Table 1.

ERAS Emergency laparotomy preoperative phase guideline review by delphi method [38, 39]

ERAS item	Guideline	Level of evidence	Recommendation grade
1. Early identification of physiological derangement and intervention	Resuscitation and correction of underlying physiological derangement should begin immediately and should continue during diagnostic pathways	High	Strong
	Rapid assessment of the patient for physiological derangement using a validated method such as an early warning scoring system should occur. Abnormal scores should trigger rapid escalation to senior personnel in line with pre-established local protocols. While awaiting surgery patients should have regular re-evaluation with a frequency dictated by local physiological track and trigger protocols	High	Strong
2. Screen and monitor for sepsis and accompanying physiological derangement	All patients for emergency laparotomy should be assessed with a validated sepsis score as early in their presentation as possible. This should be repeated at appropriate intervals in line with severity of signs, and sepsis risk stratification guidance	High	Strong
	If SIRs, sepsis or septic shock is diagnosed, treatment should begin immediately in line with the Surviving Sepsis recognized management algorithms including measurement of lactate	High	Strong
	Prompt antibiotic administration should occur in line with existing international guidelines on sepsis management when signs of sepsis are present, or when the underlying surgical pathology makes the patient at high risk of infection or sepsis such as patients with peritonitis or hollow viscus perforation. Specific antibiotic choice should be guided by local protocols in line with antimicrobial stewardship. Delay to antibiotic administration in patients with sepsis increases mortality	High	Strong
	Monitoring of blood lactate as a marker of risk and in monitoring of response to resuscitation should be considered even in the absence of sepsis	High	Strong
3. Early imaging, surgery, and source control of sepsis	Delay to surgery increases mortality in patients with sepsis and septic shock. All patients with septic shock should receive source control with surgery or interventional radiology as soon as possible and within 3 h. For patients with sepsis without septic shock source control should occur within 6 h	High	Strong
	Perform a CT scan with IV contrast as soon as possible if indicated. The CT scan should be reviewed by a radiologist immediately. Acquiring a CT scan should not cause a delay to surgery if surgery is very urgent	High	Strong
4. Risk assessment	A risk score using a validated model should be performed on all patients prior to surgery and at the end of surgery. The score can be used to guide pathways of care and facilitate discussion between team members, and with patients and family on treatment, risks and limitations	High	Strong
5. Age-related evaluation of frailty, and cognitive assessment	All patients over 65 years of age, and others at high risk, for example, patients with cancer, should be assessed for frailty using a validated frailty score	High	Strong
	Perform a validated simple assessment of cognitive function such as the Mini-Cog® in all patients over 65 years of age if time permits. For patients who are at risk for delirium and postoperative cognitive dysfunction take steps to keep the patient oriented and avoid drugs known to cause harm as defined in the Beers’ criteria	Moderate	Strong
	All patients over 65 should have regular delirium screening pre and postoperatively with a validated assessment method	High	Strong
	Patients over 65 years of age should be assessed by a physician with expertise in care of the older patient (geriatrician) preoperatively and evidence-based elder-friendly practices used. If preoperative assessment is not possible refer for postoperative follow-up	Low	Strong

ERAS item	Guideline	Level of evidence	Recommendation grade
6. Reversal of antithrombotic medications	Strongly consider reversal of home anticoagulation medications when major surgical intervention is planned. This decision should be based on both the patient’s risk of procedure-related bleeding and the risk of thromboembolism	Moderate	Strong
	Consider platelet transfusion in patients taking antiplatelet therapy when the planned procedural bleeding risk is high. In patients with a strong indication for antiplatelet therapy, specialty consultation should be obtained for perioperative co-management of these medications	Low	Weak
7. Assessment of venous thromboembolism risk	Patients should be risk assessed with a validated tool for VTE risk on admission. If pharmaceutical prophylaxis is not possible mechanical prophylaxis should be used. Reassessment should occur daily postoperatively	High	Strong
8. Pre-anesthetic medication – anxiolysis and analgesia	Sedative medication should be avoided preoperatively to avoid the risk of micro-aspiration, hypoventilation and delirium	Moderate	Strong
	Analgesia should be given to alleviate the patient’s pain and stress	High	Strong
	Multi modal opioid-sparing analgesia should be titrated to effect to maximize comfort and minimize side-effects	High	Strong
9. Preoperative glucose and electrolyte management	Hyperglycemia and hypoglycemia are risk factors for adverse postoperative outcomes. Preoperatively, glucose levels should be maintained at 144-180 mg/dL (8-10 mmol/L), a variable rate (sliding scale) insulin infusion should be used judiciously to maintain blood glucose in this range with appropriate monitoring of point of care blood glucose in line with local protocols, to avoid hypoglycemia	Moderate	Weak
	Correction of potassium and magnesium prior to surgery should be done using the intravenous route with appropriate monitoring and following local hospital policy. However, it should not delay the patient being taken to the operating room	Moderate	Weak
10. Preoperative carbohydrate loading	Authors could not recommend use of preoperative carbohydrate loading in the emergency laparotomy population
11. Preoperative nasogastric intubation	Preoperative nasogastric tube insertion should be considered on an individual basis assessing for the risk of aspiration and gastric distension depending on the pathology and patient factors	Moderate	Strong
12. Patient and family education and shared decision making	Patients and families should have the opportunity to discuss the risk of surgery with a senior physician (this could be the surgeon, anesthesiologist or intensive care physician) prior to surgery. Counselling should be informed by a validated risk score but with the clear understanding that scores have limitations when applied to individual patients. When appropriate, treatment escalation plans and advance care plans should be discussed and documented	Low	Strong
	Clear, concise, written information or decision aids combined with verbal patient education should be provided to the patient and family before surgery if possible	Low	Strong