Table 4.

ERAS elements: summary and recommendations

Perioperative element	Summary and recommendation	Recommendation grade
Risk assessment	Preoperative scoring tools and functional capacity tests can be used to identify patients at risk of complications and to stratify perioperative risk.	POSSUM: strong Lee Index: strong Cardiovascular Risk Calculator: strong Walk tests: strong CPET: strong General Surgery Acute Kidney Injury Risk Index: strong
Preoperative optimization	Cessation of smoking and alcohol intake at least 4 weeks before surgery is recommended. Encouraging patients is not enough; pharmacological support and individual counselling should be offered to every patient who smokes and to alcohol abusers undergoing elective surgery. Optimization of medical conditions, such as cardiovascular diseases, anaemia, COPD, nutritional status and diabetes should follow international recommendations.	Smoking cessation: high NRT and counselling: high Alcohol cessation: low Medical optimization: strong Optimize preoperative anaemia reduces morbidity and mortality: moderate
Pre‐anaesthetic medication	Long‐acting anxiolytic and opioids should be avoided as they may delay discharge. Short‐acting benzodiazepine should be avoided in the elderly.	Strong.
Preoperative fasting and carbohydrates (CHOs) loading	Intake of clear fluids should be allowed until 2 h before induction of anaesthesia. Solids should be allowed until 6 h. Preoperative treatment with oral CHOs should be routinely administered except in patients with documented delayed gastric emptying or slow gastrointestinal motility and as well in patients undergoing emergency surgery.	Adherence to fasting guidelines (avoid overnight fasting): strong Administration of preoperative CHOs:strong Administration of preoperative CHOs in diabetic and obese patients: weak
Preventing and treating postoperative nausea and vomiting (PONV)	Aggressive PONV prevention strategy should be included in an ERAS protocol102. All patients with 1–2 risk factors should receive a combination of two antiemetics. Patients with 3–4 risk factors should receive 2–3 antiemetics. Total intravenous anaesthesia (TIVA) with propofol and opioid‐sparing strategies should be encouraged.	Strong
Standard anaesthetic protocol	Anaesthetic depth should be guided either maintaining an end tidal concentration of 0.7–1.3 MAC or BIS index between 40 and 60 with the aim not only to prevent awareness but also to minimize anaesthetic side effects and facilitate rapid awakening and recovery. Avoid too deep anaesthesia (BIS < 45), especially in elderly patients	Strong
Neuromuscular blockade (NMB) and neuromuscular monitoring	It remains controversial if deep neuromuscular blockade during laparoscopic surgery improves operating conditions. Neuromuscular function should be always monitored when using NMBA to avoid residual paralysis. Long‐acting NMBA should be avoided. When NMBA are administered neuromuscular function should be monitored by using a peripheral nerve stimulator to ensure adequate muscle relaxation during surgery and optimal restoration of neuromuscular function at the end of surgery. A TOF ratio of 0.9 must be achieved to ensure adequate return of muscle function and thus preventing complications.	Monitoring neuromuscular function: strong Reversing neuromuscular blockade: strong
Inspired Oxygen Concentration	1) The inspired fractional concentration of oxygen should be titrated to produce normal arterial oxygen levels and saturations. Prolonged periods of high inspired oxygen concentrations which result in hyperoxia should be avoided. 2) 100% inspired oxygen concentrations can be used for pre‐oxygenation prior to anaesthesia or for short periods to overcome hypoxia.	1) Strong 2) Strong
Preventing intraoperative hypothermia	Intraoperative hypothermia should be avoided by using active warming devices.	Strong.
Surgical techniques	Laparoscopic surgery for gastrointestinal surgery is recommended when the expertise is available. Transverse incisions for colonic resections can be preferred.	Laparoscopic approach: strong Transverse incisions for colonic surgery: low
Nasogastric intubation	Prophylactic use of NGTs is not recommended for patients undergoing elective colorectal surgery, while its use in patients undergoing gastrectomy and oesophagectomy is still debatable. Patients with delayed gastric emptying after surgery should be treated by inserting a NGT.	Strong.
Intraoperative glycaemic control	Glucose levels should be kept as close to normal as possible without compromising safety. Employing perioperative treatments that reduce insulin resistance without causing hypoglycaemia is recommended.	Strong.
Perioperative haemodynamic management	The goal of perioperative fluid therapy is to maintain fluid homeostasis avoiding fluid excess and organ hypoperfusion. Fluid excess leading to perioperative weight gain more than 2.5 kg should be avoided, and a perioperative near‐zero fluid balance approach should be preferred. GDFT should be adopted especially in moderate–high‐risk patients. Inotropes should be considered in patients with poor contractility CI < 2.5 l/min). Colloids should not be used in septic patients and in patients with reduced renal function. Large amount of colloids can impair haemostasis. In patients receiving epidural analgesia arterial hypotension should be treated with vasopressors, ensuring the patient is normovolaemic. In the absence of surgical losses postoperative intravenous fluid should be discontinued and oral intake (1.5 l/day) encouraged.	GDFT: Strong in high‐risk patients and for patients undergoing surgery with large intravascular fluid loss (blood loss and protein/fluid shift) GDFT: low in low‐risk patients and in patients undergoing low‐risk surgery Perioperative near‐zero fluid balance: moderate Use of advanced hemodynamic monitoring: strong in high‐risk patients and for patients undergoing surgery with large intravascular fluid loss (blood loss and protein/fluid shift)
Balanced crystalloids vs. 0.9% saline	0.9% saline should be avoided and balanced crystalloid solution used in the preoperative period. The use of 0.9% saline should be restricted in hypochloraemic and acidotic patients.	Strong
Pain management	Analgesic techniques should aim to not only provide optimal pain control, but also to facilitate the achievement of important milestones such as tolerance of oral intake, and early mobilization. Opioids side effects are dose‐dependent and delay recovery. Opioid‐sparing analgesic strategies, including regional analgesia techniques, should be implemented in a context of a multimodal analgesic regimen. Postoperative pain management should be procedure‐specific	MMA: strong Open abdominal surgery TEA: strong for using it IVLI: moderate for using it CWI: weak for using it TAP blocks: moderate for using it Laparoscopic abdominal surgery TEA: weak for using it IVLI: moderate for using it Intrathecal morphine: moderate for using it TAP blocks: moderate for using it
Postoperative Delirium	Preventive measure as avoidance of prolonged fasting, deep anaesthesia, disturbance of sleep‐wake cycle or delirogenic medications like benzodiazepines, atropine should be implemented. Systematic delirium screening and symptom‐oriented treatment should be performed and potential underlying medical causes should be ruled out.	Strong
Attenuation and treatment of postoperative ileus	Primary POI is an inevitable consequence after gastrointestinal surgery and its pathogenesis is multifactorial. Multimodal preventing strategies should be adopted to facilitate the recovery of gastrointestinal function.	Moderate
Early mobilization	Achievement of mobilization goals requires a multidisciplinary approach. Patients should be given written information setting daily targets for ambulation in hospital. Patients should be encouraged to increase their physical activity in the preoperative period. Patients should use a diary or pedometer to record their daily physical activity.	Weak.