Perioperative nursing principles guided by the concept of enhanced recovery after surgery^†

Due to the concern of surgical patients about the uncertainty of surgical treatment prognosis and surgical risk, the body will involuntarily increase the perioperative stress response of patients through neuro-endocrine, inflammatory, and other means, thus increasing the risk of surgery and the incidence of postoperative complications.^7,8 ERAS idea guiding principles of perioperative nursing by thought that by doctors, nurses and anesthesia and other multidisciplinary personnel on health education to patients and perioperative psychological counseling is necessary, for planning operations in patients with psychological counseling can alleviate the anxiety and depression, reduce stress reaction, and accelerate the postoperative recovery of patients.⁹ Preoperative education mainly includes the communication of specific conditions, guidance of lifestyle, explanation of anesthesia methods, prevention and control of related complications, postoperative analgesic strategies, related strategies at each stage of rehabilitation, and other aspects.¹⁰ Written text, multimedia courseware, or three-dimensional models can be used during education, which not only facilitates patients to understand surgery-related problems but also helps to reduce patients’ anxiety about surgery and has a positive impact on prognosis.¹¹

Studies have confirmed that severe preoperative malnutrition is an independent risk factor leading to surgical complications, mortality, and slowing of postoperative rehabilitation of patients. Preoperative nutritional support can improve the patient’s surgical tolerance, reduce the occurrence of complications such as postoperative infection, and accelerate the patient’s postoperative rehabilitation.¹⁷ The main contents of nutritional support are to reduce disease-related symptoms, control blood glucose, and optimize physical status.¹⁸ Some nutritional screening tools such as the Nutritional Risk Score (NRS2002) and the Subjective Assessment of Global Nutritional Status (PG-SGA) have been applied, or simply according to BMI > 18.5, serum albumin > 30 g/L, and hemoglobin > 80 g/L as the bottom line of nutritional status. The daily protein intake should be 1.2 g/kg, and the protein deficient in the conventional diet is supplemented with whey protein.

Traditional preoperative dietary guidance suggests that patients should fast 12 h before surgery and stop drinking for 4–6 h to fully empty the stomach to effectively prevent the chance of respiratory obstruction and lung injury from intraoperative aspiration.^19,20 However, prolonged preoperative dietary deprivation can lead to metabolic stress in patients, poor tolerance to surgery, and postoperative adverse effects such as dehydration, hypoglycemia, and insulin resistance.^19,21,22 At present, for urological surgery, it is recommended to fast for 6 h before surgery and stop drinking for 2 h to improve the patient’s tolerance to surgery, reduce insulin resistance, and perioperative stress response.

The patient’s body temperature was maintained > 36° to prevent complications of hypothermia. Studies have shown that anesthetic drugs, long operation time, massive blood loss, infusion and continuous fluid irrigation during related surgeries can cause intraoperative hypothermia. Hypothermia can lead to coagulation and immune dysfunction, increase the occurrence of intraoperative bleeding, cardiovascular and cerebrovascular accidents, induce postoperative infection, delay wound healing, and delay drug metabolism leading to prolonged postoperative recovery time.^23,24 ERAS reduces hypothermic injury and accelerates patient recovery by using active insulation measures such as increasing preoperative core temperature, ensuring appropriate operating room temperature, warming of lavage fluid, and active postoperative insulation.

Intraoperative reasonable fluid monitoring ensures circulating blood volume and maintains blood perfusion of the heart, intestine, and kidneys, but excessive fluid infusion often causes intestinal tissue edema, cardiopulmonary and coagulation dysfunction, and prolongs intestinal recovery time. At present, the clinical fluid replacement methods mostly use open, restrictive and goal-directed fluid therapy (GDFT), but each has its own shortcomings. Open fluid replacement leads to weight gain and postoperative complications. Restrictive fluid replacement can effectively shorten the recovery time of gastrointestinal function, reduce cardiopulmonary complications, and improve wound healing.²⁵ But it will lead to insufficient circulating blood volume, affecting the intestinal tract. On this basis, the ERAS concept recommends GDFT, which can optimize organ perfusion and oxygen volume supply effectively reduce the incidence of infection, intestinal paralysis, intestinal obstruction, nausea and vomiting and improve PH value through monitoring indicators such as stroke volume variability (SVV) and arterial pulse pressure variability (PPV).²⁶ When selecting the type of fluid supplementation, crystalloids can effectively supplement physiological requirements, but the effect of maintaining blood volume is poor, and interstitial edema and pulmonary edema are more likely to occur; colloid fluid expansion effect is better, which can reduce tissue edema, but it may interfere with the coagulation effect and cause allergic reactions. Therefore, colloid volume expansion is preferred when the patient develops hypotension, and crystalloids are preferred if only physiological requirements need to be supplemented. In addition, hypotension due to vasodilatation caused by anesthetic drugs should be discerned, and vasopressors are preferred in such cases.²⁷

Pain not only causes adverse emotions and sleep disorders but also causes a series of adverse reactions such as nausea, intestinal paralysis, and postoperative infection. It affects the early postoperative ambulation of patients and the early postoperative recovery of patients.²⁸ Opioids are mostly used for previous analgesia, which leads to excessive sedation, risk of addiction, inhibition of recovery of intestinal function, and increased occurrence of postoperative complications. Opioids are also less than ideal in terms of analgesic effect. The individualized analgesic regimen of preventive analgesia, precise analgesia, and multimodal analgesia has been gradually developed in clinical practice to ensure that the adverse reactions of related drugs are reduced while rationalizing analgesia. Multimodal analgesia acts synergistically through a variety of analgesic modalities (intravenous patient-controlled analgesia, epidural analgesia, nerve block techniques, local infiltration of the incision, etc.) and analgesic drugs (opioids and nonsteroidal analgesic drugs), which in turn reduces the use of opioids and related adverse effects.^12,29 Accurate analgesia requires comprehensive consideration of the patient’s surgical site, size, pain intensity, and individual needs to achieve individualization of dose, route, and medication time. Because epidural analgesia is controversial in reducing postoperative adverse reactions and bringing new complications, the level of evidence recommended for its use in the relevant guidelines of ERAS is low.

Postoperative malignant vomiting is one of the main reasons for delaying gastrointestinal diet and prolonging hospital stay. Female patients and nonsmokers are prone to vomiting after surgery, and a history of motion sickness, use of inhaled anesthetics and opioids can lead to the occurrence of nausea and vomiting.^21,30 At present, the prevention of such complications in clinical work mainly includes two aspects: preoperative active collection of risk factor screening and prevention, or postoperative reduction of opioid use, the use of serotonin receptor antagonists as the first-line drug for the prevention of postoperative nausea and vomiting.

Early postoperative activities can not only reduce postoperative pneumonia, bedsore, deep venous thrombosis, and insulin resistance but also promote the recovery of intestinal tract, bladder function, body metabolism and accelerate the repair and regeneration of tissues.^31,32 For this reason, targeted training should be performed before surgery to provide physiological reserve and activity confidence through the concept of pre-rehabilitation, and early activity should be achieved by postoperative evaluation including general status, motor function, nutritional status, and pain management.³³

In the past, a drainage tube was routinely placed to drain local residual fluid after surgery to prevent infection and local irritation. Current concepts suggest that various types of abdominal drains should be used selectively rather than routinely.¹² This cannot only reduce infection and other related complications but also facilitate the early postoperative movement of patients. For indwelling catheters, it can be distinguished based on urethral and nonurethral surgery, and generally nonurethral surgery advocates reducing the use of catheters or early removal. For prostatic and ileal bladder replacement, the indwelling catheter time is 1–3 weeks in order to drain urine and compression hemostasis, bladder function training. Such catheters should also be removed as much as possible based on strict care to reduce the impact on postoperative activity.