Reconciling Personalized and Protocolized Perioperative Care: Lessons Learned and Paths Forward

Uday Agrawal, MD

How do we synthesize the standardization of enhanced recovery after surgery (ERAS) protocols with an increasing emphasis on personalized care, especially in the perioperative setting? In particular, how can we successfully identify and treat patients at high risk for transitioning from acute to chronic pain following surgery? During this symposium, “Personalization and Protocolization in the Perioperative Period: Are they Antithetical, or Can They Work Together?,” on Saturday, March 22, during the 2025 Annual Meeting, presented by IARS and SOCCA, Girish Joshi, MBBS, MD, FFARCSI; Kristin Schreiber, MD, PhD; and Hance Clarke, MD, PhD, FRCPC, explored these seemingly contradictory approaches to patient care and ultimately landed on a satisfying conclusion that draws from the lessons learned from ERAS protocols while tailoring specific care to the individual patients in front of us.

Dr. Joshi, Professor in the Department of Anesthesiology and Pain Management at the University of Texas Southwestern, opened the session with his talk entitled, “Protocolization Enhances Compliance with ERAS Pathways.” He explored how traditional perioperative medicine is siloed, fragmented, and often uncoordinated, and this suboptimal model paved the way for ERAS protocols which were foundational in establishing principled approaches to patient care based on the surgeries they underwent. Despite demonstrated improvement in several patient outcomes, he noted that compliance with ERAS protocols remains low. Dr. Joshi argues that part of the inertia in adopting ERAS stems from challenges in implementation and perhaps more intriguingly, a flawed interpretation of evidence. He, for example, points out that while often considered the premier level of evidence, meta-analyses are subject to misinterpretation given the grouping of multiple heterogenous conditions. He also makes the compelling case that the definition and implementation of “multimodal analgesia” across multiple studies is quite variable and as a result the conclusions from these large trials are difficult to interpret. He advocates for simplicity of ERAS protocol design to help improve compliance, overall patient care, and future study design.

Dr. Schreiber, Endowed Chair and Associate Professor in Anesthesiology at Brigham and Women’s Hospital, followed Dr. Joshi with her lecture, “Shifting the Focus to the Patient: Using the Biopsychosocial Model to Understand Pain Variability and Detect Differential Efficacy of Preventive Interventions.” She discussed how psychosocial influences such as comorbid psychiatric disease, sleep disturbances, or even social supports, isolation, and cultural beliefs impact perception of pain and was able to create a “pain phenotype” for patients undergoing surgery.

Using these pain phenotypes, she was able to identify biomarkers for predicting which patients were at risk for developing chronic pain and provided insight for which patients may benefit from particular interventions. For example, she found patients who are more prone to catastrophize benefited from an open-label placebo trial far more than patients who did not, suggesting that her pain phenotypes can be used to tailor personalized therapy. She also extended the findings of the OPPERA study in a completely separate patient population and found strikingly similar phenotypes, suggesting that her classification of patient factors that contribute to pain is generalizable across surgical interventions. Overall, she presents an important focus on personalized care and how to optimize preoperative interventions specifically for patients who are at highest risk.

Dr. Clarke, Director of Pain Services and Medical Director of the Pain Research Unit at the Toronto General Hospital, President of the Canadian Pain Society, and President of the Canadian Consortium for the Investigation of Cannabinoids, closed the session with his talk on “Switching from Procedure-Based to Person-Based ERAS Protocols: Can It Be Done.” He began with the thought-provoking question, “Where do protocols fail?” and discussed his inspiring work growing the translational pain service at his home institution to accumulate evidence to support at-risk patients.

He found that there are several risk factors that predict the development of chronic postsurgical pain, and proposed that ERAS protocols fail to adequately address the needs of these heterogeneous patients at higher risk. He noted that the ERAS model of one size fits all in fact does not work, and personalized care must extend beyond medication to include physiotherapy, occupational therapy, and psychological intervention. He described fascinating work developing a preoperative patient education platform which by itself demonstrated promise in improving patient care (check out some of the work here) and also presented soon to be published work using machine learning models to help predict the risk for transitioning from acute to chronic pain.

Dr. Joshi, Dr. Schreiber, and Dr. Clarke presented strong arguments that while ERAS protocols were a foundational effort to advance perioperative care, and still have a role in perioperative medicine, the future of anesthesiology involves integrating personalized approaches targeted to individual patients. Their work helps outline the importance of ongoing research in this field and adapting modern practice using the tools they helped to create.