Table 7.
Practice elements recommendations of multi- gradient individual ERAS (MGI- ERAS).
| Items | Gradient 1 | Gradient 2 | Gradient 3 |
|---|---|---|---|
| Preadmission information, education and counsellin | Simply completed during simple guidan c | ERAS group makes the simple guidan c | Specialized ERAS group makes systematic guidance on nutrition, smoking cessation, alcohol dependency management, and pulmonary prehabilitation |
| Airway management after admission | Climbing stairs and simple physical pulmonary training guided by surgeons or nurses | ERAS group guided the preoperative airway management | ERAS group including a specialized physiotherapist guided the preoperative airway management |
| Aspirin withdrawal or not (routinr minimally invasive surgery with low bleeding ris) | Aspirin withdrawal for at least one we | Aspirin withdrawal for 3-5 days then LMWHa bringing management | No aspirin withdrawal |
| Preoperative fasting and carbohtdrate treatment | Clear fluids be allowed up until 4 hours before the induction of anaesthesia and soilids until 8 hours before induction | Oral carbohydrate loading be allowed up until 2-4 hours before the induction of anaesthesia and solids until 8 hours before induction | Oral carbohtdrate loading be allowed up until 2 hoursv before the induction of anaesthesia and solids until 6 hours before induction |
| Preventing intraoperative Hypothermi | Temperature control of the operating room during surgery | Convective active warming devices used perioperatively | Continuous measurement of core temperature to guide the temperature control of the patients. |
| Urinary drainage (routine minimally invasive segmentectomy surgery without need for strict fluid management) | The transurethral catheter is moved immediately after the operation | Not routinely placed for patients undergo wedge resection | Not routinely placed for lobectomy, even for sleeve lobectomy or tracheal surgery with low bleeding ris |
| Anaesthetic protoco | A combination of regional and general anaesthetic techniques with lung protective strategies during one-lung ventilation | Completely tubeless protocolb for patients undergo wedge resection. | Completely tubeless protocolb for segmentectomy, lobectomy, even for sleeve lobectomy or tracheal surgery with low bleeding risk. |
| Surgical techniqu | Three- port minimally invasive surgery (including VATS and robotic surgery | Two- port minimally invasive surgery (including VATS and robotic surgery) | Uniport minimally invasive surgery (including VATS and robotic surgery) |
| Postoperative recovery Raising the head of bed (by ≥30°) Sit up straight 4- 6 hours Sit up straight 2 hours after returning to position and mobilization | Raising the head of bed (by ≥30°) immediately back to the general ward, patients should be mobilized within 24 hours of surgery | Sit up straight 4- 6 hours after returning to the general ward, try to leave the sickbed 6- 8 hours after returning to the general ward | Sit up straight 2 hours after returning tothe general ward, moderate ambulationis tried 4 hours after returning to the general ward |
| Postoperative water drinking and diet | Try water drinking 4- 6 hours after returning to the general ward if no PONVc occurs, semi- fluid diet is permitted | Try water drinking 2- 4 hours after returning to the general ward, if no PONVc occurs, semi- fluid diet is permitted. The nutrition procedures is better conducted by specialized nutritionists | Try water drinking ≤2 hours after returning to the general ward, if no PONVc occurs, semi- fluid diet is permitted. The nutrition procedure is better conducted by specialized nutritionists. |
| Removal of the chest Tubes | Thoracic closed drainage with negative pressure can be use for continuous air leak, chest tubes should be removed with the daily serous effusion without progressive bleeding or chylothorax)≤200ml. | Thoracic closed drainage with negative pressure can be used for continuous air leak, chest tubes should be removed with the daily serous effusion (without progressive bleeding or chylothorax)≤300ml. | Thoracic closed drainage with negative pressure can be used for continuous air leak, chest tubes should be removed with the daily serous effusion (without progressive bleeding or chylothorax) ≤450ml. |
| ain relief regim | Multimodal analgesic regime is recommended | Multimodal analgesic regime with the minimized opioids education and pain management consultation is needed sometimes | Multimodal analgesic regime with the minimized opioids dosage, professional psychological counselling for anxious patients and additional techniques such as transcutaneous electrical nerve stimulation carried out by physiotherapist is used. |
aLMWH, low molecular weight heparin.
bCompletely tubeless protocol: VATS surgery with both non-intubated intravenous anesthesia and no urinary catheterization protocol.
cPONV, postoperative nausea and vomiting.