Evolution of Enhanced Recovery Programs

Evolution of Enhanced Recovery Programs

Despite increasing numbers of surgical patients who present with complex surgical problems and numerous medical comorbidities, major advances in surgical and anesthetic management have pro-gressively decreased perioperative mortality and morbidity. Further improvement in perioperative outcomes, highlighted by accelerated postopera-tive convalescence and decreasing occurrence of perioperative complications, will depend on con-tinued evolution of an integrated, multidisciplinary team approach to perioperative care that requires adjustments in multiple aspects of care, including surgical and anesthetic techniques, nursing care, physiotherapy, and nutrition support. The goal is to combine individual evidence-based elements of perioperative care, each of which may have modest benefits when used in isolation, into a tightly coor-dinated effort that has a synergistic, beneficial effect on surgical outcomes.

Such coordinated, multidisciplinary periopera-tive care programs are termed enhanced recovery pro-grams (ERPs), fast-track surgery, or enhanced recovery after surgery (ERAS) (Figure 48–1). A well-functioning ERP uses evidence-based practices to decrease variation in clinical management, minimize organ dysfunction, and accelerate conva-lescence (Figure 48–2). Although many publications in the surgical literature have highlighted the positive impact of such programs on surgical outcomes, reports documenting the role of anesthesia and anal-gesia in these programs are few. Another challenge is determining how to assess the impact of anesthetic management on outcomes in an ERP. Hospital length of stay is the most commonly used measure of suc-cess, but in many systems timing of hospital dis-charge is more directly related to administrative and

organizational issues than to discrete milestones in the patient’s postoperative recovery. Little research has been undertaken to define the process of postop-erative recovery, and few outcome measures are currently available to confirm that postoperative recovery has been accomplished for a given surgical disease. Other measures of successful implementa-tion of ERPs are reduced readmission and complica-tion rates.

It is logical to assume that more effective anes-thetic interventions will reduce pain, facilitate ear-lier postoperative mobilization, and allow earlier resumption of oral feeding. In this context, the role of the anesthesia provider must evolve from merely providing satisfactory anesthetic conditions throughout the operation to a focus on enhancing overall perioperative care through techniques that shorten postoperative convalescence and reduce the likelihood of perioperative complications. These goals can be achieved by optimizing the patient’s preoperative condition, by ablating the adverseeffects of the intraoperative neuroendocrine stress response, and by providing pain and symptom control to facilitate the postoperative recovery. In endeavoring to do so, the anesthesiologist must become a perioperative physician and an active par-ticipant in the surgical team.

The problem of persistent postsurgical pain, defined as chronic pain that continues beyond the typical healing period of 1–2 months following surgery—or well past the normal period for post-operative follow-up by anesthesia providers—is increasingly acknowledged as a common and sig-nificant issue following surgery. The incidence of persistent postsurgical pain may exceed 30% after some operations, especially amputations, thora-cotomy, mastectomy, and inguinal herniorrha-phy. Although the cause is unclear, several risk factors have been identified ( Figure 48–3), and aggressive, multimodal perioperative pain control is often suggested as a fundamental preemptive strategy.