Understanding the Role of ERAS® Protocols for Anesthesia Management

Excess sedation in the OR may result in a number of unwanted side effects and outcomes, including:1,2  

  • Increased patient costs
  • Hospital costs linked to increased length of stay
  • Postoperative delirium

According to a recent panel, these results may be overcome with enhanced recovery after surgery (ERAS®) protocols along with processed electroencephalogram (pEEG) and total intravenous anesthesia (TIVA).

The following blog article contains highlights from the Medtronic Roundtable series — ERAS,® TIVA, and processed EEGs: How they help with patient anesthesia management and outcomes. In this installment, Dr. T.J. Gan of Stony Brook University, Dr. Sabry Ayad of Cleveland Clinic, Dr. Finn Radtke of Næstved Hospital in Denmark, and Joseph Chapman, CRNA of Duke University share their experiences with anesthesia management.

* Disclaimer: This blog article is a summary in question and answer format and is not a full and complete recitation of the webinar. This summary has been prepared to highlight the key elements from the podcast and every effort has been made to avoid any mischaracterizations. Any failure to do so is unintentional. Furthermore, statements of fact and opinions expressed in this webinar are those of authors and participants and do not imply an opinion on the part of Medtronic. This webinar is provided by Medtronic.

To view the whole webinar, click here.

Dr. Gan: Discuss the implementation of ERAS® and how this changed your practice?

Dr. Ayad: When we embarked on a complete change of practice — probably in the early 1990s — all the traditional concepts were switched to an evidence-based practice. Having the patient eat nothing by mouth for more than 12 hours or come with a huge mechanical bowel preparation before surgery — you no longer need to do that. You have better outcomes when patients are not overloaded with three liters of crystalloids prior to surgery. All that has changed.

Moving from traditional practice to evidence- and research-based practices were successful, not only in the United States, but all over the world. We were dealing with ERAS® protocols and it saved a lot of money, as well as saving tons of complications. All our patients had better outcomes and shorter length of stays in the hospital.

Dr. Gan: Where is the ERAS® program at Duke University?

Joseph Chapman: As Dr. Gan mentioned, enhanced recovery at Duke is part of our ethos, part of our culture — for well over a decade now, but it is progressing step-by-step.

My role at Duke as a nurse anesthetist is to help a great team of clinicians in colorectal and other disciplines understand the value of enhanced recovery. Sticking to protocols is one of the challenges that all institutions face when working with enhanced recovery. We all have  been raised with certain dogmas, and it can be challenging to move away from some of the things we’re familiar with.

Dr. Gan: We talk about reducing stress response being the important part of enhanced recovery. Could you share some of the insight to the importance of ERAS® protocols to minimize stress response and promote faster emergent recovery?

Dr. Radke: Back to the point of minimizing the impact of surgical care, we need to realize that there are primary and secondary effects when providing anesthesia. Care needs to be scrutinized to minimize the effect on the patient outcome. Anesthesia isn’t the primary cause of bad outcomes, but it contributes.

Understanding that with anesthesia, every single drop of anesthesia matters in regard a patient’s outcome, which is why brain monitoring is entering center stage.

Related: Read how brain function monitoring technology during general anesthesia can help improve patient outcomes.

Dr. Gan: What specific areas of the ERAS® protocol do you adopt in your practice?

Dr. Radtke: We adopted pretty much every single item, including delirium monitoring on all patients undergoing surgery. By choosing this approach— by minimizing side effects or harm, if you wish to call it that — you optimize patient outcomes.

In all our patients, we approach surgery in the least invasive way and we closely monitor delirium, nausea, vomiting, stress, and anxiety. We strive to have a continuous feedback loop to see if we achieved the aims of minimal side effects and highest possible wellbeing.

Dr. Gan: What type of anesthesia do you typically use — gas, TIVA, a combination — please give us a perspective on what you normally use?

Dr. Ayad: We have a combination of TIVA and non-TIVA cases with inhalation. But we also have a large portion of our patients under regional anesthesia also needing TIVA as most of our doctors don’t want patients to move.

Dr. Gan: What type of patient benefits from processed EEG?

Dr. Radtke: You could almost ask the question in reverse: which patient would not benefit from processed EEG? We always look at the processed EEG and the raw EEG as well as the suppression ratio. It’s not just the processed value — which is a benefit itself — but also the raw value, the suppression ratio, and the density spectral axrray (DSA). We use processed EEG on every patient that receives sedation. Propofol dosing does matter, which is why every single patient is monitored with pEEG.

Dr. Gan: Which patients do you use pEEG on at the Cleveland Clinic?

Dr. Ayad: Just like what Dr. Radtke said, we use our pEEG on everyone who receives a drop of sedation, even the patients under regional anesthesia. It’s for a simple reason, we are a teaching facility, and when I’m teaching I take the baseline before induction as everyone starts at a different baseline. I want to make sure they understand they don’t want to drop the patient below a 20 index value on the BIS™ monitor. Patients with a monitoring index value between 40 and 60 are doing great.

Dr. Gan: We talked about some of the challenges with TIVA, like the inability to measure end-tidal inhalational concentration, and the lack of targeted controlled infusion devices in the U.S. I’m wondering when do you decide to use pEEG in cases of TIVA in your clinical practice?

Joe Chapman: We are fortunate in our institution that we have a pEEG monitor built into our anesthesia machine. Anytime I provide TIVA, I use pEEG. Lately, there’s been some interest in doing this in colorectal surgeries — specifically colorectal cancer resections.  

We’re using TIVA more where gas has traditionally been used. And, I’ll tell you, pEEG allows you to use significantly reduced amounts of TIVA as compared to what a “textbook” would tell you.

For instance, I had a case just the other day with a 75-year-old gentleman and we were running multiple agents. We ran Propofol at 60 mcg/kg per minute. A majority of providers would not be comfortable running that dose of Propofol, however, with pEEG we were very comfortable. Processed EEG allows me to give significantly reduced amounts of anesthesia in a comfortable and reliable fashion.

Dr. Gan: What are the potential clinical benefits of adding pEEG monitoring to enhanced recovery protocols for spine and colorectal procedures?

Dr. Radtke: When you induce the patient and use your Propofol at the same time, while using pEEG and raw EEG, you will know how much the patient needs.

Looking at your bell curve of where your patient is, you can tell how your patient will react to the induction dose. Delirium in recovery room plays a role regarding intermediate and possibly long-term outcomes. Just optimizing the sedative part of anesthesia, avoiding burst suppression, you’ve already won in preventing harm to the patient, especially in ERAS® protocol.

Related: Read more about postoperative delirium and advancing monitoring for improved outcomes in this clinical guide.

Dr. Gan: Dr. Ayad, in the Cleveland Clinic, you have a number of enhanced recovery protocols. How has processed EEG brain monitoring changed your clinical practice during enhanced recovery pathway?

Dr. Ayad: The whole idea of using pEEG isn’t just to be watchful for awareness under anesthesia, it’s about tailoring the correct amount of anesthetic for patients. We want to make sure the patient is in a comfortable zone between 40 to 60 monitoring index value. We understand there is no need to go for burst suppression at this point. Minimize the number of narcotics, the amount of inhaled anesthetic, and the amount of TIVA given to keep patients at the “safe zone.”

We noticed that cognitive function was better when anesthesia was tailored to the patient’s needs and burst suppression was avoided. By not allowing the pEEG to drop at or below a monitoring index value of  20, the patient will wake up smoother and faster.

Dr. Gan: I think you bring up a good point that we’re trying to avoid burst suppression. For those of you that are not familiar, burst suppression is when you have very low base numbers — too much anesthetic. There is some data suggesting that, in fact, this can potentially increase the incidence of postoperative delirium.

I’d like to hear from each of the panelists now. Can you share an experience where pEEG brain monitoring technology made a significant difference in the patient’s experience in the OR or postoperative recovery? Can you share one of your “aha” moments when using pEEG?

Joe Chapman: Using the pEEG is part of our normal practice and it helps me wake up a lot of my patients much faster. Specifically, there is a case that sticks out to me as we had a patient that came from California for a colorectal surgery. She was anxious to have her surgery because her husband was unable to be there. We used pEEG and ERAS® methods. Within 5 minutes of the completion of surgery, she was just as awake as she was before she went into surgery. She asked to borrow my phone to call her husband back home. For me, this typifies just how using pEEG and ERAS® techniques enables your patient to return to a level of function that we didn’t think was possible.

Dr. Radtke: Choosing the proper dosage avoids side effects. Of course, in younger, healthier established patients, the effect seems to be temporary. But, as soon as you enter the vulnerable patient spectrum — aging or fragile patients — these side effects amount to immediate and long-term effects. We have patients that are more worried about anesthesia than the surgery part.

In Denmark, we have a national database where we can see all anesthesia use for the last three years. It shows how patients performed in regard to hemodynamics and medications. We can see if our approach — using EEG, pEEG, suppression ratios, and adjusting our dosage accordingly — had an impact on the patient’s recovery.

Dr. Gan: Dr. Ayad, are there any clinical examples you can share with us?

Dr. Ayad: Yes. I am in several committees, and I present data regarding cost efficiency and how I get my patients out of the OR sooner than everyone else, bypassing Phase 1 recovery.

There’s a cost to it. As Dr. Radtke mentioned, postoperative delirium is a major complication after surgery that requires the patient to stay in the facility for an extended duration. They might even be admitted to facility and it costs an average of $2,388 per night to have someone admitted to the hospital.

We see that using pEEG minimizes postoperative delirium, having the patient wake up clear headed. All of that is impactful when I go to these meetings prepared to talk about how much cost savings that is.

Related: Read recommendations for specific surgical procedures from the ERAS® Society.

To view the whole webinar, click here.


*The BIS™ monitoring system should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment. Reliance on BIS™ alone for intraoperative anesthetic management is not recommended.

1. Simpson JR, Katz SG, Vander Lann T. Oversedation in postoperative patients requiring ventilator support greater than 48 hours: A 4-year national surgical quality improvement program-driven project. The Am Surgeon. 2013;79:1106–1110.

2. Rowe K, Fletcher S. Sedation in the intensive care unit. Contin Educ Anaesth Crit Care Pain. 2008;8:50.

3. Devlin JW, Fraser GL, Ely EW, Kress JP, Skrobik Y, Dasta JF. Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies. Semin Respir Crit Care Med. 2013;34(2):201–215.

About the Author

Martina Blaho RN, BSN is a senior market development clinical specialist at Medtronic.

Related Content