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In spite of continuous advances in anaesthesia, surgery and perioperative care, major surgery is still associated with undesirable sequel such as pain, cardiopulmonary, infective and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paralysis, fatigue, and prolonged convalescence.1 Enhanced Recovery After Surgery (ERAS) was initiated by Professor Henrik Kehlet in the 1990s,1 and enhanced recovery programmes (ERPs) have become an important focus of perioperative management for most major surgeries. These care pathways are integrated as the patient moves from home through the pre-hospital/pre-admission, pre-operative, intraoperative, and post-operative phases of surgery and home again. ERAS represents a model of perioperative care in by re-examining traditional practices and replacing them with evidence-based good practices when necessary. It also covers each phase of the patient's journey through the surgical process. These programmes attempt to modify the physiological and psychological responses to major surgery,2 and have been shown to lead to a reduction in complications and hospital stay, improvements in cardiopulmonary function, earlier return of bowel function, and earlier resumption of normal activities.3,4 The key principles of the ERAS protocol include pre-operative counselling, pre-operative nutrition, avoidance of peri-operative fasting, and carbohydrate loading up to 2 h pre-operatively, standardised anaesthetic and analgesic regimens (epidural and non-opioid analgesia) and early mobilisation.5

One of the most important aspects is the ERAS team.6 It is an interdisciplinary team and refers to a group of healthcare professionals from diverse fields who work together in a cohesive and collaborative fashion with trust to share expertise, knowledge, and skills to engage and optimise the patient across the entire pathway.7,8 This includes pre-admission staff, dieticians, nurses, physiotherapists, social workers, occupational therapists, and doctors. All team members must be familiar with ERAS principles and be motivated to carry out the programme; they must be able to overcome traditional concepts, teaching, and attitudes towards perioperative care.6 For implementation to be successful, nurses were found to be key and play a central part of the team taking care of surgical patients by providing education, peri-operative care, and post-operative evaluation, as well as cost containment.9 They are at the forefront of daily patient care and have therefore a major impact on securing the adherence to ERAS pathway elements. Nursing within ERAS care implies a shift from traditional nursing to additional important tasks, including dedicated information (setting expectations), coaching of patients, and control, monitoring, and documentation of the recovery process.10 Systematic implementation of ERAS was associated with decreased nursing workload and higher compliance was associated with lower work burden for the nurses.11

Pre-admission phase

Information, education, and counselling help to set expectations about surgery and also about care plan in post op period. It also will help to reduce anxiety and increase patient satisfaction, which may improve fatigue and facilitate early discharge.12,13 Barriers like patients language, cultural and religious beliefs, health literacy, and nursing professionals attitudes, biases, behaviours, communication skills, and competencies may impact understanding of ERAS process and can make ERAS implementation challenging.

Ideally, the patient/family should meet with all members of the team including the surgeon, anaesthetist, dietician, and nurse. Studies have shown that patients prefer to be well informed, and support from a nurse at the time of diagnosis can reduce stress levels for up to six months14 However, to be effective in this area nurses should be skilled and willing to assess the individual's need for help with information, and managing their worry.14 Counselling helps to minimise anxiety by educating patients on what to expect post-surgery, pain management, post-operative phase are (deep breathing exercise, wound care), and addressing body image disturbance if any. Patients are also most successful when they are able to actively engage in lifestyle activities such as exercise to lose weight or stop smoking more than two weeks prior to surgery.15

Prehabilitation of patients with comorbidities is vital. The term ‘prehabilitation’ has been used to describe the process of optimising functional and nutritional capacity and preparing the patient to better cope with the stress of surgery.16 Inadequate nutrition, particularly for cancer patients undergoing surgery, is an independent risk factor for complications, increased hospital stay and costs.17 Therefore assessment and treatment of poor nutrition is an essential constituent of ERAS protocols. In terms of defining the problem, the European Society of Parenteral and Enteral Nutrition (ESPEN) defines “severe” nutritional risk as one or more of the following: weight loss > 10%–15% in six months, body mass index < 18.5 kg/m2 or a serum albumin of < 30 g/L.5

Pre-operative phase

Several randomised controlled trials (RCTs) have reported that clear fluids can be safely given up to 2 h, and a light meal up to 6 h, before elective procedures requiring general anaesthesia, in children and adults.18 Oral fluids including oral carbohydrates may not be administered safely in patients with documented delayed gastric emptying or gastrointestinal motility disorders as well as in patients undergoing emergency surgery.19 Decision on use of antihypertensive/hypoglycaemic agent need to be discussed. The ERAS programme needs to be discussed with patient/family and realistic goals need to be established for pain, nutrition, mobilisation, and length of stay (LOS).

Post-operative phase

Review findings highlights that ERAS protocols of post-operative care are beneficial for patients undergoing surgery.20 Nurses must note that several perioperative risk factors may contribute to post-operative morbidity. Risk factors include co-morbidities (diabetes, hypertension, chronic obstructive pulmonary disease immunosuppression, malnutrition), pain, nausea/vomiting, immobilisation, drains/naso-gastric tubes.1

Criteria for assessment, monitoring, and documentation interval need to be specified. Patient need to be assessed and evaluated for recovery status and return optimum function, for example: level of consciousness, ability to mobilise, etc. Patients are encouraged for early mobilisation and feeding.21 These activities should be supported by management of pain, preventing/minimising post-operative nausea/vomiting, surgical site care, IV fluids management, and early removal of IV catheter. Effective post-operative pain relief is a prerequisite to attain improved post-operative outcome, and when integrated into an active rehabilitation programme may reduce the surgical stress response, organ dysfunctions and improve gastrointestinal motility, to allow early oral nutrition and to facilitate early mobilisation.1 Involvement of family in care helps the family member to continue care post discharge confidently. Post-operative nausea and vomiting (PONV) risk assessment score (Table I) will help in management of PONV.22

Another aspect that nurses need to monitor is for surgical site infections (SSIs). SSIs are associated with increased patient morbidity, mortality, and healthcare expenditures. SSI reduction bundles have been demonstrated to decrease the risk of developing a surgical site infection and bundle elements include antimicrobial prophylaxis, skin preparation, avoiding hypothermia, avoiding surgical drains, and reducing perioperative hyperglycaemia.19

Discharge phase

Discharge planning begins during pre-operative phase and continues through discharge and return home. Time to recovery will vary depending on the type of surgery or symptom being measured.

Assessing patients readiness to discharge is an indispensable element of discharge planning and includes assessing functional status, re-emphasising on surgical site care, diet, exercise, lifestyle modifications, medications, and follow up. It is also essential to provide tailored information to meet the needs of the individual patient. A written information sheet will help in adhering to instructions, symptoms to report, when and how to obtain urgent care/assistance. Ensuring that patients’ informational needs have been met before hospital discharge sets the stage for successful self-management of recovery at home. With improved post-operative education and closer follow-up, it is estimated that 50% of hospital readmissions may be preventable.11,23

Conclusions

ERAS is now firmly established as a global surgical quality improvement initiative that results in clinical improvements,24 which in turn also has an impact on length of stay, and thus cost to patients. ERAS guidelines are freely available at ERAS society website and are based on the highest quality evidence.25 The effective implementation begins with the formulation of a protocol, carrying out each intervention, and gathering outcome data. The care of a patient is divided into three phases: before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy.21

Trained professional nurses remain indispensable evaluators, implementers, observers, and coordinators at all stages of ERAS programme.26 ERAS nursing pathway can be established across for all major surgeries incorporating best practices. This requires consistency across the care team, diligence to ensure compliance, and use of an audit tool for quality improvement.9 Patient reported outcomes, including symptom burden assessment, can also be tracked to guide individual post-operative care.19 Studies can also aim at improvement of hospitalisation conditions, reduction of patient stress, safer care, fewer complications, and cost effectiveness.20

Nursing professionals are well positioned as champion leaders and members of the patient-centered team for ERAS excellence.

全文翻譯（僅供參考）

盡管在麻醉、手術(shù)和圍手術(shù)期護(hù)理方面不斷取得進(jìn)步，但大手術(shù)仍然伴隨著不良的后遺癥，如疼痛、心肺、感染和血栓栓塞并發(fā)癥、腦功能障礙、惡心和胃腸麻痹、疲勞和恢復(fù)期延長(zhǎng)。1加速術(shù)后恢復(fù) (ERAS) 由 Henrik Kehlet 教授在 1990 年代發(fā)起，1增強(qiáng)康復(fù)計(jì)劃 (ERPs) 已成為大多數(shù)大型手術(shù)圍手術(shù)期管理的重點(diǎn)。當(dāng)患者從家中通過(guò)入院前/入院前、術(shù)前、術(shù)中和術(shù)后階段以及再次回家時(shí)，這些護(hù)理途徑被整合在一起。ERAS 通過(guò)重新審視傳統(tǒng)做法并在必要時(shí)用循證的良好做法取代它們，代表了一種圍手術(shù)期護(hù)理模式。它還涵蓋了患者在手術(shù)過(guò)程中的每個(gè)階段。這些計(jì)劃試圖改變對(duì)大手術(shù)的生理和心理反應(yīng)，2并且已被證明可以減少并發(fā)癥和住院時(shí)間、改善心肺功能、更早恢復(fù)腸道功能和更早恢復(fù)正常活動(dòng)。3、4 ERAS方案的關(guān)鍵原則包括術(shù)前咨詢、術(shù)前營(yíng)養(yǎng)、避免圍手術(shù)期禁食、術(shù)前 2 小時(shí)內(nèi)的碳水化合物負(fù)荷、標(biāo)準(zhǔn)化麻醉和鎮(zhèn)痛方案（硬膜外和非阿片類鎮(zhèn)痛）和早期活動(dòng)。5

最重要的方面之一是 ERAS 團(tuán)隊(duì)。6它是一個(gè)跨學(xué)科團(tuán)隊(duì)，指的是一群來(lái)自不同領(lǐng)域的醫(yī)療保健專業(yè)人員，他們以凝聚力和協(xié)作的方式相互信任，分享專業(yè)知識(shí)、知識(shí)和技能，以在整個(gè)路徑中參與和優(yōu)化患者。7 , 8這包括入院前工作人員、營(yíng)養(yǎng)師、護(hù)士、物理治療師、社會(huì)工作者、職業(yè)治療師和醫(yī)生。所有團(tuán)隊(duì)成員都必須熟悉 ERAS 原則并有動(dòng)力執(zhí)行該計(jì)劃；他們必須能夠克服對(duì)圍手術(shù)期護(hù)理的傳統(tǒng)觀念、教學(xué)和態(tài)度。6為了使實(shí)施成功，護(hù)士被認(rèn)為是關(guān)鍵，并通過(guò)提供教育、圍手術(shù)期護(hù)理和術(shù)后評(píng)估以及成本控制，在照顧手術(shù)患者的團(tuán)隊(duì)中發(fā)揮核心作用。9它們處于日常患者護(hù)理的最前沿，因此對(duì)確保遵守 ERAS 途徑要素具有重大影響。ERAS 護(hù)理中的護(hù)理意味著從傳統(tǒng)護(hù)理轉(zhuǎn)向額外的重要任務(wù)，包括專門的信息（設(shè)定期望）、對(duì)患者的指導(dǎo)以及對(duì)康復(fù)過(guò)程的控制、監(jiān)測(cè)和記錄。10系統(tǒng)實(shí)施 ERAS 與減少護(hù)理工作量相關(guān)，更高的依從性與降低護(hù)士的工作負(fù)擔(dān)相關(guān)。11

入院前階段

信息、教育和咨詢有助于設(shè)定對(duì)手術(shù)的期望以及術(shù)后護(hù)理計(jì)劃。它還有助于減輕焦慮并提高患者滿意度，這可能會(huì)改善疲勞并促進(jìn)早期出院。12 , 13患者的語(yǔ)言、文化和宗教信仰、健康素養(yǎng)以及護(hù)理專業(yè)人員的態(tài)度、偏見、行為、溝通技巧和能力等障礙可能會(huì)影響對(duì) ERAS 流程的理解，并使 ERAS 的實(shí)施具有挑戰(zhàn)性。

理想情況下，患者/家屬應(yīng)與團(tuán)隊(duì)的所有成員會(huì)面，包括外科醫(yī)生、麻醉師、營(yíng)養(yǎng)師和護(hù)士。研究表明，患者更愿意了解情況，并且在診斷時(shí)得到護(hù)士的支持可以減少長(zhǎng)達(dá)六個(gè)月的壓力水平14但是，要在這方面有效，護(hù)士應(yīng)該熟練并愿意評(píng)估個(gè)人的需要尋求信息方面的幫助，并管理他們的擔(dān)憂。14咨詢通過(guò)教育患者手術(shù)后的預(yù)期、疼痛管理、術(shù)后階段（深呼吸運(yùn)動(dòng)、傷口護(hù)理）以及解決身體形象障礙（如果有）來(lái)幫助減少焦慮。當(dāng)患者能夠在手術(shù)前兩周以上積極參與生活方式活動(dòng)（例如運(yùn)動(dòng)減肥或戒煙）時(shí)，他們也是最成功的。15

合并癥患者的康復(fù)治療至關(guān)重要?！邦A(yù)康復(fù)”一詞用于描述優(yōu)化功能和營(yíng)養(yǎng)能力以及讓患者更好地應(yīng)對(duì)手術(shù)壓力的過(guò)程。16營(yíng)養(yǎng)不足，特別是對(duì)于接受手術(shù)的癌癥患者，是并發(fā)癥、住院時(shí)間增加和費(fèi)用增加的獨(dú)立風(fēng)險(xiǎn)因素。17因此，營(yíng)養(yǎng)不良的評(píng)估和治療是 ERAS 協(xié)議的重要組成部分。在定義問(wèn)題方面，歐洲腸外和腸內(nèi)營(yíng)養(yǎng)學(xué)會(huì) (ESPEN) 將“嚴(yán)重”營(yíng)養(yǎng)風(fēng)險(xiǎn)定義為以下一項(xiàng)或多項(xiàng)：六個(gè)月內(nèi)體重減輕 > 10%–15%，體重指數(shù) < 18.5 kg/m 2或血清白蛋白 < 30 g/L。5

術(shù)前階段

幾項(xiàng)隨機(jī)對(duì)照試驗(yàn) (RCT) 報(bào)告說(shuō)，在需要全身麻醉的選擇性手術(shù)之前，兒童和成人可以安全地給予清澈的液體長(zhǎng)達(dá) 2 小時(shí)，并在 6 小時(shí)內(nèi)安全地給予清淡的食物。18對(duì)于有記錄的胃排空延遲或胃腸動(dòng)力障礙的患者以及接受緊急手術(shù)的患者，可能不安全地給予包括口服碳水化合物在內(nèi)的口服液。19需要討論使用降壓藥/降糖藥的決定。ERAS 計(jì)劃需要與患者/家屬討論，并且需要為疼痛、營(yíng)養(yǎng)、活動(dòng)和住院時(shí)間 (LOS) 建立現(xiàn)實(shí)目標(biāo)。

術(shù)后階段

審查結(jié)果強(qiáng)調(diào)，ERAS 術(shù)后護(hù)理方案對(duì)接受手術(shù)的患者有益。20護(hù)士必須注意，一些圍手術(shù)期風(fēng)險(xiǎn)因素可能會(huì)導(dǎo)致術(shù)后發(fā)病率。風(fēng)險(xiǎn)因素包括合并癥（糖尿病、高血壓、慢性阻塞性肺疾病免疫抑制、營(yíng)養(yǎng)不良）、疼痛、惡心/嘔吐、制動(dòng)、引流/鼻胃管。1

需要指定評(píng)估、監(jiān)控和記錄間隔的標(biāo)準(zhǔn)。需要評(píng)估和評(píng)估患者的恢復(fù)狀態(tài)和恢復(fù)最佳功能，例如：意識(shí)水平、活動(dòng)能力等。鼓勵(lì)患者早期活動(dòng)和進(jìn)食。21這些活動(dòng)應(yīng)通過(guò)疼痛管理、預(yù)防/減少術(shù)后惡心/嘔吐、手術(shù)部位護(hù)理、靜脈輸液管理和早期拔除靜脈導(dǎo)管來(lái)支持。有效的術(shù)后疼痛緩解是改善術(shù)后結(jié)果的先決條件，當(dāng)整合到積極的康復(fù)計(jì)劃中時(shí)，可以減少手術(shù)應(yīng)激反應(yīng)、器官功能障礙并改善胃腸道運(yùn)動(dòng)，從而允許早期口服營(yíng)養(yǎng)并促進(jìn)早期活動(dòng)。1家人參與護(hù)理有助于家人在出院后自信地繼續(xù)護(hù)理。術(shù)后惡心嘔吐（PONV）風(fēng)險(xiǎn)評(píng)估評(píng)分（表一) 將有助于 PONV 的管理。

護(hù)士需要監(jiān)測(cè)的另一個(gè)方面是手術(shù)部位感染 (SSI)。SSI 與患者發(fā)病率、死亡率和醫(yī)療保健支出的增加有關(guān)。SSI 減少束已被證明可降低發(fā)生手術(shù)部位感染的風(fēng)險(xiǎn)，束元素包括抗菌預(yù)防、皮膚準(zhǔn)備、避免低溫、避免手術(shù)引流和減少圍手術(shù)期高血糖。19

放電階段

出院計(jì)劃從術(shù)前階段開始，一直持續(xù)到出院和回家。恢復(fù)時(shí)間會(huì)因手術(shù)類型或所測(cè)量的癥狀而異。

評(píng)估患者出院準(zhǔn)備情況是出院計(jì)劃不可或缺的要素，包括評(píng)估功能狀態(tài)、重新強(qiáng)調(diào)手術(shù)部位護(hù)理、飲食、鍛煉、生活方式改變、藥物治療和隨訪。提供量身定制的信息以滿足個(gè)體患者的需求也很重要。書面信息表將有助于遵守說(shuō)明、報(bào)告癥狀、何時(shí)以及如何獲得緊急護(hù)理/援助。確保在出院前滿足患者的信息需求，為在家中成功進(jìn)行自我康復(fù)管理奠定了基礎(chǔ)。隨著術(shù)后教育的改進(jìn)和更密切的隨訪，估計(jì) 50% 的再入院是可以預(yù)防的。11 , 23

ERAS 現(xiàn)在已被牢固確立為一項(xiàng)全球手術(shù)質(zhì)量改進(jìn)計(jì)劃，可帶來(lái)臨床改善，24這反過(guò)來(lái)也會(huì)影響住院時(shí)間，從而影響患者的成本。ERAS 指南可在 ERAS 協(xié)會(huì)網(wǎng)站上免費(fèi)獲取，并且基于最高質(zhì)量的證據(jù)。25有效實(shí)施始于制定方案、實(shí)施每項(xiàng)干預(yù)措施并收集結(jié)果數(shù)據(jù)。對(duì)患者的護(hù)理分為三個(gè)階段：術(shù)前、術(shù)中和術(shù)后。每個(gè)階段都需要多學(xué)科團(tuán)隊(duì)中少數(shù)或全部成員的積極參與。該團(tuán)隊(duì)的職責(zé)也是跟上快速通道方法的最新發(fā)展并對(duì)政策進(jìn)行適當(dāng)?shù)母摹?1

在 ERAS 計(jì)劃的各個(gè)階段，訓(xùn)練有素的專業(yè)護(hù)士仍然是不可或缺的評(píng)估者、實(shí)施者、觀察者和協(xié)調(diào)者。26條 ERAS 護(hù)理路徑可以針對(duì)所有包含最佳實(shí)踐的大型手術(shù)建立。這需要整個(gè)護(hù)理團(tuán)隊(duì)保持一致，努力確保合規(guī)性，并使用審計(jì)工具來(lái)改進(jìn)質(zhì)量。9還可以跟蹤患者報(bào)告的結(jié)果，包括癥狀負(fù)擔(dān)評(píng)估，以指導(dǎo)個(gè)體術(shù)后護(hù)理。19研究還可以旨在改善住院條件、減輕患者壓力、更安全的護(hù)理、更少的并發(fā)癥和成本效益。20

護(hù)理專業(yè)人士處于卓越的 ERAS 卓越領(lǐng)導(dǎo)者和以患者為中心的團(tuán)隊(duì)的成員中。

THE

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