Table 1.

ERAS emergency laparotomy intra- and postoperative phase, consensus guideline review by Delphi method [19, 20]

ERAS Item whole pathway (this paper)	Guideline	Level of evidence	Recommendation grade
Surgical approach
13 (1) Intra-abdominal Drains	Routine, prophylactic use of intra-abdominal surgical drains is discouraged given a lack of evidence to their benefit in clean and clean/contaminated cases. The situation may differ in contaminated abdominal cases	Low	Weak
14 (2) Prevention of Infection 14.1 Perioperative Antibiotics	Perioperative broad spectrum intravenous antibiotics should be administered within 60 min before skin incision unless the patient is already receiving appropriate antibiotic therapy, some agents such as fluoroquinolones and vancomycin require administration over 1–2 h, and therefore, administration should begin, if possible, within 120 min. Local and national guidelines should be followed for choice of antibiotic, dosing, and administration. Continuation of antibiotics should be based on pathology and contamination during surgery	High	Strong
14.2 Skin Asepsis	Preoperative skin antisepsis with alcohol-based solutions, or chlorhexidine for patients with an allergy to alcohol-based skin solutions should be used. Chlorhexidine with alcohol is optimal	High	Strong
14.3 Fascial Wound Protector, irrigation, and glove change in Abdominal closure	Routine use of a fascia abdominal wound protector, abdominal irrigation, and new gloves and closure instruments is recommended to reduce SSI	Moderate	Strong

ERAS Item	Guideline	Level of evidence	Recommendation grade
Anesthesia and perioperative management
15. (3) Rapid Sequence Induction of Anesthesia	To minimize the risk of aspiration after induction of anesthesia, rapid control of the airway with intubation using a fast-acting muscle relaxant such as succinylcholine 1–2 mg kg −1 or rocuronium 0.9 to 1.2 mg kg −1 for placement of an endotracheal tube should be used. We recommend the use of cricoid pressure according to the practitioner’s respective national guidelines. Drugs for induction of anesthesia should be selected and dosed appropriately to maintain hemodynamic stability	Moderate	Strong
16.1 (4) Maintenance Anesthetic Agent and Depth of Anesthesia Monitoring	There is no evidence to recommend one anesthetic agent over another for maintenance of anesthesia	Low	Weak
16.2	Consider using depth of anesthesia monitoring in patients over 60 years of age at risk of postoperative delirium and anesthesia-induced hypotension	Moderate	Strong
17 (5) Postoperative Nausea and Vomiting (PONV) Reduction	All patients undergoing emergency laparotomy are at high risk of PONV due to physiological derangement and gastrointestinal insult. A multimodal approach to reducing PONV should be utilized, minimizing triggers and opioids	High	Strong
18.(6) Temperature Management	Measurement of Core Temperature, using a reliable method to monitor the efficacy of warming measures, should be routine	High	Strong
	Active warming devices and warming of intravenous fluids should be used to maintain normothermia	High	Strong
19. (7) Lung Ventilation Strategy	Routine use of low tidal volume (6–8 ml/kg/predicted body weight) and positive end-expiratory PEEP >  = 5 cm H2O, with titration according to flow-volume loops and clinical evaluation is recommended	Moderate	Strong
20.1 (8) Monitoring and Reversal of Neuromuscular Block (NMB)	Neuromuscular blockade should be monitored using a quantitative peripheral nerve monitor to ensure adequate reversal before endotracheal extubation, with the most reliable site of monitoring being the abductor pollicis muscle	High	Strong
20.2	Reversal of NMB using a selective relaxant binding agent (if available) as compared with neostigmine is recommended	Moderate	Strong
21.1 (9) Intravenous fluid and electrolyte replacement	Patients should have ongoing treatment to correct electrolyte disturbances throughout the perioperative period	Moderate	Strong
21.2	Balanced crystalloids should be used in preference to 0.9% normal saline for resuscitation and to maintain intravascular volume	Low	Weak
22.1, 2 (10) Goal Directed Hemodynamic Therapy (GDHT), Cardiovascular Monitoring, Maintenance of blood pressure and vasopressor use	Use of arterial and/or central venous pressure catheters should be considered at an early stage to aid in physiological assessment and to deliver and titrate vasopressors and fluid therapy	Moderate	Strong
	GDHT should be considered during surgery in high-risk patients to optimize cardiac index. A MAP of 60–65 mmHg and Cardiac Index > 2.2 L/min/m2, individualized to the patient, should be maintained during surgery using appropriate vasopressors and inotropes as needed	Moderate	Strong
23. (11) Management of Blood Glucose	Patients should have their glucose closely monitored and controlled in the range of 7.7–10 mmol/l preferably with the use of a variable rate insulin infusion	Moderate	Strong
24. (12) Blood Product Management	Transfusion of red blood cells should be restrictive (trigger Hb 70 -90 g/l), with exceptions based on individualized clinical status and comorbidities	Moderate	Strong
25.1 (13) Multimodal Systemic Analgesia	Each patient should be assessed for the optimal perioperative analgesic regimen, considering the presence of sepsis and coagulation abnormalities. Multimodal management should include acetaminophen and non-steroidal anti-inflammatory drugs if there are no contraindications	Low	Strong
25.2	The use of wound catheters and/or local abdominal wall blocks and catheters should be considered to reduce postoperative opioid demand but may have variable efficacy	Low	Weak
25.3	Thoracic epidural analgesia and spinal anesthesia should be used only after assessment for sepsis and abnormal coagulation. Hypotension necessitates appropriate monitoring, volume and vasopressor therapy	Low	Weak
26. (14) End of Surgery, Evaluation and Endotracheal Extubation	A multidisciplinary discussion at the end of surgery should be used to assess suitability for endotracheal extubation as the risk of postoperative pulmonary complications and reintubation is high	Moderate	Strong
27.1 (15) Prevention of postoperative Pulmonary complications	Patients who have undergone emergency laparotomy and show evidence of hypoxemia, should receive continuous positive airway pressure or noninvasive positive pressure ventilation (technique based on local expertise), rather than standard oxygen therapy, if the risk of aspiration is considered to be low. This should occur in an environment where staff are skilled in these techniques, continuous physiological monitoring is available, and arterial blood gases can be sampled	High	Strong
27.2	Respiratory physiotherapy involving the training and supervision of patients’ sputum clearance, developing inspiratory muscle strength, and deep breathing exercises, should be used in emergency laparotomy patients in the postoperative period	Moderate	Strong
28. (16) Admission to the Intensive Care Unit (ICU) or higher level of care postoperatively	Health Systems should establish protocols for determining the appropriate location for postoperative care based on a validated preoperative risk score, impact of the surgical procedure, ongoing physiological instability and continuing supportive and therapeutic requirements	Moderate	Strong
29. (17) Postoperative Delirium Screening and Prevention	Patients over 65 years of age should receive regular postoperative delirium screening. At-risk patients should be managed with non-pharmaceutical interventions such as regular orientation, sleep hygiene approaches and cognitive stimulation to prevent delirium, and medication triggers minimized	High	Strong
30.1 (18) Continuation of venous thromboembolism risk assessment and treatment	Patients should be assessed with a validated tool for VTE risk on admission and throughout their hospital stay. If pharmacological prophylaxis is not possible, mechanical prophylaxis should be administered. For very high-risk patients (many emergency laparotomy patients will fall into this category), pharmacological combined with mechanical prophylaxis should be given. Reassessment should occur daily postoperatively	High	Strong
30.2	The duration of prophylaxis, including after discharge, should be determined by patient risk factors and underlying conditions	Moderate	Strong
31. (19) Urinary Catheter Removal	Urinary catheter use should be evaluated daily, and the catheter should be removed as early as possible	Moderate	Strong
32. (20) Peri- and Postoperative Nasogastric Tube Use	Nasogastric tube use should be considered on an individual basis, taking into account the risk of gastric stasis and aspiration related to gut dysfunction. Daily revaluation of the need for NGI should occur and it should be removed as early as possible	Moderate	Strong
33.1 (21) Postoperative Nutrition	Early tube feeding (within 24 h) should be initiated in patients in whom early oral nutrition cannot be started, and in whom oral intake will be inadequate (< 50% of caloric requirement) for more than 7 days	Moderate	Strong
33.2	If enteral feeding is contraindicated, early parenteral nutrition is indicated to mitigate the period of inadequate oral/enteral intake. Enteral or oral nutrition may be reinitiated as gastrointestinal function recovers and/or contraindications end and replace parenteral nutrition when caloric needs can be safely met through oral/enteral routes	Moderate	Weak
34. (22) Postoperative Ileus Minimization	A multifaceted approach to minimizing postoperative ileus, including minimally invasive surgery, optimized fluid management, opioid-sparing analgesia, early mobilization, early postoperative food intake, laxative administration, and omission/early removal of nasogastric intubation should be used	Moderate	Strong
35. (23) Early Mobilization	Patients should be assisted to mobilize as soon as possible after surgery	Weak	Strong