Canadian journal of anaesthesia = Journal canadien d'anesthésie
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The optimal management of postoperative pain using multimodal analgesia is a key component of Enhanced Recovery After Surgery (ERAS). Pain has adverse clinical implications on postoperative recovery, including prolonging the time to recovery milestones and length of hospital stay. Moreover, the ubiquity of opioids in postoperative analgesic regimens results in adverse effects, such as sedation, postoperative nausea and vomiting, urinary retention, ileus, and respiratory depression, which can delay discharge. Thus, multimodal analgesia, i.e., the use of more than one analgesic modality to achieve effective pain control while reducing opioid-related side effects, has become the cornerstone of enhanced recovery. The purpose of this review is to address the analgesic techniques used as part of multimodal analgesic regimens to optimize postoperative pain control and to summarize the evidence for their use in reducing opioid requirements and side effects. ⋯ There are continuing advancements in multimodal analgesic techniques; however, postoperative pain in general continues to be undermanaged. Furthermore, a continuing challenge in multimodal pain research related to ERAS is the difficulty in carrying out randomized trials to determine the relative importance of any one component, including analgesia.
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The Enhanced Recovery After Surgery (ERAS) program aims to combine and coordinate evidence-based perioperative care interventions that support standardizing and optimizing surgical care. In conjunction with its clinical benefits, it has been suggested that ERAS reduces costs through shorter convalescence and reduced morbidity. Nevertheless, few studies have evaluated the cost-effectiveness of ERAS programs. The aim of this systematic review, therefore, is to evaluate the claims that ERAS is cost-effective and to characterize how these costs were reported and evaluated. ⋯ In conclusion, ERAS protocols appear to be both clinically efficacious and cost effective across a variety of surgical specialties in the short term. Nevertheless, studies reporting out-of-hospital cost data are lacking. Further research is required to determine how best to evaluate both medium- and long-term costs relating to ERAS pathways while taking quality of life data into account.
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Review
Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS).
Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. ⋯ Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and "permissive oliguria" could be tolerated.
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Enhanced Recovery After Surgery (ERAS) programs have increasingly attracted the attention of clinicians who are intent on minimizing postoperative morbidity, decreasing variability in surgical care, and containing hospital costs. The purpose of this review is to discuss the relevant pathophysiology of the surgical stress response and its associated mechanisms that regulate important metabolic changes. ⋯ The implementation of a targeted ERAS program has been shown to modulate perioperative insulin sensitivity, thus improving postoperative outcomes and accelerating the return of baseline function.