Enhanced Recovery Protocol Elements: What Is the Level of Evidence?

It’s the first day of the IARS Annual Meeting in Chicago!

We’re starting out with some of the most hotly debated arguments for those focused on enhanced recovery in surgical patients. Specifically, we dived into peri-operative nutritional status assessment, peri-operative fluid management, preventing post-operative ileus, and measurement of outcomes and quality in enhanced recovery pathways.

Dr. Paul Wischmeyer, of the Duke University School of Medicine and Duke Clinical Research Institute, focused our attention on pre-operative nutrition and asked the vital questions, What can do better? Should a malnourished patient ever have surgery? Research certainly supports malnutrition increases the risks of post-operative complications and has a big impact on outcomes. Also, the pre-operative nutrition care pathway and Nutrition SIX are tools we could easily work into our everyday practices.

Also from the Duke University School of Medicine, Dr. Julie K. Marosky Thacker focused our attention on the post-operative gastrointestinal dysfunction and how I-FEED scoring treatment algorithm is a valid system for the management of patients with impaired post-operative GI function according to the clinical presentation of the patient in real time. She strongly reminded us that we need to keep in mind less opioids are better and advised not to forget Alvimopan!

Dr. Timothy E. Miller not only represents the Duke University School of Medicine but is president-elect of American Society of Enhanced Recovery and an associate editor of Anesthesia & Analgesia. Dr. Miller faces a never-ending debate around pre-operative fluid management. He argued successfully that peri-operative fluid management is important – and here are his three most important points:

• Both hypovolemia and excessive fluid administration are associated with harm.
• Prolonged fasting before major abdominal surgery is not justified and is not supported by evidence.
• Goal-directed fluid therapy aims to replace losses from the circulation and to optimize stroke volume throughout the peri-operative period. Goal-directed fluid therapy has been shown to reduce hospital length of stay and complications after major surgery.

Closing out the Panel was Dr. Elliott Bennett-Guerrero from Stony Brook School of Medicine talking about patient reported outcomes. He asks:

What is the patient telling us? Health care quality of life is composed of various physical, mental, and social domains, which are measured by PROMs.

What are their feelings? Positive outcome measurements that come directly from the patient without interpretation from the health care team, and can be categorized into outcomes, outcome measures, or performance measures.

References:

1. Wischmeyer PE, Franco C, Evans D, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. Anesth Analg 2018; Published Ahead of Print; DOI: 10.1213/ANE.0000000000002743
2. Abola RE, Bennett-Guerrero E, Kent ML, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Patient-Reported Outcomes in an Enhanced Recovery Pathway. Anesth Analg 2018; Published Ahead of Print; DOI: 10.1213/ANE.0000000000002758