Implementation of Enhanced Recovery After Surgery Protocol in a Second-level Hospital

Abstract

Background: Enhanced recovery after surgery (ERAS) became standard perioperative care in the western world. However, little is known about the implementation of fast-track pathways (FTP) in developing countries. The objectives of the study were to assess the feasibility of the FTP program and adherence to the ERAS protocol in general surgery patients implemented in low-resource setting. Methods: In this retrospective, observational study, we evaluated perioperative care for elective and emergency surgical population changed in accordance with the ERAS program in a second-level hospital in Zambia. Ninety-eight patients aged two weeks to 87 years (median 32 years) with a male to female ratio of 2.3:1 and categorised by the American Society of Anaesthesiologists (ASA) in classes I to IV were included. Outcomes of interest were functional recovery, postoperative complications, length of hospital stay, and compliance with the protocol. Results: All elements of the ERAS protocol, including minimal access surgery (through mini-laparotomy incisions) and accelerated postoperative care, were employed. A successful recovery with discharge home by day 4 after the operation and the absence of complications and readmissions was achieved in 45.5% of patients. The postoperative period was complicated in 18.8% of cases, with a total mortality rate of 6.3%. The overall adherence level to the protocol was 72.2%. The highest levels of adaptation (≥95%) were reported for preoperative stratification, antimicrobial prophylaxis, modification of preanaesthetic medications, and prevention of intraoperative hypothermia. The poor compliance to the program was recorded for fasting and carbohydrate loading before surgery and postoperative thromboprophylaxis (17.9% and 21.4%, respectively). Conclusion: The study indicates that the employment of the ERAS program for the general surgery population at a second-level hospital is feasible and safe. It is possible to achieve a high level of adherence to the ERAS pathway in a resource-limited environment. A reasonable modification of the protocol can bring additional clinical benefits. Integrating elements of FTP into perioperative care and including the ERAS program in postgraduate education in developing nations is recommended. Further studies are needed, first, to frame ERAS pathways for application in emergency general surgery, and second, to present the local initiatives and identify barriers to the implementation of FTP in low-income countries. Doi: 10.28991/SciMedJ-2022-04-04-04 Full Text: PDF