Table 1:
A summary of pre, peri and post-operative stages of medications in ERAS protocols from different institutions adapted from (Alboog et at, 2019; Ali et al.,2018; Ali et al., 2019; Ali et al.; 2023; Bhatia & Buvanendran, 2019; Debano et al, (2021); Grasu et al., 2018; Naftalovich et al., 2022; Pahwa et al., 2024; Soffin et al.,2019)
| ERAS Protocol/medication protocol (Host/Institution) | Type of surgery and primary study | Pre-operative | Intra-operative | Post-operative | Outcomes |
|---|---|---|---|---|---|
| Enhanced recovery after surgery society guidelines | Debang et al, (2021) Society Guideline | Manage expectations Patient optimization: Smoking cessation, alcohol nutrition and anaemia. Optimisation of medication Dosing of acetaminophen, NSAIDs, and gabapentinoids should ideally be adjusted based on age, renal function, and other comorbidities | Multimodal analgesia, opioid sparing. Hypothermia prevention Post-operative nausea and vomiting prevention Optimal fluid management Anti-microbial prophylaxis Anti-thrombotic therapy, catheter and management of drain/s. | Early mobilisation Nutrition management Multimodal aralgesia, opioid sparing. Fluid management Prevention of Nausea and Vomiting Anti-thrombotic therapy Management of catheter and drain/s. | Optimisation of pain relief for patients |
| Rush University Medical Centre, USA | Spine surgery (Bhatia & Buvanendran 2019). Pain medication Protocol | 1,000mg IV acetaminophen 600mg Gabapentin Or 150mg pregabalin 10mg cyclobenzaprlne 10mg oxycodone Meds 1 hour before surgery Cydobenzaprine 10 mg
| Propofol infusion at induction, inhaled anaesthesia, ketamine at induction, dexamethasone, fentanyl, methadone, lidocaine, acetaminophen (see below) Induction of anaesthesia—propofol 2 mg/kg plus ketamine 50 mg Maintenance of anaesthesia—sevoflurane with fentanyl 1–2 mg/kg titrated to clinical effect Additional medications administered intraoperatively
| NSAID Gabapentin Pregahalin Tramadol Postoperative day 0
Postoperative day 1
| Potential to make difference to length of stay. |
| Weill Cornell Medical College, USA | Minimally invasive lumbar decompression spine surgery (Soffin et al.,2019) | oral acetaminophen (1000 mg) and gabapentin (300 mg) in the preoperative holding area | Total intravenous anaesthesia, ketorolac, lidocaine, dual antiemetic, prophylactic therapy | Acetaminophen, NSAIDr Two 50mg tramadol or 5mg oxycodone based on NRS pain score | Potential for quicker discharge and reduced opioid use. |
| Retrospective Matched cohort study (n = 18) | boluses of fentanyl (1–2 μg/kg, titrated to effect) or Dilaudid (up to 2 mg total). accordingto the judgment of the anesthesiologist to achieve optimal hemodynamic and anesthetic conditions for surgery. All patients received infusions of the following: 1) propofol (50–150 μg/kg/hr), adjusted to maintain the mean arterial pressure within ± 20% of each patient’s baseline value, 2) ketamine (0.1–0.5 mg/min), >and 3) lidocaine (2 mg/kg/hr until closure of the surgical incision). Inhaled halogenated agents (isoflurane or sevoflurane) were permitted, up to 0.5 minimum alveolar Patients concentration (MAC), as needed. Dual antiemetic therapy with dexamethasone (4 or 8 mg) and ondansetron (4 mg) were provided. Ketorolac (15 or 30 mg, according to age and weight) was given durjng surgical closure. | Patients with reported NRS scores ≤ 4 should be treated with non-opioid analgesics (acetaminophen, ketorolac-, gabapentin, and/or non-pharmacotherapies, including ice, distraction, and position changes); for those with NRS scores 5–7, patients may receive two 50-mg doses of tramadolif needed; and for those with NRS scores 8–10, patients may receive a 5-mg oxycodone. Further escalation of opioids requires assessment by the anesthesiologist. PONV are treated with metoclopramide (10 mg intravenously) or ondansetron (4 mg). prescribed scopolamine (1.5 mg transdermal). | |||
| University of Western Ontario, Canada | Spine surgery (Alboog et al., 2019) Review | Pregabalin, gabapentin 0.2mg per KG, methadone | Selective COX-2 inhibitors, ketamine administration (bolus or infusion), tramadol, analgesics mixture | NA | Recommend a combined use of gabapentiniods, ketamine, and opioids to achieve optimal analgesia |
| Perelman, School of Medicine, University of Pennsylvania, USA | Spine surgery (Ali et al.,2018; Ali et al., 2019; Ali et al.; 2023) ERAS Pilot study (n = 202) Randomised Controlled Trial (n = 142) | Education, nutrition, diabetes management, smoking cessation counselling, chronic opioid screen use, obstructive sleep apnoea screen, and discharge planning. 600mg Gabapentin | Metabolism management, multimodal analgesia, safe spinal surgery checklist, early mobilisation and wound care. NSAIDS opioids, anticonvulsants, other analgesia | Clinical team communication, wound care management, post-acute care neurosurgery triage pathway. 975mg 6 hourly acetaminophen, diazepam po, cydobenzaprine, ketorolac, wound care, gum chewing (1 piece for 3 minutes daily), physiotherapy | ERAS protocol greatly improves postoperative mobilization and ambulation and, most importantly, has the potential to safely reduce opioid use both in the perioperative period and at 1 month after surgery, with important potential for relief of chronic opioid dependence. |
| University of Texas, USA | Spine surgery for metastatic tumours (Grasu et al., 2018) Preliminary analysis of implementation of ERAS (n = 97) | Education, sedation and anxiety management, pain management and pre-op fasting patient on ≥5 opioid tablets/day; patient on long-acting opioid medication; rapidly increasing opioid requirements; pain not responsive to prescribed analgesics; patient treated by an outside pain physician; significant psychosocial distress related to pain &/or surgery; curτent or history of recreational drugs use. Consider starting w/low-dose (eg.. 100 mg/daily) gabapentin for neuropathic pain & patient <65 yrs of age Day of surgery: tramadol ER 300 mg oral y + gabapentin 300 mg (or pregabalin 75 mg) orally + acetaminophen 1000 mg orally upon arrival in preoperative holding area; consider decreasing dosage if patient ≥65 yrs old | Fluid, temperature and transfusion management, surgical management IV anesthesia maximization: infusions of propofol, dexmedetomidine, ketamine, lidocaine, methadone (0.1– 0.2 mg/kg) single upfront IV dose in opioid-tolerant patients; IV dexamethasone 10 mg every 6 hrs; consistent risk-based antiemetic, & DVT prophylaxis; emphasis on lung-protective mechanical ventilation strategies | Early ambulation, early oral intake, DVT prophylaxis, physical therapy Gabapentin 300 mg orally every 8 hrs, celecoxib 200 mg orally every 12 hrs, tramadol ER 200 mg orally every 12 hrs, acetaminophen 1 g orally every 6 hrs, continue preop long-acting opioids plus IV PCA; cancer pain consult if pain poorly controlled, daily hydromorphone requirement >12 mg/day or morphine >60 mg/day, pain limits daily function/rehabilitati¤n, significant psychosocial distress | Improved analgesia and decreased opioid consumption in the perioperative care of patients undergoing spine surgery for metastatic tumors |
| Westmead ERAS Protocol, Australia | Elective spiral (lumbar and cervical) decompression surgery (Pahwa et al., 2024) ERAS Protocol | Modern fasting, prioritised as first or second surgical case. Preceeded by: Period (1) Operative consultation (operative plan, patient education, ERAS inception) Period (2) Preadmission clinic (patient re-education, ERAS principles &reinforcement) Pre-emptive analgesia: 200mg celecoxib, 75mg pregabalin, lg paracetamol | Post-operative nausea & vomiting prophylaxis Normovolemia Normothermia Microscope assisted Surgery No IDC No wound drains Local anaesthetic General anaesthetic with minimal dose of buplvacaine and 0.25% adrenaline, lmg/kg oxycodone, 10-20 mmol Magnesium sulphate & 2mcg/kg clonidine | Early mobilisation Multimodal analgesia Same day discharge (within 4 hours) Phone call follow up day 1 postoperatively Follow up in clinic on day 5 Routine follow-up at 6 weeks post-surgery 8mg dexamethasone for postoperative nausea & vomiting Opioid sparing multimodal analgesia: (regular paracetamol, celecoxib, tapentadol as required (PRN) as provided as a script at time of discharge. | Early discharge post surgery |