What is ERAS?
Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based perioperative care pathway designed to reduce the physiological stress of surgery — enabling patients to recover faster, with less pain, fewer complications, and shorter hospital stays.
Originally developed in human colorectal surgery in the 1990s by Dr. Henrik Kehlet, ERAS has been progressively adopted in veterinary medicine and is now a core component of how Dr. Morgan and the VERG surgical team approach every case.
The fundamental principle of ERAS is that recovery begins well before the patient enters the operating room and continues carefully after they go home. Every phase of the perioperative period is actively optimised — not just the surgery itself.
Pre-Operative Optimisation
The pre-operative phase begins at the time of diagnosis — not the morning of surgery. This is where some of the highest-impact ERAS interventions occur, at the lowest cost and complexity.
Modified Fasting Protocols
Traditional overnight fasting (NPO after midnight — often 12–16 hours) has been replaced with evidence-based guidelines. Prolonged fasting increases insulin resistance, causes dehydration, elevates cortisol, and increases post-operative nausea — without providing meaningful anaesthetic safety benefit.
2–4h water
Pre-Emptive Analgesia
Administering pain medication before surgery — before the first incision — significantly reduces central sensitisation ("wind-up"). This is one of the highest-impact, lowest-cost ERAS interventions. At VERG, pre-emptive analgesia routinely includes:
- NSAID (carprofen or meloxicam) given 30–60 min before induction
- Opioid pre-medication (hydromorphone or methadone) as part of the pre-med
- Dexmedetomidine for co-analgesic and sedative effects — reduces MAC of inhalant anaesthetic by 20–40%
Stress & Anxiety Reduction
Stress activates the HPA axis, increasing cortisol and catecholamines — worsening pain sensitivity, slowing healing, and increasing anaesthetic requirements.
- Trazodone prescribed the night before and morning of surgery
- Pheromone diffusers (Adaptil for dogs / Feliway for cats) in ward areas
- Admit on the day of surgery — not the night before
- Fear-Free handling and low-stress examination techniques throughout
Nutritional Assessment
Patients in poor body condition or with significant weight loss receive nutritional support before elective procedures. Protein-calorie malnutrition impairs wound healing, immune function, and increases complication rates. A body condition score (BCS) and muscle condition score (MCS) at the initial consultation identifies at-risk patients who may benefit from pre-operative nutritional intervention.
Perioperative Management — Intraoperative
The intraoperative phase focuses on minimising physiological disruption during surgery. Four pillars: opioid-sparing anaesthesia, locoregional nerve blocks, goal-directed fluids, and normothermia maintenance.
Multimodal Opioid-Sparing Anaesthesia
High systemic opioid doses cause post-op ileus, dysphoria, nausea, slow recovery, and respiratory depression. Dr. Gingold's opioid-sparing approach uses a balanced combination:
Locoregional Anaesthesia — Ultrasound-Guided Nerve Blocks
Ultrasound-guided peripheral nerve blocks are the cornerstone of ERAS at VERG. They provide dense, targeted analgesia in the surgical region for 6–18 hours — far longer than systemic drugs — while dramatically reducing systemic side effects. Dr. Gingold's area of specialty is locoregional analgesia and interventional procedures.
| Surgery Type | Nerve Block(s) Used | Duration | Benefit |
|---|---|---|---|
| TPLO / stifle surgery | Femoral + sciatic nerve block | 8–12 hrs | Dense hind-limb analgesia; patient weight-bearing sooner |
| Hip surgery / femur fracture | Femoral + sciatic or PENG block | 8–12 hrs | Reduces systemic opioid requirements 40–60% |
| Shoulder / forelimb surgery | Brachial plexus block | 6–10 hrs | Excellent forelimb anaesthesia |
| Thoracic / chest wall surgery | Intercostal blocks + epidural | 4–8 hrs | Critical for post-thoracotomy pain management |
| Abdominal / GI surgery | Epidural + incisional splash block | 4–12 hrs | Supports early gut motility; reduces ileus risk |
| Hemilaminectomy (spinal) | Epidural morphine + bupivacaine | 8–16 hrs | Excellent peri-spinal analgesia post-operatively |
Goal-Directed Fluid Therapy
Goal-directed fluid therapy replaces the traditional "give lots of fluids" approach. Over-hydration causes tissue oedema, delays gut motility, impairs wound healing, and increases infection risk.
Normothermia — Temperature Management
Hypothermia occurs in up to 80% of anaesthetised dogs without active warming. Consequences include impaired coagulation, increased surgical site infection, prolonged recovery, and cardiac arrhythmias. The VERG normothermia protocol:
- Forced-air warming blanket (Bair Hugger™) from pre-med through recovery
- Circulating warm-water mattress on the operating table
- IV fluid warmer in-line for all procedures >30 minutes
- Warm (not cold) surgical prep solutions
- Continuous rectal temperature monitoring throughout anaesthesia
Post-Operative Management
The post-operative phase is where the gains from excellent surgical technique and anaesthesia are consolidated — or lost. Early feeding, multimodal oral analgesia, and structured rehabilitation are the key pillars.
Early Feeding
Food is offered as soon as the patient is fully awake with a normal swallow reflex — typically within 2–4 hours of recovery for most procedures. Not the next morning. Early enteral nutrition: maintains gut mucosal integrity, reduces bacterial translocation across the gut wall, supports wound healing through amino acid delivery, and reduces patient anxiety and distress.
Multimodal Oral Analgesia — Discharge Protocol
Discharge protocols target multiple pain pathways simultaneously, achieving better control with lower doses of each individual drug — and fewer side effects:
| Drug Class | Example | Target Pathway | Duration |
|---|---|---|---|
| NSAID | Carprofen, grapiprant, meloxicam | Peripheral inflammation (COX pathway) | 10–14 days |
| Gabapentinoid | Gabapentin 5–10 mg/kg q8–12h | Central sensitisation, neuropathic pain | 7–14 days |
| Opioid (if needed) | Tramadol or buprenorphine | Opioid receptors — moderate-severe pain | 3–5 days |
| NMDA antagonist | Amantadine (selected cases) | Central wind-up, chronic pain prevention | 7–21 days |
Early Mobilisation
Controlled movement begins as early as 24 hours after most orthopaedic surgeries. Evidence shows that controlled early weight-bearing reduces muscle atrophy and accelerates bone healing compared to strict immobilisation. TPLO example:
Rehabilitation Referral
All TPLO, fracture repair, hemilaminectomy, and thoracic surgery patients receive a referral letter for certified canine rehabilitation therapy (CCRT). Published evidence demonstrates significantly superior functional outcomes — including faster return to normal gait, higher peak vertical force on force plate analysis, and reduced long-term OA progression — in patients receiving formal rehabilitation compared to cage rest alone.
ERAS in Orthopaedic Surgery — TPLO Example
TPLO is the most commonly performed procedure by Dr. Morgan and one of the clearest demonstrations of ERAS benefits in veterinary surgery:
| Phase | Traditional Approach | VERG ERAS Approach |
|---|---|---|
| Pre-op fasting | NPO midnight (12–16h) | Food: 6–8h; Water: 2–4h before induction |
| Pre-op analgesia | NSAID morning of surgery | Pre-emptive NSAID + opioid 30–60 min before induction |
| Intraoperative analgesia | IV opioids alone | Femoral + sciatic nerve block + ketamine CRI + dexmedetomidine CRI |
| Fluid therapy | 10–20 mL/kg/hr fixed rate | Goal-directed 5–10 mL/kg/hr, titrated |
| Temperature management | Standard blanket | Bair Hugger + warm-water mattress + IV fluid warmer throughout |
| Post-op feeding | Next morning | Same evening — 2–4h after recovery |
| Mobilisation | 8 weeks strict cage rest | Controlled leash walking from day 1; formal rehab from week 2 |
| Discharge analgesia | NSAID + tramadol | NSAID + gabapentin ± tramadol ± amantadine (multimodal) |
ERAS in GI Surgery
Gastrointestinal surgery patients are among the highest-risk for post-operative complications including ileus, dehiscence, and sepsis. ERAS principles are particularly impactful here:
| Phase | VERG ERAS Approach |
|---|---|
| Pre-op nutrition | Nutritional support if compromised; enteral or IV nutrition for malnourished patients |
| Anti-emesis | Maropitant (Cerenia) pre-op and post-op; metoclopramide CRI if high ileus risk |
| Intraoperative analgesia | Epidural morphine + bupivacaine; incisional splash block with bupivacaine; lidocaine CRI |
| Fluid therapy | Goal-directed; avoid over-hydration which delays return of gut motility |
| Early feeding | Small, highly-digestible meal offered 4–12h post-recovery (case-dependent) |
| Prokinetics | Metoclopramide or cisapride if gut motility is delayed |
| Discharge analgesia | NSAID + gabapentin; opioids reserved for severe breakthrough pain |
| Minimally invasive | Laparoscopic approach for gastropexy, splenectomy, liver biopsy wherever possible |
What ERAS Means for Your Referred Patients
When you refer a patient to VERG Brooklyn, your patient receives a higher standard of perioperative care than the surgical procedure alone. ERAS is integrated into every case — not just selected ones.
- Lower post-op pain scores — board-certified anesthesiologist (DACVAA) on every surgical case
- Ultrasound-guided nerve blocks performed by a locoregional anaesthesia specialist
- Complete anaesthetic and analgesic protocol included in every discharge summary
- Seamless continuation of multimodal analgesia at your practice — with specific drug names, doses, and durations
- Rehabilitation referral letter included for all orthopaedic and spinal cases
- Same-day or next-day imaging review for urgent cases — email [email protected]
What ERAS Means for Your Pet
Less Pain
Multiple pain pathways are blocked simultaneously — not just one. Nerve blocks, CRI drugs, and oral multimodal protocols work together so your pet is as comfortable as possible.
Faster Recovery
Clinical studies show a 20–40% reduction in hospital stay with ERAS. Your pet goes home sooner, eats sooner, and returns to normal activity faster.
Fewer Complications
Hypothermia, ileus, and wound infections are actively prevented — not just treated if they happen. Prevention is always better than cure.
A Clear Home Plan
Written discharge instructions, specific medication schedules, a rehabilitation referral, and 24/7 access to the VERG team. You are never left wondering what to do.
Further Reading & References
- ERAS Society Guidelines — erasociety.org
- Kehlet H. (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. British Journal of Anaesthesia
- Portela DA et al. Locoregional analgesia in veterinary patients. Veterinary Anaesthesia and Analgesia
- Canine Rehabilitation Institute — caninerehabinstitute.com
- Grubb T. et al. (2020) WSAVA pain management guidelines. Journal of Small Animal Practice