Authors: Ramon Abola, M.D. et al
ASA Monitor 10 2017, Vol.81, 22-25.
Ramon Abola, M.D., is Assistant Professor, Stony Brook Medicine, Stony Brook, New York.
T.J. Gan, M.D., M.B.A., M.H.S., FRCA, is Professor and Chairman, Stony Brook Medicine, Stony Brook, New York.
How can I ensure that this patient does well through today’s surgery? How can I improve the care that I provide to my patients? These are questions that we as anesthesiologists ask ourselves each and every day. Answers to these questions elucidate the role that anesthesiologists have in optimizing postoperative outcomes.
Developing enhanced recovery pathways (ERPs) and protocols is a way for anesthesiologists to improve the clinical outcomes of our patients. Enhanced recovery after surgery emphasizes a multimodal and multidisciplinary approach to management of the surgical patient.1 ERPs should be created with input from the various members of the medical care team (i.e., surgery, anesthesia and nursing) who each bring their own perspectives and expertise. Enhanced recovery protocols incorporate evidence-based best practices. Successful implementation of ERPs has been shown to decrease variability between patients, resulting in earlier return of gastrointestinal function and reductions in hospital length of stay, complications and total cost.2
During the preoperative period, a key role of the anes-thesiologist is to ensure that a patient is optimized prior to surgery. The preoperative clinic provides an opportunity for the anesthesiologist to evaluate a patient’s fitness for surgery. A preoperative anesthesia clinic evaluation was associated with a decreased risk of in-hospital mortality.3 It also facilitates patient education to improve their experience in the perioperative time period. Setting expectations allows patients to anticipate their postoperative course (e.g., the expectation of ambulation with physical therapy on postoperative day one and discharge home on postoperative day two).
During the preoperative clinic visit, anemia can be detected and treated (Figure 2). Anemia and blood transfusion are both independently associated with adverse patient outcomes.4 In a review of the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database, preoperative anemia, even to a mild degree, is independently associated with an increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery.5 Iron deficiency anemia can be treated with intravenous iron therapy prior to surgery. Alternatively, delay in surgery should be considered in elective surgery until the anemia has been corrected. Anesthesiologists under-appreciate the potential harm of preoperative anemia. Improved management prior to surgery and on the day of surgery (i.e., cell salvage, tranexamic acid) should decrease the incidence of anemia and transfusion during the peri-operative period. A simple process change such as obtaining blood tests four to eight weeks prior to surgery will provide time for appropriate management of preoperative anemia.
Preoperative malnourished patients have significantly higher postoperative mortality, morbidity, length of stay, re-admission rates and increased hospital costs.6 Patients should be routinely screened for malnutrition prior to surgery. Patients who are found to be at nutritional risk should undergo a formal nutritional assessment and receive oral nutritional supplements, or possibly enteral or parenteral nutrition. Preoperative nutritional optimization should result in fewer postoperative complications and improved patient outcomes.
Further research needs to be done to evaluate the possible beneficial role of prehabilitation prior to surgery.7 Physical exercise training programs have demonstrated an improvement in clinical outcomes in patients with medical conditions; however, it is unknown if widespread implementation of exercise programs will result in improved outcomes after surgery.8
Day of Surgery
The day of surgery presents multiple opportunities for the anesthesiologist to improve patient outcomes. A key tenet of enhanced recovery is to reduce metabolic stress and physiological derangements associated with surgery. Patients should be encouraged to drink clear fluids up until two hours prior to surgery to decrease preoperative dehydration and patient thirst. Ingestion of preoperative maltodextrin carbohydrate beverage has been shown to decrease insulin resistance in the postoperative period.9 Hyperglycemia after surgery has been associated with an increased rate of complications.10
A rational approach to fluid therapy should be adopted that assesses whether patients are fluid responsive. Noninvasive monitors that measure changes in stroke volume or cardiac output can be used to assess a patient’s response to a fluid challenge in major surgery. Fluid administration in the O.R. should aim to avoid problems associated with either hypovolemia or hypervolemia.11
Recent studies have reported the association of intra-operative hypotension with adverse patient outcomes such as myocardial injury, stroke or acute kidney injury.12 Intra-operative hypotension with a MAP of <55-65 is associated with worse patient outcomes, particularly if these events occur over a longer period of time.13,14 Modification of anesthetic technique and the use of vasoactive medications provide opportunities to keep patients out of this blood pressure range. Further research is needed to understand if avoidance of hypotension impacts the risk of myocardial injury, stroke or acute kidney injury.
Postoperative nausea and vomiting (PONV) occurs frequently and is preventable. Patients regularly rate nausea as the anesthesia adverse event they would most like to avoid. Key to management of PONV is risk-stratifying patients and then choosing an appropriate multimodal regimen for prophylaxis.15 PONV prophylaxis decreases patient length of stay in the postanesthesia care unit, improves patient satisfaction and facilitates early feeding.
Multimodal analgesia is the cornerstone for improving a patient’s postoperative pain experience. The use of non-opiate analgesics, such as acetaminophen, ibuprofen, local anesthetics, pregabalin and ketamine, can decrease or possibly eliminate the need for opioid analgesics.16 Multimodal analgesia strategy decreases pain scores, resulting in improved mobility and function.17 Reduction in opioid use should decrease the associated side effects of PONV, sedation and postoperative ileus. Regional analgesia is effective in reducing pain and opioid use postoperatively. Efforts to reduce postoperative opioid use are particularly important in light of the opioid epidemic that we are confronting, as there is increasing evidence that postoperative over-prescription of opioids may contribute to the epidemic.
A multidisciplinary approach to postoperative analgesia allows for the incorporation of competing perspectives to focus on what is best for patients. The use of regional analgesia after total knee arthroplasty illustrates this concept. For these patients, the anesthesiologist’s focus on optimal pain control may conflict with the surgeon’s focus on mobility and ambulation, key factors of patient recovery and length of stay. The use of an epidural catheter or femoral nerve block will provide excellent pain control but will also cause motor block. An adductor canal catheter represents a regional anesthetic technique that provides sufficient analgesia and preserves function of the quadriceps muscle, allowing for better ambulation.
“The emphasis on a multidisciplinary approach requires the appropriate coordination between the different care teams. Various members of the health care team may be resistant to changing their entrenched clinical practices. A key factor to a successful ERP is the ability of local team members working together to incorporate the principles and protocols within the local processes of their hospital.”
Development of an ERP allows heath care teams to evaluate their current practices. An emphasis is placed on early feeding, early mobilization and rational use of tubes and drains. Restarting a regular diet soon after surgery may decrease gastrointestinal dysfunction and decrease the need for intravenous hydration. Having patients out of bed immediately after surgery should decrease their risk of atelectasis and deep vein thrombosis. Early ambulation may require additional physical therapy or nursing staff to assist patients. Urinary catheters can be removed earlier during the hospital course and for certain surgeries could be avoided altogether. This should decrease the incidence of urinary tract infection and bladder dysfunction.
Challenges and Future Directions
There are multiple challenges when developing an ERP. The emphasis on a multidisciplinary approach requires the appropriate coordination between the different care teams. Various members of the health care team may be resistant to changing their entrenched clinical practices. A key factor to a successful ERP is the ability of local team members working together to incorporate the principles and protocols within the local processes of their hospital. The ERPs that we have developed at Stony Brook Medical Center may not necessarily integrate well into the health system of a neighboring hospital. Another challenge is the process of auditing and evaluating patient outcomes with regard to the ERP. Identification of problems or areas for improvement will require implementing new process changes.
Ideally, the auditing process can utilize the electronic medical record with the automated collection of data and meaningful patient outcomes. Traditional measures of health care quality (complication rate, hospital length of stay, re-admission rate), while important, may not necessarily represent meaningful outcomes to patients. These may include freedom from disability, return to normal function and independence. Patient-reported outcomes (PROs), measures that come directly from the patient, would allow us to capture that information. Collection of PROs will improve our understanding of recovery trajectories and allow us to understand what is truly valued by patients.
There are a number of opportunities during the preoperative, intraoperative and postoperative time period where anesthesiologists can impact patient outcomes. Creation of enhanced recovery pathway facilitates a multidisciplinary approach to the surgical patient with incorporation of evidenced-based best practices. We should move away from a certain outcome being categorized a “surgical problem” or an “anesthesia problem.” Improve-ment of all patient outcomes should be the goal for the entire perioperative team.
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