Anaesthesiology Clinical Pharmacology

ERAS – The dawn of a new era! Ramachandran Gopinath, Kumar G Belani Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):1-2

Enhanced recovery after surgery Neerja Bhardwaj Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):3-4

Enhanced recovery after surgery: An anesthesiologist's perspective Srilata Moningi, Abhiruchi Patki, Narmada Padhy, Gopinath Ramachandran Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):5-13 Enhanced recovery after surgery (ERAS) protocols are a combination of multimodal evidence-based strategies, applied to the conventional perioperative techniques, to reduce postoperative complications and to achieve early recovery. These strategies or protocols, require a dedicated and organized team effort for their implementation to enable early discharge and thus reduce the length of hospital stay. Anesthesiologists play an important role in facilitating these protocols as some of the key elements such as preoperative patient preparation and assessment, perioperative fluid management, and perioperative pain relief are handled by them. This article discusses in detail the various components of ERAS and the anesthesiologist's role in implementing them.

Preoperative patient preparation in enhanced recovery pathways Usama Iqbal, Jeremy B Green, Srikant Patel, Yiru Tong, Marcus Zebrower, Alan D Kaye, Richard D Urman, Matthew R Eng, Elyse M Cornett, Henry Liu Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):14-23 Enhanced recovery pathways are a novel approach focused on enhancing the care of surgical patients. “Prehabilitation” is the term applied to any intervention administered before surgery to reduce surgery-related morbidity, decrease the length of hospital stay, expedite the return of organ function, and facilitate the patient's return to normal life. A PubMed search was performed with the following key words: enhanced recovery, preoperative preparation, cessation of smoking and euvolemia. The results from this Pubmed search revealed that female patients may have higher levels of anxiety than male patients. Intensive smoking and alcohol cessation 6–8 weeks before elective surgery may reduce the incidence of postoperative morbidity. Preoperative exercise can be effective for reducing the postoperative complications like pulmonary complications and shortening the length of hospital stay. It is safe to allow patients to drink clear fluids up until 2 h before elective surgery (Level II evidence). Perioperative normoglycemia is the single most important factor to prevent surgical site infection. Intermittent pneumatic compression devices and low molecular weight heparin are effective in preventing postoperative thromboembolism. No advantage is gained by preoperative mechanical bowel preparation in elective colorectal surgery. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. Mild perioperative hypothermia may promote surgical wound infection by triggering thermoregulatory vasoconstriction, which decreases subcutaneous oxygen tension.

Implementing enhanced recovery pathways to improve surgical outcomes Shilpadevi Patil, Elyse M Cornett, June Jesunathadas, Kumar Belani, Charles J Fox, Alan David Kaye, Lee A Lambert, Richard D Urman Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):24-28 An enhanced recovery pathway is a structured perioperative healthcare program that incorporates evidence-based interventions including protocols and guidelines with the aim of providing standardized care. Enhanced recovery pathways can help maintain operating room safety and efficiency, improve postoperative recovery and a variety of important patient outcomes, and reduce overall costs of patient care following major surgery. Postoperative complications are minimized, which, in part, are attributed to adjustments in fasting and postoperative nutrition, interventions aimed at improving early mobilization, and careful selection of pharmacological agents for anesthesia and analgesia. Major surgery can lead to a variety of physiological stressors including organ dysfunction, and hormonal and neurological disturbances. The current notion of fast-tracking (bypassing phase I recovery level of care) differs from enhanced recovery pathways as the principles of enhanced recovery pathways are often applied to inpatient and complex procedures and span the entire spectrum of patient care. Also, enhanced recovery pathways programs are being used for pediatric patients especially with the hope of minimizing opioid exposure and the quality of recovery. A PubMed literature search was performed for articles that included the terms enhanced recovery pathways to improve surgical outcomes. In this article, we summarized the clinical application of enhanced recovery pathways and highlighted the key elements that characterize implementing an enhanced recovery pathway in surgery.

Goal-directed fluid therapy in the perioperative setting Julia B Kendrick, Alan David Kaye, Yiru Tong, Kumar Belani, Richard D Urman, Christopher Hoffman, Henry Liu Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):29-34 Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a “zero-balance” approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications.

Enhanced recovery pathways in orthopedic surgery Alan David Kaye, Richard D Urman, Elyse M Cornett, Brendon M Hart, Azem Chami, Julie A Gayle, Charles J Fox Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):35-39 The enhanced recovery after surgery (ERAS)©concept, sometimes referred to as “fast track”, “accelerated,” or “Rapid Recovery” surgery, was first introduced in 1997. The concept of ERAS targets factors that delay postoperative recovery such as surgical stress and organ dysfunction. ERAS protocols or programs are a care package of evidence-based interventions used in a multimodal and coordinated clinical care pathway. They represent a multidisciplinary approach directed to reducing postoperative complications, shortening length of hospital stay, improving patient satisfaction, and accelerating recovery. ERAS was initially centered on abdominal and colorectal surgery patients; however, ERAS protocols have been widely extended to include other specialties. Orthopedic surgery, particularly elective hip and knee arthroplasty is one of such areas where ERAS principles have been adopted. It has been associated with reduced length of hospital stay, readmission rate, and improved functional recovery. The common interventions used in orthopedic ERAS programs have been divided into those performed in the preoperative, intraoperative, and postoperative phases of care. A PubMed literature search was performed for articles that included the terms enhanced recovery and orthopedic surgery. In this article, we summarized the clinical application of ERAS and highlighted the key elements that characterize an enhanced recovery program.

Multimodal analgesia as an essential part of enhanced recovery protocols in the ambulatory settings Alan David Kaye, Richard D Urman, Yury Rappaport, Harish Siddaiah, Elyse M Cornett, Kumar Belani, Orlando J Salinas, Charles J Fox Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):40-45 Enhanced recovery after surgery protocols are multimodal perioperative care pathways designed to achieve early recovery in patients after surgical procedures by defining and maintaining preoperative organ function and minimizing the profound stress response following surgery. Enhanced recovery protocols have primarily been studied for major abdominal surgeries, however, the knowledge acquired from studying these protocols has facilitated treating patients in ambulatory settings. The key components of enhanced recovery protocols include preoperative counseling, preoperative nutrition, altering the standard perioperative fasting guidelines, and the value of carbohydrate loading up to 2 hours preoperatively, standardized analgesic, and anesthetic regimens (epidural and nonopioid analgesia) and early mobilization. A PubMed search was performed with the following key words: multimodal analgesia, enhanced recovery, ambulatory care, pain management, and opioids. We discuss the use of enhanced recovery protocols and multimodal pain care plans in the ambulatory setting.

Perioperative surgical home models and enhanced recovery after surgery Amir Elhassan, Ihab Elhassan, Amjad Elhassan, Krish D Sekar, Elyse M Cornett, Richard D Urman, Alan David Kaye Journal of Anaesthesiology Clinical Pharmacology 2019 35(5):46-50 In recent years, numerous initiatives have been introduced to address changes in health-care costs, delivery methods, reimbursements, and the health-care needs of our aging population. The American Society of Anesthesiologists (ASA) defines the Perioperative Surgical Home (PSH) as a patient-centric, team-based model of care to help meet the demands of a rapidly approaching health-care paradigm emphasizing value, patient satisfaction, and a reduction in costs. Enhanced recovery pathways were initially established by a group of surgeons from Europe who formed a research group with the aim to explore the ultimate care pathway for patients undergoing colonic resections. Similar protocols were later expanded to various surgical specialties with promising outcomes. A PubMed and World Wide Web search was performed with the following key words: “ERAS®,” “enhanced recovery after surgery,” “PSH,” “perioperative surgical home,” “protocols,” “outcomes.” Articles found were published over a 20-year time range (1997-2017). In the present investigation, the most common elements of enhanced recovery protocols are reviewed. Review of how existence of a PSH model facilitates the creation of an enhanced recovery protocol and improves cost-efficiency, patient satisfaction, and clinical outcomes observed in enhanced recovery studies that are applicable to health-care systems universally is described.