Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization
ERAS Society · 2021 · international
Source and licence
- Authors
- Carol J. Peden, Geeta Aggarwal, Robert J. Aitken et al.
- Title
- Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization
- Journal
- World Journal of Surgery, 2021
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC8026421
Licence statement of the original publication
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
1. Early identification of physiological derangement, and intervention
- Recommendations• Resuscitation and correction of underlying physiological derangement should begin immediately and should continue during diagnostic pathways. • Rapid assessment of the patient for physiological derangement using a validated method [49] such as an Early Warning Scoring (EWS) system should occur. Abnormal scores should trigger rapid escalation to senior personnel in line with pre-established local protocols. While awaiting surgery patients should have regular re-evaluation, with a frequency dictated by local physiological track and trigger protocols.
2. Screen and monitor for sepsis and accompanying physiological derangement
- Recommendations• All patients for emergency laparotomy should be assessed with a validated sepsis score as early in their presentation as possible. This should be repeated at appropriate intervals in line with severity of signs and sepsis risk stratification guidance [61, 63]. • If SIRS, sepsis or septic shock are diagnosed, or when the underlying surgical pathology makes the patient at high risk of infection or sepsis, such as patients with peritonitis or hollow viscus perforation, treatment should begin immediately in line with the Surviving Sepsis management algorithms including measurement of lactate [46]. Delay to antibiotic administration in patients with sepsis increases mortality [64]. • Monitoring of blood lactate as a marker of risk and in assessment of physiological response to resuscitation should be considered even in the absence of sepsis.
3. Early imaging, surgery, and source control of sepsis
- Recommendations• Delay to surgery increases mortality in patients with sepsis and septic shock. All patients with septic shock should receive source control with surgery or interventional radiology as soon as possible and within 3 h. For patients with sepsis without septic shock, source control should occur within 6 h.
Radiological investigation
- Recommendation• Perform a CT scan with IV contrast as soon as possible if indicated. The CT scan should be reviewed by a radiologist immediately. Acquiring a CT scan should not cause a delay to surgery if surgery is very urgent.Level of evidence: High.
4. Risk assessment
- Recommendation• A risk score using a validated model should be performed and documented on all patients prior to surgery, and at the end of surgery. The score can be used to guide pathways of care and facilitate discussion between team members and with patients and family on treatment, risks and limitations.
Delirium and perioperative neurocognitive disorders
- Recommendations• All patients over 65 years of age, and others at high risk, for example patients with cancer, should be assessed for frailty using a validated frailty score [83]. Evidence: High. Recommendation grade: Strong. • Perform a validated simple assessment of cognitive function such as the Mini-Cog® [112] in all patients over 65 years of age if time permits. For patients who are at risk for delirium and postoperative cognitive dysfunction take steps to keep the patient oriented and avoid drugs known to cause harm as defined in the Beers’ criteria [111]. Level of evidence: Moderate. Recommendation grade: Strong. • All patients over 65 should have regular delirium screening pre and postoperatively with a validated assessment method [113]. Level of evidence: High. Recommendation grade: Strong. • Patients over 65 years of age should be assessed by a physician with expertise in care of the older patient (geriatrician) pre-operatively and evidence-based elder-friendly practices used. If preoperative assessment is not possible refer for postoperative follow-up.
Anticoagulants (Warfarin, DOACs, Heparin/Enoxaparin)
- Recommendation• Strongly consider reversal of home anticoagulation medications when major surgical intervention is planned. This decision should be based on both the patient’s risk of procedure-related bleeding and the risk of thromboembolism.
Platelet inhibitors: (including Aspirin, Clopidogrel, Dipyridamole, Ticagrelor)
- Recommendation• Consider platelet transfusion in patients taking antiplatelet therapy when the planned procedural bleeding risk is high. In patients with a strong indication for antiplatelets, specialty consultation should be obtained for perioperative co-management of these medications.
7. Assessment of venous thromboembolism risk
- Recommendation• Patients should be risk assessed with a validated tool for VTE risk on admission. If pharmaceutical prophylaxis is not possible mechanical prophylaxis should be used. Reassessment should occur daily postoperatively [131].
8. Pre-anesthetic medication—anxiolysis and analgesia
- Recommendations• Sedative medication should be avoided preoperatively to avoid the risk of micro-aspiration, hypoventilation and delirium.
9. Preoperative glucose and electrolyte management
- Recommendations• Hyperglycemia and hypoglycemia are risk factors for adverse postoperative outcomes. Pre-operatively, glucose levels should be maintained at 144–180 mg/dL (8–10 mmol/L), a variable rate (sliding scale) insulin infusion should be used judiciously to maintain blood glucose in this range with appropriate monitoring of point of care blood glucose in line with local protocols to avoid hypoglycemia. • Correction of potassium, magnesium and phosphate prior to surgery should be done using the intravenous route with appropriate monitoring and following local hospital policy. However, it should not delay the patient from being taken to the operating room.
10. Preoperative carbohydrate loading
- Recommendation• Level of evidence: Low and potential harm. • Recommendation grade: Strong, do not use in the emergency laparotomy population.
11. Pre-operative nasogastric intubation
- Recommendations• Pre-operative nasogastric tube insertion should be considered on an individual basis assessing for the risk of aspiration and gastric distension depending on the pathology and patient factors.
12. Patient and family education and shared decision making
- Recommendation• Patients and families should have the opportunity to discuss the risk of surgery with a senior physician (this could be the surgeon, anesthesiologist or intensive care physician) prior to surgery. Counseling should be informed by a validated risk score but with the clear understanding that scores have limitations when applied to individual patients. When appropriate, treatment escalation plans and advance care plans should be discussed and documented. • Clear, concise, written information or decision aids combined with verbal patient education should be provided to the patient and family before surgery if possible.
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.
Contents of the original publication
The section headings of the original.
- Introduction
- Materials and methods
- Definitions
- Commentary
- Results
- Evidence and recommendations
- Preoperative phase
- Conclusions
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