Pediatric Surgical Services
Hasbro Children's Hospital

Enhanced Recovery After Surgery (ERAS)

Albert S. Woo, MD, FACS
Albert S. Woo, MD, FACS

by Albert S. Woo, MD, director of the Cleft and Craniofacial Center, and chief of pediatric plastic surgery at Rhode Island Hospital and its Hasbro Children’s Hospital

Surgery takes a huge toll on the body, both physically and emotionally. But what if we worked to minimize pain, anxiety, and some of the physical stresses on the body whenever a major surgical procedure was being performed? Would this improve patient care?

This is exactly the question that has been asked by the surgical community and gave birth to the concept of enhanced recovery after surgery, or ERAS for short.

To be more specific, the idea behind ERAS was that a scientific, multi-pronged, evidence-based approach could be developed for individual surgeries with protocols to make sure that all patients received consistent, standardized, team-based care with minimal variability – similar to how airline pilots might utilize a checklist to make sure that critical details are not forgotten or overlooked for every flight. 

The multi-pronged, team-based approach of ERAS includes several key components to its execution. Some of this starts even before the day of surgery. To begin with, patients and their families are considered key players in their own welfare.

Special care is therefore taken with patient education and counseling, so that patients know exactly what to expect with their surgeries. They are allowed to tour surgical facilities and ask lots of questions to minimize any anxiety associated with the unknown. The nutritional status of each patient is also maximized by reducing preoperative fasting and allowing people to eat as quickly after surgery as possible.

The Surgical Experience

On the day of surgery, anesthesiologists do their best to minimize the use of narcotic medications, which may serve as effective pain killers but only last for a short period of time, and also have the side-effects of prolonging sedation and decreasing gastrointestinal function. Instead, other strategies are utilized, including the use of nerve blocks, when available. Surgeons, in turn, do their best to minimize incisions and the size of the surgical procedure, taking advantage of minimally invasive techniques as much as possible. Medications are also given to decrease inflammation and prevent against infection.

After surgery, patients are encouraged to begin mobilizing as quickly as possible. They are helped by avoiding the use of narcotics and other sedatives. At the same time, patients are kept comfortable with non-narcotic options for pain management. Standardized protocols for pain management and control of nausea are utilized and care is taken to optimize rest. Doctors and nurses work very closely as a team to make sure that care is consistent and thorough.

The Growing Adoption of ERAS Protocols

ERAS protocols initially took hold in adult colorectal surgery. After years of testing, scientific studies have demonstrated a number of surprising benefits.  Overall, patients described improved well-being and satisfaction with surgery, with decreased postoperative pain, narcotic use and length of hospital stay compared to those who had not received ERAS-based care. It also had the added benefit of increasing healthcare value by decreasing healthcare costs. 

Given these impressive benefits, ERAS principles have become widely adopted by the surgical community, with the development of a new society to advocate for their adoption ( While most of this work has been done in adult patients, new efforts are now exploring such benefits in pediatric patients. On this front, Hasbro Children’s Hospital is exploring the benefits of ERAS in children. 

ERAS in Action at Hasbro Children's Hospital

As a first step, an ERAS protocol was developed for cleft palate surgery by the plastic surgery team, headed by Albert Woo, MD. Based on a similar protocol at the Children’s Healthcare of Atlanta, the preliminary results from this protocol to improve patient care have been outstanding.

So far, patients undergoing cleft palate surgery have seen at least a 90 percent reduction in the use of narcotics both during surgery as well as post-operatively. Despite this, patients have been more comfortable, with babies feeding better immediately after surgery.

Overall, this has translated to a dramatic decrease in patient hospital stays, with nearly all patients going home the day after surgery.

As a result of these extremely promising results, the plastic surgery team is beginning to employ ERAS principles in the care of virtually all their surgical patients. Similarly, Hasbro Children’s Hospital hopes to expand ERAS protocols into other surgical fields to deliver the best possible healthcare to its patients.