Eras Protocols for Pulmonary Complication Prevention After Major Abdominal Surgery

Abstract

Background: Postoperative pulmonary complications are associated with substantial morbidity and mortality. They are a common outcome after emergency major abdominal surgery. Enhanced Recovery After Surgery (ERAS) pathways reduce pulmonary risk through specific perioperative interventions. Evidence from emergency abdominal surgery is still limited. This study assessed the implementation of ERAS and its association with reduced pulmonary complications within seven days of emergency major abdominal surgery.

Methods: This is a prospective single center study that included 240 adult patients undergoing emergency abdominal surgeries. These included colorectal, gastric, bowel, hepatobiliary and pancreatic surgeries. All patients received usual perioperative care during the pre and post ERAS phases (n=240), they were equally divided into two pre and post ERAS groups. The primary outcome was at least one postoperative pulmonary complication within seven days of surgery. Secondary measures included ERAS compliance. Risk ratios and absolute risk differences with 95% confidence intervals were used to compare pulmonary complication risks.

Results: Among the total study participants in the pre ERAS group only 28 (23.3%) patients had postoperative pulmonary complications while the post ERAS phase saw only 17 out of 120 patients (14.2%). The risk ratio was 0.61 (95% CI 0.35 -- 1.05) with an absolute risk difference of −9.2 percentage points (95% CI −19.0 to 0.6; p = .069). ERAS compliance increased from 53.9% (SD 12.4) before training and implementation to 85.7% (SD 9.4). There was a mean increase of 31.7 percentage points (95% CI 28.9–34.5; p < .001) in compliance after training. In the post-ERAS phase sepsis was more common compared to the pre ERAS phase (33.3% vs. 21.7%).

Conclusions: Protocol compliance was significantly improved after ERAS implementation and was accompanied by a clinically important reduction in seven-day pulmonary complications. The primary comparison however, was statistically inconclusive.