Enhanced Recovery After Surgery (ERAS) Pathways


The overarching focus of an Enhanced Recovery After Surgery (ERAS) program is to take a collaborative team approach to achieve an optimal preoperative condition before the date of surgery while minimizing disruption of the normal physiologic state through the remainder of the perioperative timeframe. Each surgical service meets on a regular basis with all team members who participate in the care of the patient to create a pathway from preoperative, intraoperative, and postoperative, that utilizes best practices from each stakeholder’s specialty.  

Specific to pain management, there is much reliance on utilization of multimodal analgesics such as gabapentin, acetaminophen, NSAIDs and regional anesthesia as examples with the goal to minimize opioid-related side effects.

Preoperative Interventions

One of the goals during preoperative care is to optimize the patient for surgery and postoperative recovery.  If a patient has a complex pain history or is already on opioid medications, preoperative interventions focused on opioid reduction or cessation may improve the safety and outcomes from surgery (shorter lengths of stay, less readmission, less likelihood to be discharged to a rehabilitation facility and less costs).  

Some surgical services have a unique ERAS protocol which may encompass nutritional supplements such as Boost Breeze prior to NPO, optimizing cardiac performance, and weight loss. 

Educating patients on how to use spirometry properly during preop helps increase utilization and compliance post-operatively.  This simple exercise helps minimize atelectasis and reduces the risk of pneumonia. Another simple addition to preop protocol is warming the patient with a Bair Hugger to decrease risk of surgical site infections.

In terms of preemptive pain management, utilization of multimodal analgesics (gabapentin, acetaminophen, NSAIDs) is preferred. In addition, adjuncts that address common opioid-related side effects are routinely used: At UCSF, some surgical  services administer alvimopan prior to surgery to mitigate opioid induce ileus after surgery when bowel work is involved.  Patients who are at increased risk of PONV are recommended to use multiple antiemetics including scopolamine patch prior to surgery. 

All of these interventions, when used in conjunction, improve patient outcomes.

Intraoperative Interventions

During the intraoperative portion of care, the continued use of multimodal analgesics is encouraged while minimizing the use of opioids. This protocol enhances post-operative recovery by avoiding opioid induced side effects (most notably respiratory depression and constipation/ileus) and avoids the risk of opioid induced hyperalgesia.  Studies have shown the effectiveness of multimodal analgesics through measurable metrics such as decreased time to eat solids, ability to pass gas, ability to have a bowl movement, and the ability to walk within 24 hours postoperatively.  

  • Neuraxial anesthesia, peripheral block or truncal blocks can be great adjuncts along with surgeon infiltration with local anesthetics or liposomal bupivacaine in lieu of opioids.  It is best to utilize regional anesthesia when possible. This targeted area of anesthesia decreases the systemic toll from general anesthesia and opioids, hence providing a speedier recovery for the patient. 
  • Lidocaine infusion and magnesium infusions are adjuncts to the non-opioid analgesic arsenal that can be used to help control pain when regional anesthesia is not possible. 
  • Ketamine infusion can be used for opioid tolerant patients to decrease the amount of opioid needed and to help break the cycle of escalating opioid use. 
  • Dexamethasone is a useful adjunct to be used to reduce pain and opioid use (as well as prophylaxis against PONV). 

Postoperative Interventions

During the postoperative phase, there should be continued minimization of opioids. Providers are encouraged to continue multimodal analgesics (gabapentin, acetaminophen, NSAIDs) to control pain.  Neuraxial or peripheral nerve catheter infusions can be a great post-operative option for analgesia if appropriate.  Ketamine infusion can be used for opioid tolerant patients. Lidocaine infusion is now an option for patients who were not able to receive a regional technique. Patient controlled analgesia using pumps that administer opioids can generally be avoided.  Overall, establishing a multidisciplinary protocol leads to a more rapid patient recovery and ultimately decreasing the length of stay in the hospital.


Waljee, Jennifer F. MD, MPH, MS; Cron, David C. BS; Steiger, Rena M. MPH; Zhong, Lin MD, MPH; Englesbe, Michael J. MD; Brummett, Chad M. MD Effect of Preoperative Opioid Exposure on Healthcare Utilization and Expenditures Following Elective Abdominal Surgery, Annals of Surgery: April 2017 - Volume 265 - Issue 4 - p 715-721 

Zhang, Xingxia MDa; Yang, Jie MDb; Chen, Xinrong MDa; Du, Liang MDc; Li, Ka MDa,; Zhou, Yong MDb,Enhanced recovery after surgery on multiple clinical outcomes, Medicine: July 17, 2020 - Volume 99 - Issue 29 - p e20983

Lauren K. Dunn, Marcel E. Durieux; Perioperative Use of Intravenous Lidocaine. Anesthesiology 2017; 126:729–737

Gildasio S. De Oliveira, Lucas J. Castro-Alves, Jamil H. Khan, Robert J. McCarthy; Perioperative Systemic Magnesium to Minimize Postoperative Pain: A Meta-analysis of Randomized Controlled Trials. Anesthesiology2013; 119:178–190

Fan, Kenneth L. MD*; Luvisa, Kyle MPH; Black, Cara K. BA; Wirth, Peter BA; Nigam, Manas MD*; Camden, Rachel MS*; Won Lee, Dong MD; Myers, Joseph MD§; Song, David H. MD, MBA* Gabapentin Decreases Narcotic Usage: Enhanced Recovery after Surgery Pathway in Free Autologous Breast Reconstruction, Plastic and Reconstructive Surgery - Global Open: August 2019 - Volume 7 - Issue 8 - p e2350 

Sarin, A., Lancaster, E., Chen, Ll. et al. Using provider-focused education toolkits can aid enhanced recovery programs to further reduce patient exposure to opioids. Perioper Med 9, 21 (2020). 

Gildàsio S. De Oliveira, Marcela D. Almeida, Honorio T. Benzon, Robert J. McCarthy; Perioperative Single Dose Systemic Dexamethasone for Postoperative Pain: A Meta-analysis of Randomized Controlled Trials. Anesthesiology 2011; 115:575–588