Dissecting the Perioperative Care Bundle

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Key points

  • Enhanced recovery after surgery (ERAS) has been shown to be safe and effective, improving outcomes and decreasing length of stay after major abdominal surgery.

  • Individual components of ERAS bundles have varying levels of supporting literature, and it is often difficult to dissect out their true contributions.

  • Nonnarcotic agents to assist with pain control are integral to the success of an ERAS pathway.

What is enhanced recovery after surgery and how does it work?

In the 1990s, the Danish surgeon Dr Henrik Kehlet postulated that the surgical stress response induced widespread physiologic changes that increased demand on various organ systems, thereby increasing the risk of postoperative morbidity.9 Subsequent research expanded on this idea and examined the various biological cascade systems and metabolic pathways involved in maintaining homeostasis.2 From here, various points of intervention were identified, and this ultimately led to the development of

Outcomes

ERAS protocols are designed to tackle several factors that prolong a patient’s recuperation period after surgery. Interestingly, no single item included in ERAS protocols can be identified as the major contributor to reduction of perioperative morbidity or mortality29; this is inherent in the way these protocols were developed—as multimodal care “bundles,” which generate cumulative benefit from those interventions that when taken individually, produce only marginal gains,30 and this creates

Controversial components of typical enhanced recovery after surgery bundles

Although mounting evidence supports adaptation of ERAS protocols, the individual components of these protocols are under increasing scrutiny not just for their beneficial contributions but also for any associated adverse effects. Areas of controversy include the usage of nonsteroidal antiinflammatory drugs (NSAIDs) due to their association with anastomotic leak, gabapentanoid administration in the elderly patient, prophylactic placement of thoracic epidural catheters for pain management,

Areas of further study

The number of studies demonstrating the advantages of ERAS pathway care for surgical patients continues to grow. The original concept of bundled care creating positive outcomes that are amplified beyond the sum of the individual components holds firm. However, these care pathways must be continuously examined for areas of improvement, omission, and addition, concurrent with developments in each of the treatment phases. Advances in pain management, surgical practice, and pharmacology, plus

Promising additions to enhanced recovery after surgery protocols

Further iterations of ERAS protocols will potentially make use of ileus-reducing medications. Two such medications have been prescribed for years in selected cases: alvimopan and methylnaltrexone.

Alvimopan is a mu-receptor antagonist that has shown reduced rates of postoperative ileus, with faster return of bowel function and shorter hospital stay.64, 65, 66, 67, 68 The effect is most pronounced after open surgery. Cost, which can be upward of $170 per pill, remains the main drawback of using

Summary

Ongoing examination of the individual components of ERAS protocols may be inherently complicated by the nature of how these care bundles are proposed to work. The efficacy and contribution of each component to the patient’s overall well-being may be vague and difficult to quantify in relation to each other. However, as ERAS protocols gain traction across disciplines and health systems, ongoing examination of the various elements of the protocols and their utility in varying contexts will be

Clinics care points

  • The traditional NPO after midnight has been supplanted by clear liquids until 2-3 hours prior to surgery.

  • Minimally invasive approaches should be utilized whenever possible to enhance recovery.

  • It remains controversial if NSAIDS contribute to anastomotic leak.

  • Gabapentanoids should be avoided/minimized in the elderly due to the risk of somnolence.

  • Oral antibiotics with (or without) mechanical bowel preparation is recommended to reduce SSI.

  • Regional nerve blocks and/or epidurals can serve as adjuncts

Disclosure

The authors have nothing to disclose.

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