ERAS 2025–2026: The Anaesthesiologist's Guide to Enhanced Recovery

Enhanced Recovery After Surgery began as a colorectal surgery protocol in 2005. Twenty years later, the ERAS Society has published procedure-specific guidelines covering nearly every major surgical specialty. For anaesthesiologists, the challenge has been fragmentation: each guideline is written for its own surgical audience, and the anaesthetic recommendations are scattered across dozens of documents.

A 2026 systematic review in the British Journal of Anaesthesia changed that. Bornemann-Cimenti and colleagues screened all ERAS Society guidelines published between 2013 and 2025, extracting every anaesthesiological recommendation and classifying them against 45 umbrella terms. Of 39 publications, 24 guidelines were included in the final analysis. The result: a consistent anaesthesiological core does exist — eight domains that appear across guidelines with >80% consistency, plus ten more that are mostly consistent (60–80%).

How to read the tags in this guide

Strong means the panel recommends this for most patients. Recommend means it is advised where circumstances allow. Consensus reflects expert agreement where high-quality evidence is limited. New 2025 marks what entered the guideline for the first time. Emphasis Shift tracks where the philosophy changed materially. Evidence Gap marks where the recommendation is strong but the underlying evidence quality is low or very low — these are the areas most in need of local judgment and structured audit.

The universal anaesthesiological core: eight consistently represented domains

Across 24 procedure-specific guidelines published over twelve years, eight anaesthesiological domains were recommended consistently in more than 80% of guidelines. These are the domains most consistently represented across ERAS guidelines and therefore form the transposable anaesthesiological core.

The eight consistent domains identified in the BJA systematic review. These form the transposable anaesthesiological core across ERAS guidelines.

The 2025 colorectal guideline is the first full de novo rewrite since the original 2005 consensus, not a simple update. It introduces a new, more rigorous methodology and explicitly separates anaesthetic recommendations from surgical ones. The most consequential changes for anaesthesiologists involve fluid management, epidural analgesia, and cerebral monitoring.

Preoperative preparation

• Fasting: Clear fluids until 2 hours before anaesthesia; solids until 6 hours. Prolonged overnight fasting is discouraged when contemporary fasting recommendations can be safely followed.
• Carbohydrate loading: Clear carbohydrate drink the evening before and 2 hours before anaesthesia, unless contraindicated (severe diabetes, gastric emptying delay).
• Preanaesthetic medication: Routine anxiolytic premedication is not recommended; short-acting agents may be considered for specific patients. This domain was identified in the BJA review as having mixed-strength recommendations across guidelines.
• Preoperative optimisation: Anaemia correction, smoking cessation, nutritional assessment, and management of coexisting comorbidity should be completed before the day of surgery.

Intraoperative anaesthetic considerations

• Induction: Propofol or volatile induction; short-acting neuromuscular blockade with sugammadex reversal available.
• Maintenance: Volatile or TIVA; depth guided by pEEG where available. Avoid deep anaesthesia.
• Analgesia: Multimodal — paracetamol, NSAIDs (unless contraindicated), regional techniques as appropriate (TAP block, ESP block, or TEA for open surgery), and opioid rescue.
• Fluids: Goal-directed, balanced crystalloids; avoid both hypovolaemia and excessive administration.
• Temperature: Active warming to maintain ≥36°C.
• PONV: Multimodal prophylaxis for high-risk patients.

The 2025 cesarean update is the first revision of the intraoperative ERAS recommendations since 2018. It defines ten intraoperative intervention categories, all graded as strong recommendations — despite evidence quality ranging from very low to moderate. For the obstetric anaesthesiologist, the key domains are spinal hypotension prevention, antiemetic prophylaxis, multimodal analgesia, and uterotonic optimisation.

The ten intraoperative ERAS recommendations for cesarean delivery. All are strong recommendations, but note the low evidence quality underlying spinal hypotension prevention, antiemetic prophylaxis, and multimodal analgesia.

Practical interpretation: preventing spinal hypotension

A commonly used approach is prophylactic phenylephrine infusion with crystalloid co-loading, titrated to maintain maternal blood pressure. The guideline supports prevention of spinal hypotension and identifies vasopressor use and fluid management as important components, but exact dosing should follow local obstetric anaesthesia protocols. The steps below illustrate a widely used clinical approach — they are not prescriptive ERAS dosing.

Multimodal analgesia for cesarean

The ERAS guideline supports a multimodal approach including neuraxial morphine, paracetamol, NSAIDs, and opioid rescue. The specific agents and doses below illustrate a commonly used institutional approach — they are not ERAS-prescribed doses and should be adapted to local protocols and patient factors.

• Intrathecal morphine: Provides prolonged analgesia. Monitor for respiratory depression — especially in patients with obesity or sleep apnoea. Dosing per local protocol.
• Paracetamol: Scheduled dosing, per local protocol.
• NSAID: Scheduled dosing, per local protocol, unless contraindicated.
• Opioid rescue: Oxycodone or morphine for breakthrough pain. Avoid codeine in breastfeeding mothers (CYP2D6 ultra-rapid metaboliser risk).
• Dexamethasone: Serves dual purpose for PONV and analgesia; dosing per local protocol.

The cardiac surgery ERAS consensus is the newest addition to the ERAS family, developed by a multidisciplinary panel including cardiac surgeons, anaesthesiologists, intensivists, and nurses. It defines 24 ERAS measures grouped into five perioperative phases. For the cardiac anaesthesiologist, the most relevant domains are opioid-sparing multimodal analgesia, lung-protective ventilation, early extubation, and preoperative carbohydrate loading.

The cardiac ERAS bundle: what the anaesthesiologist owns

The 2026 gynecologic oncology update is the third revision of the ERAS Society guideline for this specialty. It emphasises opioid-sparing multimodal anaesthesia and introduces the concept of same-day discharge for selected patients — a significant shift from the traditional overnight admission paradigm.

Anaesthetic protocol for gynecologic oncology

• Fasting: Clear fluids until 2 hours; solids until 6 hours.
• Carbohydrate loading: As per universal core.
• Premedication: Avoid routine anxiolytics; consider short-acting agents for specific patients.
• Induction: Propofol; short-acting neuromuscular blockade.
• Maintenance: Volatile or TIVA; consider pEEG monitoring for depth.
• Analgesia: Multimodal — paracetamol, NSAID, dexamethasone, regional blocks (TAP/ESP) for open or laparoscopic procedures, opioid rescue only.
• Fluids: Goal-directed, balanced crystalloids; avoid overload.
• PONV: Multimodal prophylaxis.
• Temperature: Active warming.
• Urinary catheter: Remove as early as possible — on the day of surgery for minimally invasive surgery and no later than postoperative day 1 for laparotomy, unless contraindicated. Catheters should remain in place for 7 days in patients with elective or traumatic cystotomy or cystectomy.

The ERATIC guidelines represent the first attempt to apply ERAS principles to major trauma and polytrauma — a population with deranged physiology, unpredictable timing, and high mortality. Published in three parts in the World Journal of Surgery, the guideline covers pre-hospital care, resuscitation-room management, intraoperative care, and postoperative ICU care. Thirty-seven aspects of trauma care were considered, with 87% overall agreement on all statements after a modified Delphi process (100% agreement on 31 of the main statement sets).

Key anaesthetic recommendations for trauma

• Shortened fasting: Clear liquids up to 2 hours before anaesthesia where feasible. In the acute trauma setting, this may not be achievable — do not delay necessary surgery for fasting.
• Balanced anaesthesia: Use balanced techniques with short-acting agents; avoid excessive depth. Maintain normothermia aggressively — trauma patients are at high risk of hypothermia.
• Goal-directed fluid therapy: Avoid both under-resuscitation and fluid overload. Use appropriate haemodynamic assessment and dynamic indices where valid and applicable; interpret them in the context of the patient's ventilation, rhythm, bleeding and overall physiology. Judicious vasopressor use when hypotension persists despite adequate volume.
• Early antibiotic prophylaxis: Timed appropriately for open fractures and penetrating injuries.
• Multimodal analgesia: Opioid-sparing where possible; regional techniques may be appropriate for isolated limb trauma, but consider coagulopathy and compartment syndrome risk.
• Early nutrition: Initiate enteral nutrition within 24–48 hours in ICU patients, unless contraindicated.

The cross-specialty comparison: what differs, what doesn't

For the anaesthesiologist working across multiple specialties, the following table compares the anaesthetic recommendations across the five major guidelines covered in this guide. The universal core remains constant; the specialty-specific modifications are what change.

Cross-specialty comparison of anaesthetic recommendations across the five major ERAS guidelines. The universal core is constant; the specialty-specific modifications are what change.

The BJA systematic review: what it found, why it matters

The 2026 systematic review by Bornemann-Cimenti and colleagues is the most important ERAS publication for anaesthesiologists in the last decade. Its key findings:

• 24 guidelines published between 2013 and 2025 were included in the final analysis. Anaesthesiological involvement was identifiable in 23 of 24.
• Of 45 anaesthesiological umbrella terms, eight were consistent (>80%), ten were mostly consistent (60–80%), sixteen were mixed (20–60%), and eleven were sparse (≤20%).
• The mean AGREE II methodological quality score was 76% — highest for scope/purpose and clarity of presentation, lowest for stakeholder involvement.
• The consistent domains — multimodal analgesia, fasting, thromboprophylaxis, antimicrobial prophylaxis, nutrition, temperature management, fluid management, and surgery-specific recommendations — define the transposable anaesthesiological core.
• Domains with high consistency but mixed recommendation strength — fluid management, preoperative carbohydrate administration, and preanaesthetic medication — warrant structured local appraisal rather than blind adoption.