DREAMS of Enhanced Recovery After Surgery

By Douglas A. Colquhoun, MB ChB, from the IARS, AUA and SOCCA 2019 Annual Meetings*

The American Society for Enhanced Recovery (ASER) Review Course Lecture: Perioperative Medicine and Enhanced Recovery: Current State and Future Directions was presented jointly by Santhanam Suresh, MD, MBA, Professor of Anesthesia and Pediatrics, Northwestern University and Tong Joo (TJ) Gan, MD, MHS, MBA, Professor of Anesthesia, Stony Brook University School of Medicine. Susan Goobie, MD, Associate Professor, Harvard Medical School, hosted the session and moderated the Q&A session. The session addressed potential opportunities for implementing Enhanced Recovery After Surgery (ERAS), the value of using this method in preoperative care, and implications of these protocols in value-based care.

Dr. Suresh’s presentation focused on the application of ERAS techniques in children. To set the framework for the discussion, he traced the history of ERAS concepts, in particular in the United States and noted the 2014 formation of the American Society of Enhanced Recovery (ASER), a journal affiliate society of Anesthesia & Analgesia, the official journal of the IARS. He reviewed a number of guidelines that exist primarily in the adult population and noted that pediatric guidelines are less developed at this time.

However, in reviewing common elements across ERAS guidelines he was able to highlight a number of practice patterns, which are directly applicable to pediatric anesthesia. Additionally, he noted some of the emerging evidence in regional anesthesia in particular with pediatric populations including those undergoing spinal fusion, major abdominal surgery and pectus excavatum repair. Using the example of spine surgery, Dr. Suresh described his institution’s pectus excavatum ERAS protocol, which includes paravertebral catheters, patient-controlled analgesia (PCA), pain adjuvants and standardized postoperative follow-up with introduction and withdrawal of each modality at standardized time points.

He additionally highlighted the success such protocols have had at his institution in posterior spinal fusion, appendectomy, adenotonsillectomy and low complexity cardiac surgery. Dr. Suresh offered practical advice for implementation including use of a multidisciplinary ERAS team and starting with a small number of well-delineated procedures. He described a research agenda in pediatric patients including delineating sub-populations for which ERAS is efficacious, clarifying the role of long-acting local anesthetic agents and development of a registry for follow-up.

The second half of the session was presented by Dr. TJ Gan, who began by describing the imperative task of improving patient outcome in U.S. healthcare in light of the current expenditure. He then argued that enhanced recovery is about increasing value in healthcare. Given that major morbidity (complications) after surgery is a driver of cost and long-term outcome in this population, developing interventions, which are about preventing this, are key. Recognizing that good outcomes interventions emerge from multidisciplinary collaborations, Dr. Gan explored the benefits of particular elements of these protocols: pre-operative carbohydrate-loading, preoperative nutritional assessment, opioid minimization, multimodal pain management, minimally invasive surgery, early nutrition and avoidance of delirium.

Collectively, he suggested that a good surgical outcome could be thought of based on the acronym DREAMS (Drinking, Eating, Analgesia, Mobilizing and Sleeping). A good enhanced recovery program will result in improvement in each domain. Dr. Gan outlined that rollout of ERAS protocols have been shown to, and should be expected to upon implementation, result in a decrease in length of stay, complications, variability, and cost as well as the promotion of teamwork across disciplines.

The Q&A session included discussion of practical surgical engagement via the use of champions and development of long-term relationships and robust outcome ascertainment at time of roll out of the protocols, advanced regional anesthetic techniques and the role of postoperative sleep in patient recovery.

*Coverage from the ASER Review Course Lecture: Perioperative Medicine and Enhanced Recovery: Current State and Future Directions during the IARS 2019 Annual Meeting