Anesthetic Management: Issues in the Implementation of Enhanced Recovery Programs

Issues in the Implementation of Enhanced Recovery Programs

The success of ERPs depends upon the capacity of multiple stakeholders to reach interdisciplinary con-sensus. Several aspects of perioperative care, such as use of drains, dietary and activity restrictions, fluid management, and bedrest, have been part of surgi-cal “traditions” and must be significantly revised in ERPs. Patient involvement and patient and family expectations are critically important, but frequently overlooked, aspects of these programs. New surgical techniques, like transverse incisions or minimally invasive surgery, may require surgeons to acquire and perfect new skills. Similarly, the emphasis on thoracic epidural blockade or peripheral nerve blocks, pharmacological modulation of the neuro-endocrine stress response to surgery, goal-directed fluid and hemodynamic therapy, and integral involvement of a well-organized and managed APS requires an expansion of the traditional role of anes-thesia providers. Aggressive analgesia and symptom management, early ambulation and physiotherapy, early nutrition protocols, and early removal or total avoidance of urinary drainage catheters significantly change the way patients are cared for in the post-anesthesia recovery unit and on the surgical unit and require a well-organized, highly trained, highly motivated nursing staff.

Although there are published studies of suc-cessful ERPs, there are no “off-the-shelf” protocols,

and local differences in expertise, experience, and resources influence the development of such pro-tocols for each institution. Each family of similar surgical procedures requires a standardized interdis-ciplinary clinical protocol or pathway, with special-ized input from a team with experience in caring for those patients. Such an interdisciplinary team should include representatives from surgery, anesthesiol-ogy, nursing, pharmacy, physiotherapy, nutrition, and administration, and it should be responsible not only for the clinical protocol’s creation, but also for continuously monitoring its efficacy and for insti-tuting performance improvement-related protocol modifications and provider feedback as indicated by outcomes data (Figure 48–5).

The current era is one in which optimal sur-gical care requires the anesthesia provider to be part of the perioperative medicine team. The anes-thesiologist’s skill sets are essential for the success of ERPs and have potential benefits for surgical care delivery on a global basis, from preoperative evaluation and presurgical preparation to recovery and final dismissal from care. This opportunity must be seized