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 International Journal of Medical Sciences and Pharma Research 

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Implementing Enhanced Recovery After Surgery (ERAS) Protocols in Resource-Limited Environments: A Critical Review for Nigerian Surgical Patients

* Fagbohun Omolola ¹, Oshunpidan Adekunbi ², Eke Ngozi ³

¹ Department of Anaesthesia, Lagos State University College of Medicine and Teaching Hospital, Ikeja, Lagos, Nigeria

² Department of Anaesthesia, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria

³ Department of Surgery, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria

 

 

Introduction

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized perioperative care, demonstrating improved patient outcomes, reduced complications, and shorter hospital stays ^{1, 2.} ERAS protocols involve a multidisciplinary approach to patient care, incorporating evidence-based practices to minimize surgical stress, maintain physiological stability, expedite functional recovery and ultimately optimize patient outcomes ³. However, implementing ERAS protocols in low – middle income countries with limited resource poses unique challenges, ^{4, 5.} This discussion critically examines the feasibility, benefits, and challenges of implementing ERAS protocols for all surgical patients in Nigeria.

Components of ERAS

The Enhanced Recovery After Surgery (ERAS) protocol consists of multiple components that work together to improve patient outcomes. These components include:

• Preoperative Components:
• Patient education: This entails educating patients about the surgery, anaesthesia technique, recovery process, and their role in ERAS ^{2, 6.} These empower patients with the knowledge and skill necessary for them to play an active role in their own care. Several strategies are employed.^{2, 4}    These include :
• The use of multimedia resources such as interactive videos, animations and virtual reality experiences to educate patient about their anaesthesia, surgery and recovery. 
• Mobile applications that provide personalized information, reminders, and tracking features to support patients throughout their ERAS journey may be made available
• Provision of support groups sessions with other patients who have undergone similar procedure. Thus providing a platform for sharing experiences and advice.
• Comprehensive written materials, detailed guide lines and pamphlets covering various aspects of ERAS, including perioperative care and expectations
• Pain management education including pharmacological and alternate therapies ^{2, 4,  7}

2. Preoperative optimization: Optimizing patients' medical conditions, such as anemia, diabetes, and nutrition, before surgery. Preoperative fasting: Reducing preoperative fasting periods and providing carbohydrate-rich drinks to minimize catabolism ^{2, 4, 8} 

4. Thromboprophylaxis: This could be pharmacological, (such as heparin, clexane, enoxaparin) or non-pharmacological like thrombo embolic deterrent stockings and Sequential Compression Devices like pneumatic compression devices ^{4, 8, 9}

1. Anesthesia: Using evidence-based anesthesia technique to minimize side effects and promote rapid recovery². use of short acting anesthetic agents with rapid recovery profile ^{2, 9}

2. Surgical technique: Using minimally invasive surgical techniques to reduce tissue trauma ², ¹¹

3. Fluid management: Managing fluids to prevent dehydration while avoiding fluid overload and maintaining optimal blood flow ^{2, 4}

4. Temperature management: Maintaining normothermia to prevent temperature-related complications²

1. Pain management: Using multimodal pain management strategies to minimize pain and reduce opioid use²

2. Early mobilization: Encouraging patients to move and mobilize early after surgery² Some advanced centers have walkers and other physical therapy devices

3. Early oral hydration/ feeding: Encouraging patients to eat and drink early after surgery². With some centers providing tube feeding formulas to patients.

4. Fluid management: Managing fluids to prevent dehydration and maintain optimal blood flow²

5. Monitoring and follow-up: Regularly monitoring patients' progress and adjusting the ERAS protocol as required²

Challenges to implementing ERAS in Resource-Limited Settings

Anaesthetists in resource-limited environments like Nigeria are likely to encounter significant challenges in implementing ERAS protocols due to several factors which includes: 

1. Limited access to essential infrastructure, medications and equipment like advanced anaesthetic machines, ventilators⁷

2. Inadequate training and support for healthcare providers ^{8, 9}.

3. Limited availability of multidisciplinary team members ^{2, 9}

4. Difficulty in maintaining normothermia and managing fluids in patients ^2, 

These factors can hinder the delivery of high-quality perioperative care. In 2017, Ibeanusi and colleagues highlighted the need for improved infrastructure, training, and resources to support surgical care in Nigeria⁸

Strategies to enhance the implementation of ERAS protocols in Resource Constrained Setting 

A systematic and planned approach can facilitate the successful implementation of ERAS protocols. These includes:

1. Adapting ERAS protocols to the existing generally accepted local peri-operative Anaesthetic protocols. These tailors ERAS protocols to suit the specific needs and resources of the local setting ^{8, 9}
2.  Prioritizing low-cost, evidence-based interventions: Focusing on cost-effective interventions that improve patient outcomes. Low cost alternatives like warm fluids, warming pads and others to maintain normothermia ^{2, 9}
3. Partnerships and collaborations: Collaborating with international organizations, local healthcare providers, and stakeholders to facilitate ERAS protocol implementation and sustainability^{8, 11}

These 3 key strategies are further elaborated below offering practical guidance and examples to support implementation.

- Modified preoperative fasting: Instead of traditional fasting from midnight, patients could be allowed to drink clear fluids up to 2 hours before surgery, reducing dehydration and discomfort.

- Low-cost preoperative optimization: Implementing low-cost interventions like anemia correction, glycemic control, and smoking cessation programs to optimize patients' health before surgery ¹.

-Thromboprophylaxis: This could be pharmacological or non-pharmacological.  The resource limited environments can use less expensive devices such as the   thrombo embolic deterrent stockings   to  prevent venous thromboembolism compared with more expensive  Sequential Compression Devices like pneumatic compression   devices^{2, 9}

- Using low-cost anesthesia techniques: Utilizing regional anesthesia or spinal anesthesia instead of general anesthesia to reduce side effects and costs.

- Maintaining normothermia: Using simple and low-cost methods like warm blankets or warm IV fluids to prevent hypothermia compared with the more expensive forced air warming systems, heated humidifiers, thermal suits, radiant warmers in more elite theaters.

-Fluid management: Fluid administration may be guided by clinical judgment rather than advanced hemodynamic monitoring.

-Monitoring: Availability of advanced monitoring equipment such as multi-parameter  monitor for invasive and non-invasive monitoring may not be feasible but basic standard monitoring such as  capnography, pulse oxymetre, temperature, non-invasive blood pressure and pulse rate should be ensured.^3,5

• Postoperative Phase-
• Pain management: Using multimodal pain management strategies could include systemic analgesics like paracetamol, NSAIDs, acupan, epidural technique, skin infiltration in a step-wise approach to minimize opoid consumption.

- Early mobilization: Encouraging patients to mobilize early after surgery with the help of family members or caregivers, reducing the need for expensive physiotherapy services and devices.

- Multidisciplinary team involvement: Involving surgeons, anesthesiologists, nurses, and other healthcare professionals in the development and implementation of a practical ERAS protocols tailored to individual health facility.

- Training and education: Providing regular training and education for healthcare professionals on ERAS principles, protocols and their benefits.

- Monitoring and evaluation: Regularly monitoring and evaluating the effectiveness of ERAS protocols and making adjustments as needed ².

• Cultural and social factors must be considered when implementing ERAS protocols in Nigeria. 
• Cultural factors

- Family involvement: In some cultures, family members play a significant role in patient care. ERAS protocols may need to accommodate family involvement in patient care and decision-making. This can improve patient satisfaction and outcomes.

-Dietary preferences: Cultural dietary preferences may impact postoperative nutrition plans. For example, certain cultures may avoid specific foods or have specific meal preferences.

- Pain expression: Cultural norms around pain expression can impact pain management. Some cultures may emphasize stoicism, while others may be more expressive.

-Culturally sensitive patient education: Providing patient education materials in multiple languages and formats can improve understanding and adherence to ERAS protocols.

- Culturally adapted pain management technique: Using culturally sensitive pain assessment tools and incorporating non-pharmacological interventions can improve pain management.

-Socioeconomic status: Patients from lower socioeconomic backgrounds may face barriers to accessing ERAS protocols, such as lack of transportation or inability to afford medical care and medications.

-Language barriers: Patients with limited proficiency in the dominant language may require additional support to understand ERAS protocols and participate in care.

-Social support: Patients with strong social support networks may have better outcomes due to emotional support and practical assistance.

By understanding and addressing these cultural and social factors, healthcare providers can tailor ERAS protocols to meet the unique needs of diverse patient populations ^{11, 12}. 

Adapting ERAS protocols to accommodate local needs and values can improve patient satisfaction and outcomes¹¹. Bentrem et al.¹² in their study on enhanced recovery after surgery demonstrated the importance of cultural sensitivity in ERAS protocol implementation.

By adopting these strategies, ERAS protocols can be effectively adapted to already existing traditional Nigerian perioperative Anesthetic and surgical care protocols and healthcare providers can ultimately implement ERAS protocols and further improve the chances of better surgical outcome in patients in resource-limited settings.^{2, 11, 12}

Conclusion

Implementing Enhanced Recovery After Surgery (ERAS) protocols in resource-limited environments, such as Nigeria, requires careful consideration of the local context, challenges, and socio-cultural factors. This critical review highlights the potential benefits of ERAS protocols in improving patient outcomes and reducing healthcare costs. By adapting ERAS protocols to the local context, prioritizing low-cost interventions, and collaborating with stakeholders, healthcare providers can improve the quality of care for Nigerian surgical patients. Ultimately, successful implementation of ERAS protocols in resource-limited environments can lead to better patient outcomes, reduced complications, and improved healthcare systems.

Recommendations        

1. Individual Aneasthetic Teams in collaboration with relevant stakeholders in their respective facilities should develop context-specific ERAS protocols that take into account local resources and challenges.

2. The teams should prioritize low-cost, evidence-based interventions that can be adapted to resource-limited settings.

3. They should foster collaboration and partnerships among healthcare providers, policymakers, and stakeholders to support ERAS protocol implementation.

4. Adequate provision should be made for training and education of healthcare professionals on ERAS protocols and their benefits.

5. They should monitor, evaluate and audit the effectiveness of ERAS protocols in resource-limited environments and make adjustments as needed.

By following these recommendations, healthcare providers and policymakers can work together to improve the quality of surgical care for patients in resource-limited environment

Conflict of Interest: The authors declare no potential conflict of interest concerning the contents, authorship, and/or publication of this article.

Author Contributions: All authors have equal contributions in the preparation of the manuscript and compilation.

Source of Support: Nil

Funding: The authors declared that this study has received no financial support.

Informed Consent Statement: Not applicable. 

Data Availability Statement: The data supporting this paper are available in the cited references. 

Ethical approval: Not applicable.

References

1. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg. 2008; 248(2):189-98. https://doi.org/10.1097/SLA.0b013e31817f2c1a PMid:18650627

2. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care for elective gastrointestinal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2013; 37(2):259-84. https://doi.org/10.1007/s00268-012-1772-0 PMid:23052794

3. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005; 24(3):466-77. https://doi.org/10.1016/j.clnu.2005.02.002 PMid:15896435

4. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. Enhanced recovery after surgery (ERAS) pathway in elective abdominal surgery: A systematic review and meta-analysis. Br J Surg. 2015; 102(3):188-98.

5. Greer NL, Gunnar WP, Dahm P, Lee AE, MacDonald R, Shaukat A, et al. Enhanced recovery after surgery (ERAS) for gastrointestinal surgery: A systematic review and meta-analysis. Ann Surg. 2018; 267(5):860-70.

6. Pędziwiatr M, Pisarska M, Kisielewski M, Małczak P, Major P, Wierdak M, et al. ERAS protocol in laparoscopic surgery for colonic versus rectal cancer: Are there differences in short-term outcomes? Med Oncol. 2016; 33(6):57. https://doi.org/10.1007/s12032-016-0772-6 PMid:27154634 PMCid:PMC4859853

7. Ologunde R, Leff R, Sharma S, Harrison S, Davies J, Shinde S, et al. Anaesthesia and surgical care in Nigeria: A review of the current situation. Afr J Anaesth Intensive Care. 2015; 15(1):34-40.

8. Ibeanusi SE, Nwankwo UA, Onyemaechi NO. Surgical care in a Nigerian teaching hospital: Challenges and prospects. Niger J Surg. 2017; 23(2):63-7.

9. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240(2):205-213.10. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015; 386(9993):569-624. https://doi.org/10.1016/S0140-6736(15)60160-X PMid:25924834

11. Kwok AC, Leff R, Seshadri R, Magee WP, Fitzgerald TN, Hodges AM, et al. Implementation of an enhanced recovery after surgery (ERAS) program in a resource-limited setting: A pilot study. World J Surg. 2018; 42(12):3801-8.

12. Bentrem DJ, Kushner DM, Stein S, McGree ME, Dowdy SC, Cliby WA, et al. Enhanced recovery after surgery in Ghana: A feasibility study. J Surg Res. 2018; 221:103-11