Clinical bottom line
Enhanced Recovery After Surgery (ERAS) protocols represent a multidisciplinary, evidence-based approach to perioperative care that improves patient outcomes by reducing complications, shortening hospital stays, and accelerating functional recovery. Anesthesia plays a pivotal role within ERAS pathways, focusing on multimodal analgesia, opioid-sparing techniques, and optimized fluid management. Current guidelines emphasize tailoring anesthetic strategies to specific surgical populations, with regional anesthesia and goal-directed therapy as key components. Despite robust evidence supporting ERAS benefits, implementation variability and patient heterogeneity require ongoing refinement and individualized application (Batchelor et al., 2019; Cukierman et al., 2023; Venkat Sai Sashanka Kotipalli et al., 2023).
What the evidence shows
Batchelor et al. (2019) provide comprehensive ERAS guidelines for lung surgery, underscoring anesthesia’s role in minimizing opioid use, facilitating early extubation, and promoting pulmonary function. Their recommendations include preoperative education, intraoperative lung-protective ventilation, and multimodal analgesia incorporating regional blocks.
Cukierman et al. (2023) review ERAS protocols in ambulatory surgery, highlighting the importance of anesthetic techniques that enable rapid recovery and discharge, such as short-acting agents and effective nausea prevention.
Venkat Sai Sashanka Kotipalli et al. (2023) critically analyze anesthesia’s contribution to ERAS, emphasizing opioid-sparing multimodal analgesia, regional anesthesia, and hemodynamic optimization as cornerstones for enhancing recovery.
Albisinni et al. (2025) discuss ERAS implementation in radical cystectomy, noting that anesthetic management tailored to reduce stress response and improve pain control correlates with decreased morbidity.
Mancel et al. (2021) focus on regional anesthesia’s role within ERAS, demonstrating its benefits in reducing opioid consumption, improving pain scores, and facilitating early mobilization across various surgical specialties.
Ullah et al. (2026) summarize current evidence in general surgery ERAS protocols, reinforcing that anesthetic components such as goal-directed fluid therapy and avoidance of excessive sedation improve postoperative outcomes.
Caveats and uncertainty
Heterogeneity in ERAS protocol components and adherence complicates direct comparison of outcomes across studies.
Patient factors such as comorbidities and surgical complexity influence ERAS efficacy and anesthetic choices.
Limited high-quality data exist for ERAS protocols in certain surgical populations, including neonates and complex cases.
Optimal combinations and timing of anesthetic interventions within ERAS remain areas of active investigation.
Resource availability and institutional culture impact ERAS adoption and sustainability.
How this may change practice
Anesthesiologists should actively engage in ERAS pathway development and implementation, advocating for multimodal, opioid-sparing analgesia and individualized fluid management.
Incorporation of regional anesthesia techniques should be prioritized where feasible to enhance recovery.
Preoperative patient education and optimization, including smoking cessation and nutrition, should be integrated into perioperative planning.
Continuous quality improvement initiatives and protocol adherence monitoring will improve ERAS outcomes.
Collaboration with surgical, nursing, and rehabilitation teams is essential to ensure comprehensive perioperative care.