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617.
https:// doi. org/ 10. 1093/ bja/ 78.5. 606

Irish Journal of Medical Science (1971 -)
2. Kehlet H, Wilmore DW (2002) Multimodal strategies to improve
surgical outcome. Am J Surg 183(6):630–641. https:// doi. org/ 10.
1016/ s0002- 9610(02) 00866-8
3. Laparoscopic colon resection patient information from sages
[Internet]. Society of American Gastrointestinal and Endoscopic
Surgeons; 2019 [cited 2024 May 12]. Available from: https://
www. sages. org/ publi catio ns/ patie nt- infor mation/ patie nt- infor
mation- for- lapar oscop ic- colon- resec tion- from- sages/
4. Zhang W, Ayanian JZ, Zaslavsky AM (2006) Patient characteris-
tics and hospital quality for colorectal cancer surgery. Int J Quality
Health Care 19(1):11–20. https:// doi. org/ 10. 1093/ intqhc/ mzl047
5. Kelly M, Sharp L, Dwane F, Kelleher T, Comber H (2012) Factors
predicting hospital length-of-stay and readmission after colorectal
resection: A population-based study of elective and emergency
admissions. BMC Health Services Research. 12(1). https:// doi.
org/ 10. 1186/ 1472- 6963- 12- 77
6. Hallam S, Rickard F, Reeves N etal (2018) Compliance with
enhanced recovery protocols in elderly patients undergoing
colorectal resection. Ann Royal College Surgeons of England.
100(7):570–9. https:// doi. org/ 10. 1308/ rcsann. 2018. 0102
7. Wei IH, Pappou EP, Smith JJ, Widmar M, Nash GM, Weiser MR,
Paty PB, Guillem JG, Afonso A, Garcia-Aguilar J (2020) Monitor-
ing an ongoing enhanced recovery after surgery (ERAS) program:
adherence improves clinical outcomes in a comparison of three
thousand colorectal cases. Clin Surg 5:2909
8. Pędziwiatr M, Kisialeuski M, Wierdak M etal (2015) Early imple-
mentation of enhanced recovery after surgery (ERAS®) protocol
– compliance improves outcomes: A prospective cohort study.
International Journal of Surgery. 75–81. https:// doi. org/ 10. 1016/j.
ijsu. 2015. 06. 087
9. Shah PM, Johnston L, Sarosiek B etal (2017) Reducing readmis-
sions while shortening length of stay: The positive impact of an
enhanced recovery protocol in colorectal surgery. Dis Colon Rectum
60(2):219–227. https:// doi. org/ 10. 1097/ dcr. 00000 00000 000748
10. Au Yeung YF, Liu YH, Si LP etal (2022) Enhanced recovery after
elective colectomy in a Regional Hospital in Hong Kong. Surg
Pract 27(1):10–14. https:// doi. org/ 10. 1111/ 1744- 1633. 12611
11. Brescia A, Tomassini F, Berardi G and others (2017) Development
of an enhanced recovery after surgery (ERAS) protocol in lapa-
roscopic colorectal surgery: Results of the first 120 consecutive
cases from a University Hospital. Updates in Surgery 69(3):359–
65. https:// doi. org/ 10. 1007/ s13304- 017- 0432-1
12. M.íximo MA, Santos D, F.lix-Oliveira A etal (2023) Association
between enhanced recovery after surgery protocol compliance and
clinical complications: A cohort study. Braz J Anesthesiol (Eng-
lish Edition). 73(1):25–35. https:// doi. org/ 10. 1016/j. bjane. 2021.
08. 018
13. Achrekar MS (2022) Enhanced recovery after surgery (ERAS)
nursing programme. Asia Pac J Oncol Nurs 9(7):100041. https://
doi. org/ 10. 1016/j. apjon. 2022. 02. 003
14. Groot MW, Spronk A, Hoeks SE etal (2017) The preoperative car-
diology consultation: Indications and risk modification. Neth Hear
J 25(11):629–633. https:// doi. org/ 10. 1007/ s12471- 017- 1004-1
15. Weimann A, Braga M, Harsanyi L and others (2006) Espen guide-
lines on enteral nutrition: Surgery including organ transplantation.
Clin Nutr 25(2):224–244. https:// doi. org/ 10. 1016/j. clnu. 2006. 01. 015
16. Fan KL, Luvisa K, Black CK, Wirth P, Nigam M, Camden R, etal
(2019) Gabapentin decreases narcotic usage: Enhanced recovery
after surgery pathway in free autologous breast reconstruction.
Plastic and Reconstructive Surgery - Global Open. 7(8). https://
doi. org/ 10. 1097/ gox. 00000 00000 002350
17. Li Z-L, Ma H-C, Yang Y etal (2024) Clinical study of enhanced
recovery after surgery in laparoscopic appendectomy for acute
appendicitis. World J Gastrointestinal Surg 16(3):816–822. https://
doi. org/ 10. 4240/ wjgs. v16. i3. 816
18. Braga M, Scatizzi M, Borghi F and others (2018) Identification of
core items in The enhanced recovery pathway. Clinical Nutrition
ESPEN 25:139–144. https:// doi. org/ 10. 1016/j. clnesp. 2018. 03. 003
19. Long M, Machan M, Tollinche L (2017) Intraoperative gastric
tube intubation: A summary of case studies and review of the
literature. Open J Anesthesiol 07(03):43–62. https:// doi. org/ 10.
4236/ ojanes. 2017. 73005
20. Meltvedt R, Knecht B, Gibbons G etal (1985) Is nasogastric
suction necessary after elective colon resection? Am J Surg
149(5):620–622. https:// doi. org/ 10. 1016/ s0002- 9610(85) 80140-9
21. Bauer V (2013) The evidence against prophylactic nasogas-
tric intubation and oral restriction. Clin Colon Rectal Surg
26(03):182–185. https:// doi. org/ 10. 1055/s- 0033- 13511 36
22. Vignarajah M, Berg A, Abdallah Z and others (2023) Intra-
operative use of balanced crystalloids versus 0.9% saline: A
systematic review and meta-analysis of Randomised Controlled
Studies. British J Anaesthesia 131(3):463–71. https:// doi. org/
10. 1016/j. bja. 2023. 05. 029
23. Lee JJ, Kilonzo K, Nistico A, Yeates K (2013) Management of
hyponatremia. Can Med Assoc J 186(8):281–286. https:// doi.
org/ 10. 1503/ cmaj. 120887
24. Lobo DN, Awad S (2014) Should chloride-rich crystalloids
remain the mainstay of fluid resuscitation to prevent ‘pre-renal’
acute kidney injury?: Con. Kidney Int 86(6):1096–1105. https://
doi. org/ 10. 1038/ ki. 2014. 105
25. Sizemore DC. Postoperative nausea [Internet]. U.S. National
Library of Medicine; 2022 [cited 2024 May 12]. Available from:
https:// www. ncbi. nlm. nih. gov/ books/ NBK50 0029/
26. Savant K, Khandeparker RV, Berwal V etal (2016) Compari-
son of ondansetron and granisetron for antiemetic prophylaxis
in maxillofacial surgery patients receiving general anesthesia:
A prospective, randomised, and double blind study. J Korean
Assoc Oral Maxillofac Surg 42(2):84–89. https:// doi. org/ 10.
5125/ jkaoms. 2016. 42.2. 84
27. Ho C-M, Wu H-L, Ho S-T, Wang J-J (2011) Dexamethasone
prevents postoperative nausea and vomiting: Benefit versus risk.
Acta Anaesthesiologica Taiwanica 49(3):100–4. https:// doi. org/
10. 1016/j. aat. 2011. 06. 002
28. Weilbach C, Rahe-meyer N, Raymondos K etal (2006) Postop-
erative nausea and vomiting (PONV): usefulness of the Apfel-
score for identification of high risk patients for PONV. Acta
Anaesthesiol Belg 57(4):361–363
29. Before skin incision (2009) In: WHO Guidelines for Safe Sur-
gery 2009: Safe Surgery Saves Lives. WHO, Geneva
30. Biondi A, Mele MC, Agnes A, Lorenzon L, Cintoni M,
Rinninella E, etal (2022) Feasibility of discharge within
72 hours of major colorectal surgery: Lessons learned after 5
years of institutional experience with the eras protocol. BJS
Open. 6(1). https:// doi. org/ 10. 1093/ bjsop en/ zrac0 02
31. Wainwright TW, McDonald DA, Burgess LC (2017) The role of
physiotherapy in enhanced recovery after surgery in the inten-
sive care unit. ICU Management & Practice 17(3):146–147
32. Vlad O, Catalin B, Mihai H, Adrian P, Manuela O, Gener I,
etal (2020) Enhanced recovery after surgery (ERAS) protocols
in patients undergoing radical cystectomy with ileal urinary
diversions. Medicine. 99(27). https:// doi. org/ 10. 1097/ md. 00000
00000 020902
33 Staicovici S, Sarbu V, Gheorghe E and others (2023) Effective-
ness of continuing post-surgery antibiotic prophylaxis in reducing
nosocomial infections - a literature review. Chirurgia 118(4):358–
69. https:// doi. org/ 10. 21614/ chiru rgia. 2023.v. 118.i. 4.p. 358
34. Kocián P, Whitley A (2021) Prolonged postoperative ileus in colo-
rectal surgery within an enhanced recovery protocol: A multivari-
ate analysis. Indian Journal of Surgery 84(2):340–344. https:// doi.
org/ 10. 1007/ s12262- 021- 02899-8

Irish Journal of Medical Science (1971 -)
35. Marcotte JH, Patel K, Desai R and others (2018) Acute kidney
injury following implementation of an enhanced recovery after
surgery (ERAS) protocol in colorectal surgery. Int J Colorectal
Dis 33(9):1259–1267. https:// doi. org/ 10. 1007/ s00384- 018- 3084-9
36. Gustafsson UO, Scott MJ, Hubner M and others (2018) Guide-
lines for perioperative care in elective colorectal surgery:
Enhanced recovery after surgery (eras®) society recommenda-
tions: 2018. World J Surg 43(3):659–695. https:// doi. org/ 10. 1007/
s00268- 018- 4844-y
37. Uyanıklar ÖÖ, Türk P, Aslan K and others (2022) How does the
ERAS protocol work in patients who underwent cesarean section?
(HERMES study). Int J Gynecol Obstet 161(1):168–174. https://
doi. org/ 10. 1002/ ijgo. 14420
38. Yin Z, Sun J, Liu T etal (2013) Gum chewing: Another simple
potential method for more rapid improvement of postoperative
gastrointestinal function. Digestion 87(2):67–74. https:// doi. org/
10. 1159/ 00034 2637
39. NHSGOLDENJUBILEE [Internet]. NHS; 2021 [cited 2024 May
12]. Available from: https:// hospi tal. nhsgo ldenj ubilee. co. uk/ appli
cation/ files/ 5316/ 6696/ 8010/ Preha bilit ation_-_ prepa re_ for_ y our_
lung_ surge ry_ v1. pdf
40. Butti F, Pache B, Winiker M etal (2020) Correlation of postop-
erative fluid balance and weight and their impact on outcomes.
Langenbeck’s Archives Surg 405(8):1191–1200. https:// doi. org/
10. 1007/ s00423- 020- 02004-9
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