The effectiveness of the concept ERAS (Enhanced Recovery After Surgery) in patients of surgical intensive care unit

Method: For searching of the needed information and data they were used the literature sources and comparative studies from the open access and licensed database sources (Scopus, SpringerLink, Medline Complete, ScienceDirect, Web of Science, ProQuest, EBSCOhost, Wiley Online Library). The conclusions of the concrete comparative studies dealing with the conceptual effectivity of the perioperative care ERAS were analysed. On the analytical base of the gained information drawing from the accessible literature and from 8 quantitative studies published in the years 2009-2013.

Following of the ERAS protocol is advised by The European Society for the Enhanced Postoperative Rehabilitation (ERAS society) and The European Society for the Parenteral and Enteral Nutrition (ESPEN). The individual principles of the ERAS protocol are also verifi ed by the scientifi c proofs of EBM (Evidence-Based Medicine), based on the results of the randomized trials and the subsequent meta-analyses [1,[4][5][6][7]9,[11][12][13][14].
Despite of the clear scientifi c proof, the adoption of the ERAS protocol faces many problems in the workplaces all over the world. The aim of the message is, with the analysis of literature sources which deal with effectivity of the ERAS method, to describe situation of adoption ERAS protocol in the Czech Republic and to compare the traditional concept of the perioperative care with the specifi c aspects of the ERAS protocol at the intervention fi elds, which are fundamental ones.

Selective criteria
For the literature analysis, they were chosen the articles or chapters in the expert publications concerning the given problems. It was mostly about the comparative trials observing the introduction of the individual items of the ERAS concept in practice. The authors of the trials analysed the effectivity of the applied items of the ERAS concept in the observed workplaces. The analysis was aimed at the observation of the patients which underwent the demanding surgical interventions and their postoperative period spent in the intensive care clinical bed. The results drawing on the gained literature sources concerned in the concrete mainly of the early recovery of the peroral or parenteral intake, non-aggressive fl uid replacement, early removing of the nasogastric probe, non-functional drains, and catheters. The study of the expert literature was also aimed at the problems of the early mobilization. By means of the excluding criteria they were the expert articles and studies concerning the preoperative period and operation stage which take place outside of the intensive care unit and thus the individual procedures, which are characteristic for the mentioned periods were not the subject of the deeper analysis in this message.

Sources
The  For searching it was used the logical search operator and  then it was entered the various combination of the following  key words: ERAS, the perioperative care, postoperative  complications,  hospitalization  period,  surgery, fasttrack surgery, enhanced recovery after surgery, surgery, perioperative care, postoperative complications, length of hospitalization, surgery.

Selection and analysis of studies
In this way it was found all in all 77 of the expert articles from that 8 duplicate articles were immediately removed. After reading of the article annotation and verifi cation which articles will suit to our selected criteria, unused articles were removed along with unsuitable ones. The gradual removing of the expert articles according to the recommendation of PRISMA [15] shows the scheme No: 1. The expert information and data were obtained from the review articles, the original papers, the systematic reviews, the instructions, the expert analyses and results of the national survey. The literature analysis were also performed except of the above mentioned, with the eight quantitative studies (the two comparative studies, one randomized prospective study, one controlled randomized study, two meta-analytical randomized controlled studies, one prospective randomized controlled study, one randomized study), they were no qualitative studies in the article selection. The found proofs were evaluated on the hierarchic base level of the proofs, according to the authors which classify the proofs into the seven categories. The proofs of the level Ia and III were included in our overview article [16].

Results
The results are based on the analysis of the eight quantitative studies (Table 1), the next related expert information and data were gained from the overview articles, original papers, systematic reviews, instructions, expert analyses and results of the national survey.
Vlug, et al. evaluate the possible infl uence the independent determinants in their study (the female sex, laparoscopic resection, postoperative diet, forced postoperative mobilization) on the quicker recovery. [4]. Šerclová also shows in her prospective study a quicker recovery by means of introduction of the individual principles of the fast-track concept especially in the fi eld of the controlled postoperative pain and the earlier recovery of the patient´s intestinal passage [17]. The conclusions of the performed randomized controlled study identify with the above-mentioned claims. The study was published by Wang, et al. it shows the realization of the present ERAS concept which leads to the earlier recovery of the intestinal function and acceleration of the postoperative recovery [18].
The clinical randomized study focuses on length of the hospitalization period comparing the effect of traditional care against the modern procedures in the perioperative care [19]. Thanks to the ERAS protocol it was reduced the hospital stay including the expenditures connected to the stay. Varadhan Citation: Richtarova  positively evaluates not only the reduction of hospital stay but the less occurrence of the possible complication after the big-opened intestinal operations [20]. Gouvas, et al. confi rm by means of the meta-analyses of the randomized studies that following of the fast-track concept leads to shortening of the hospital stay and the patient´s safety is not jeopardized [8]. Ren, et al. in their prospective randomized controlled study pay attention to the selected aspects of the ERAS protocol and their implementation in practice, as well. It shows the better nutritive state, the less stress reactions, and the quicker recovery in the observed patients [21]. Hübner, et al. by means of the randomized study, proved the negative impact of the fl uid restriction and epidural analgesia according to the fast-track concept on the haemodynamic stability and renal dysfunction [22].

Intake per Os in postoperative period
The traditional access of the early recovery of peroral intake lies in following steps -nothing per os in the operation day, the limited amount of allowed fl uids in the 1st postoperative day, soft food diet only during the recovery of intestinal peristalsis [1,23].
For the ERAS concept it is the standard procedure now vice-versa the early recovery of peroral intake in the day of performed intervention. If we compare the traditional access to the fast-track principles than the fl uids are already served out to the patients after 2-3 hours from the performed operation, the yoghurts, bouillons, sponge cakes are served out in the evening. During the fi rst postoperative day they are served out the snack, sponge cakes, bouillons, the liquid nutritional diet, and soft food diet according to the patient´s tolerance, as well. During the second operation day it is served out soft food diet according to the patient´s tolerance again or it is fl uently changed to the patient´s standard diet regimen. It is kept a record of the portion of eaten serving, the effort towards the nutritional therapeutant's presence during the morning doctor´s round [24].
The concept ERAS was performed in the patients suffering from the colorectal cancer from the beginning, now it is also used i.e. in the oesophageal, pancreatic, and gastric operations.
It even exceeds the scope of surgery in itself and it directs to the urological, gynaecological, and obstetric fi eld [25].

Enteral probe alimentation
The enteral alimentation is the important treatment part of the patients and serving meal is one of the base competences of a nurse. The supposed insuffi cient food intake per os in the postoperative period means the indication for the enteral probe alimentation in the emergency ward in the fast-track concept.
In case the digestive system is able to admit and process the food, the patient can be nourished by means of the nasoenteral probes (the nasogastric or nasojejunal probe) or jejunostomia. The enteral alimentation by means of a probe is not the contraindication for per os intake, the patients are allowed to take the fl uids, it is about the so called "drinking round the probe".

Infusion therapy in perioperation period
It is necessary the adequate fl uid intake in the patients in the perioperative period. It is important to fi ll the fl uid volume loss in the vascular bloodstream to achieve of the normal The records looked up in the databases (n = 77) The additional records looked up in the other sources (n = 0) The records after the duplications removing (n = 69) The duplicate records (n = 8) The discarded records unsuitable to the selection criteria (n = 21) The records in the full extent which were used and utilized (n = 33) The records in the full extent evaluated as the suitable ones (n = 38) The discarded records unrelated to the deeper analysis of the message (n = 10) The verified records (n = 48) The not used and not quoted records (n = 5) The records included in the analysis (n = 25) The articles included in the qualitative synthesis (n = 0) The articles included in the quantitative synthesis (n = 8) The The insertion of the mentioned probes is associated with the higher risk of pneumonia, as well [1,3,17,26].
In case of the fast track the usage of the nasogastric probes is sharply eliminated, the probes are inserted during the repeated vomiting and signs of the gastric overpressure. It is preferred the earlier and interrupted closing of the used probe (during the gastric residual volume making < 200ml/6 hrs), for removing of the nasogastric probe it is tolerated 500ml of the residual volume /24 hrs. And vice-versa after the vaster operation interventions the nasogastric probe is used for the application of enteral alimentation. The mentioned way of the used application of enteral alimentation can be used for the period of 6 weeks at the most. For the enteral alimentation lasting more than the mentioned 6 weeks they are used the nutritional stomia (the common insertion of nutritional jejunostomia during the performed operation intervention) which enable the patient´s qualitative realimentation [27].

Urinary catheters and drains
The traditional access in the mentioned problems means the supposed benefi t for all, i.e. for the patient, nurse, and physician. For example, when the catheterized patient has not the problems concerning retention, reaching the toilet and bed pollution. The patient´s diuresis is exactly monitored. But generally, the all invasive accesses limit the patient´s mobilization and they have the important psychological infl uence, the more hoses the more ill they feel and it is associated with the patient´s unwillingness to participate in the rehabilitation procedures.
In the occupational conditions of the emergency care unit and in accordance with the ERAS concept we try for the early removing of the drain, probes and catheters which represent the infectious risk for the patient, including the movement limitation and psychological impact. It is recommended the early removing of used drains which have the minimum or no secretion at all during the last 24 hours [3,28]. If we put the question in spirit of the fast-track concept: "Does the patient still need the catheter?". We remove the urinary catheter in the 1st -3rd postoperative day in case it is not necessary to let it for the next exact monitoring of the patient´s diuresis.

Rehabilitation
According to the traditional access the patients kept the strict calm in the bed during the operation day, the patients started to sit on the 1st postoperative day and only on the 2nd postoperative day they started to walk shortly and slowly and the most of day they spent in the beds.

Discussion
In the introduction it was already mentioned that introducing of the fast track in the perioperative care leads to the patient´s recovery acceleration after the performed surgical intervention -decreasing of the perioperative stress [30,31], minimalizing of the postoperative complications [17], shortening of the hospitalization period [18,19,26,31,32], the economic benefi t [6,[20][21][22]. However, they often struggle with the traditional concept, both in the medical staff and nurse staff, as well [4,14,18,28,29].
The traditional concept of the patient´s care in the perioperative period often looks in the individual stages as follows. In the preoperative period the patients undergo some additional or missing examinations during the hospitalization which could be performed, or which should be performed in the out-patient departments. The patients are exposed to the temporary fast in the hospital as a result of the mentioned performed examinations. The dogma concerning the prohibition of food and fl uid intake from the midnight before the planned operations still persists in the most surgical workplaces [3,28,33,34]. It is still and routinely performed the mechanical pre-operation intestinal preparation [1,28]. Especially in the fi eld of the patient´s pre-operation preparation it came about the strong changes. In the many workplaces it is still common that the patient hungers for around 6-8 or more hours before the planned surgical intervention [28]. The new fi ndings show that within the preoperative preparation the patients can take the clear and sweet liquids up to 2 hours before the surgical intervention naturally providing that the gastrointestinal passage in fully functional. It is supposed that during intake of 400 ml of the such fl uids the gastric volume will be evacuated within 90 minutes [1,10,11]. The patient´s benefi t is proved in the sense of the patient´s sensation of thirst decreasing, sensation of mouth dryness, postoperative headache, mental stress and postoperative insulin resistance decreasing [9]. The physicians communicate the detailed information concerning the performed surgical intervention and postoperative course, they care of the non-aggressive fl uid intake. The non-medical health staff is responsible for the correct preparation of the operation fi eld (shaving via the electric shaver instead of the traditional shaving by means of a razor) and application of the prescribed premedication [1,3]. It also comes about the strong change as for the administration of premedication in the concept ERAS -it is often limited to the peroral administration of sedation in the evening before the planned operation only and with omission of the opiate and parasympatholytic drugs (Atropine).
The antibiotic prophylaxis is focused on the necessity of proper timing of the antibiotic application before the planned intervention, maximally 30 min. before the introduction to anaesthesia (one of the possible ways is the antibiotic application only in the operating theatre in the introduction to anaesthesia). The selection of suitable antibiotics is performed according to the place and type of the surgical intervention and the bacterial risk level is taken into account, as well [5,26].
During the operation stage it is placed emphasis on the selection of anaesthesia. The properly performed anaesthesia and analgesia decrease the stress neuro-endocrine respond of the organism to the surgical intervention [3,7,14].
Keeping of normothermia also contributes to decreasing of the perioperative blood loss and decreasing of the cardiac complications [1,20,34]. It is also placed emphasis on the  the occurrence of pulmonary complications and postoperative paralytic ileus [9,14].
The postoperative stage is focused on the early removing of present drains, probes, and catheters. It is recommended the early mobilization of the patients participating in the intensive rehabilitation procedures. The recommended rest regimen in a bed leads to the loss of muscular tissue and weakness, the pulmonary function gradually deteriorates including the risk of phlebothrombosiss [9]. The early postoperative peroral intake or early enteral alimentation positively infl uences the postoperative glucose metabolism including the nitrogen substances and it also has the favourable effect on the peristaltic recovery, i.e. it is recommended chewing of the chewing gums [11]. The introduction of the mentioned concept in practice is to seek mainly due to the patient´s benefi t. The result is not only the less occurrence of postoperative complications, the shortening of hospitalization period but also the economic consequences resulting from the lower expenditures concerning the patient´s treatment and nursing care.
Compared to the established ERAS protocol, the principles in the Czech Republic are applies less signifi cantly and their adoption faces many problems in the workplaces. It is desirable for the concept ERAS to fi nd the wider use in Czech health facilities.

Author contributions
JR, EM, IS: The concept and design, the data collection, the data analysis and interpretation, the draft of the handwriting processing, the critical fi nal proof of the handwriting, the fi nal refi nishing of the handwriting.