Sociedade ERAS e América Latina

The volume of surgeries and their complexity has been increasing steadily worldwide. In our region, this demand is not resolved in quantity or quality and the lack of register of the care process leads to great misspending of funds, time and energy from health systems and their professionals. The goal of ERAS® (Enhanced Recovery After Surgery) is to develop perioperative care and improve its recovery through research, education, auditing and implementation of evidence-based practices. Systematically registration of the care process, actions based on accurate diagnosis and, finally, audit and adjustments of the actions are the working principles common to all ERAS® protocols. The different stages of surgical care are approached by a multidisciplinary team as an indivisible process that constitutes perioperative care. This team works week by week using the ERAS Society data management system that provides a registry with variables globally standardized that allow internal audit and external comparison. The implementation of ERAS® programs in Europe and North America showed significant reductions in hospital stay, postoperative complications and costs of care. At a regional level, the ERAS® protocols have expanded to 6 countries and 10 centers with results similar to those reported in the rest of the world. A major change in perioperative care is underway in the region, and our goal is to make it available to  everyone.El volumen de cirugías y su complejidad aumenta de forma constante en el mundo. En nuestra región, esta demanda no resuelta, ni en cantidad ni en calidad de atención, además de la deficiencia en el registro del proceso de cuidado conduce a grandes desperdicios de dinero, tiempo y energía de los sistemas de salud y sus profesionales. Los objetivos de ERAS® (Enhanced Recovery After Surgery) incluyen desarrollar el cuidado perioperatorio y mejorar su recuperación a través de la investigación, educación, auditoría e implementación de prácticas basadas en la evidencia. Registrar sistemáticamente el proceso de cuidado, actuar con base en el diagnóstico y, por último, auditar y ajustar las acciones constituyen los principios de trabajo común a todos los protocolos ERAS®. Las diferentes etapas de la atención quirúrgica son abordadas como un proceso indivisible que constituye la atención perioperatoria a través de un equipo multidisciplinario. Este equipo trabaja semana a semana utilizando el sistema de gestión de datos de ERAS Society que provee un registro con variables estandarizadas mundialmente lo que permite la auditoría interna y la comparación externa. La implementación de programas ERAS® demostró, en el ámbito mundial, reducciones significativas en la estancia hospitalaria, complicaciones postoperatorias y los costos de atención. En el ámbito regional los protocolos ERAS® se han expandido estando al momento presentes en 6 países y 10 centros de atención con resultados similares a los reportados en el mundo. Un gran cambio en el cuidado perioperatorio está en marcha en la región, y nuestro objetivo, es hacer que esté disponible para todos.O volume de cirurgias e sua complexidade aumenta constantemente no mundo. Na nossa região, essa procura não atendida, nem em quantidade nem em qualidade de assistência, além de uma deficiência no registro do processo de assistência, gera grande desperdício de dinheiro, tempo e energia nos sistemas de saúde e nos seus profissionais. Os objetivos do ERAS® (Enhanced Recovery After Surgery) incluem o desenvolvimento de cuidados perioperatórios e a melhoria da recuperação por meio de pesquisa, educação, auditoria e implementação de práticas baseadas em evidências. Registar sistematicamente o processo de cuidar, atuar com base no diagnóstico e por fim auditar e ajustar os procedimentos, constituem os princípios de trabalho comuns a todos os protocolos ERAS®. As diferentes etapas do atendimento cirúrgico são abordadas como um processo indivisível que constitui o cuidado perioperatório por meio de uma equipe multidisciplinar. Essa equipe trabalha semana após semana usando o sistema de gestão de dados da Sociedade ERAS, que fornece um registo com variáveis estandardizadas mundialmente, o que permite uma auditoria interna e a comparação externa. A implementação dos programas ERAS® demonstrou, em todo o mundo, reduções significativas no tempo de internamento hospitalar, nas complicações pós-operatórias e nos custos com os cuidados. A nível regional, os protocolos ERAS® se expandiram estando neste momento presentes em 6 países e 10 centros de atendimento com resultados semelhantes aos relatados pelo mundo. Uma grande mudança no atendimento perioperatório está em andamento na região, e o nosso objetivo é que esteja disponível para todos

Perioperative Opioids - Reclaiming Lost Ground

Opium (poppy tears) has been in use since 3400 BCE, with historical writings recording its sedative, euphoric, and analgesic properties, but it was not until the 19th century that morphine was isolated, paving the way for its therapeutic use. The 20th century witnessed advances in pharmacology and molecular biology, leading to the development of many different types of opioids and the recognition and classification of opioid receptors.Analgesia is fundamental to recovery from surgery, and while opioids continue to be the cornerstone of perioperative analgesia, overreliance on these agents and their many adverse effects has led to a reevaluation of their role in modern perioperative practice. Persistent postoperative opioid use (with disordered substance use at the extreme end of the spectrum) and opioid-induced ventilatory impairment have led to a global opioid crisis that has resulted in more than 100 000 deaths per annum worldwide, a number that rises yearly.1 Persistent postoperative opioid use and opioid-induced ventilatory impairment are exacerbated by other factors, such as nonmedical opioid use and opioid diversion. While the numbers of deaths are clearly not on the scale of the current COVID-19 pandemic, regrettably, there are few signs of measures that will force mortality to recede in the near future. In addition, the financial costs for increased health care and substance use disorder treatment, lost productivity, and criminal justice interventions ran to $150 billion in the US alone in 2015.1 While the opioid epidemic may have originated in the US, it has spread to other areas of the world, with Europe having more than 1.3 million individuals with high-risk opioid use.1 Besides the modifiable risk factors (Box),2 indiscriminate use of opioids has also been fueled by aggressive marketing strategies by pharmaceutical companies and the erroneous impression that consumption of opioids for pain does not lead to substance use disorders

Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery?

There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay—LOS (75 patients in group 1—≤4 days, 68 patients in group 2—>4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre- and postoperative compliance and the subsequent complications. In uni- and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery

International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery

Background: Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. Objective: To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. Study Design: The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. Results: Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4–11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90–0.95; P\u3c.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82–0.93; P\u3c.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P\u3c.05) among low-complexity patients. Conclusion: Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation

The reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist: a joint statement by the ERAS® and ERAS® USA societies

Background: Enhanced Recovery After Surgery (ERAS) programs are multimodal care pathways designed to minimize the physiologic and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. Methods: To improve the quality of ERAS reporting, the ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. Results: The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. Conclusions: The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals

Perioperative Nutrition: Recommendations from the ESPEN Expert Group

Background and aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization

BackgroundEnhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs fora large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.MethodsExperts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1.ResultsTwelve components of preoperative care were considered. Consensus was reached after three rounds.ConclusionsThese guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations