The World Congress on Enhanced Recovery 2015 Conference Summary

From May 9 to 12, 2015, The World Congress on Enhanced Recovery was held in Washington, DC, with the collaboration of the newly formed American Society for Enhanced Recovery, Enhanced Recovery After Surgery Society for Perioperative Care (The ERAS® Society), and Evidenced Based Perioperative Medicine (EBPOM). A total of 512 attendees from 34 countries participated in this 4-day conference, which featured 36 speakers and 87 poster presentations. Representing the individual societies were Dr. Tong Joo (TJ) Gan (American Society for Enhanced Recovery), Dr. Olle Ljungqvist (ERAS Society), and Dr. Monty Mythen (EBPOM). The scientific chairs presented an overview of the enhanced recovery (ER) concept by describing the ER “wheel” in which multiple elements from various members of the health care team are needed to successfully implement an ER program. These elements include patient education, preoperative nutrition, fluid management, multimodal analgesia, early oral intake, and early mobilization. The purpose of implementing ER is not simply to expedite recovery but to improve overall quality of care. In successive presentations by various speakers (see Appendix 1), the importance of the ER team (the surgeon, the anesthesiologist, the nurse, and the patient themselves) was discussed. An entire day was devoted to an ER workshop, which was attended by >150 delegates. After the workshop, a series of 8 individual sessions were conducted, which covered the full depth and breadth of the different ER components. Session 1 of the conference focused on organizing the hospital for an ER program. Dr. Arthur Revlang focused his talk on fighting old dogmas (replacement of third space fluid loss, preoperative fasting guidelines, the universal use of mechanical bowel preparation, routine nasogastric, and abdominal drainage). The importance of identifying new knowledge that may refute old practices was highlighted. Ms. Dorthe Hjort (registered nurse) highlighted that educating members of the ERAS team (nurses, physician assistants, and physicians) is crucial and must be done repeatedly to ensure that all the members are compliant with their role in the process. Examples include preoperative education on smoking cessation, adequate nutrition, adoption of preoperative carbohydrate drink, and zero balance intraoperative fluid therapy. In addition, outpatient counseling via phone calls or visits is pivotal to ensuring patient recovery after discharge. Finally, facilities must focus on equipment that promotes early ambulation such as a bed that folds into a chair. This would promote ambulation although clinical trials demonstrating benefits have yet to be conducted. Dr. Ljungqvist discussed the pitfalls and successes of the ERAS implementation by presenting the ERAS Society Implementation Program that has been used successfully in several countries in Europe, North America, and more recently also starting up in other continents. However, with a promising outcome and wide dissemination of successes, ERAS programs are still not widely practiced in the United States. The obstacles to ERAS implementation lie significantly on compliance. Resistance to changing old practices is a challenge as well. However, many centers that claim to implement the ERAS protocol do not conduct formal audit to ensure all elements are followed; thus, the beneficial effects are not achieved in these circumstances. Most centers that claim to practice ERAS cannot provide data on compliance. The 4 important elements of a successful ERAS program are (1) integration in which all of the health care workers own and integrate the care of the patient, (2) local leadership that consists of a clinical medical lead and an ERAS coordinating nurse, group workshops, etc., (3) an audit tool, which allows capture of data that can identify any element that is not being implemented, and (4) the international network of expertise that develop, update, and help implement the Enhanced Recovery Guidelines. Session 2 of the conference focused on outcomes. Dr. Roy Soto spoke about the specific need for group and individual performance benchmarks. Examples include a low incidence of postoperative nausea and vomiting and severity postoperative pain, complication rate, and length of stay (LOS). Ms. Deobrah Watson (registered nurse) described the nurse’s perspective, focusing on the 3 phases of recovery: the postanesthesia care unit (PACU), the ward, and the community, as well as the need to bridge the gap between the ward and the community through availability of a telephone number and the creation of an ERAS community nurse for follow-up. Ms. Tracy Wasylak, Vice President of Strategic Clinical Network Alberta Health Systems, spoke about how the ERAS Society Implementation Program allows the same amount of money being spent on a patient as a non-ERAS program, but there is a greater value (decrease in complications and faster recovery) and substantial savings (decrease cost to the patient and hospital secondary to decrease hospital LOS, decrease readmission, and follow-up from complications). Ms. C. Canfield spoke from the patient’s standpoint, having had a family member die in the hospital after a routine excision of a lower extremity sarcoma. The importance of coordination of care was emphasized. The ERAS Society Henrik Kehlet Lecture was presented by Dr. Anthony Senagore, Parma, Ohio, on The Economics of ERAS. The main message is that ERAS saves costs. The ERAS Society Lecture on Physiology was delivered by Dr. Sreekumaran Nair, USA, on ageing, and its impact on recovery with the main message that the capacity to improve physical function remains with advancing age. Individuals at all ages, not just young patients, have the ability to improve their physical function through exercise training protocols. Session 3 consisted of 6 best abstracts out of the total submitted to the ERAS congress. Session 4 featured a presentation of the ERAS guidelines for gynecology and bariatric surgery. In both types of surgeries, it is important to optimize the patient’s health preoperatively, ensure euvolemia, avoid alcohol and smoking for 4 weeks, initiate carbohydrate loading, avoid anxiolytics, and institute multimodal postoperative nausea and vomiting (PONV) with >2 antiemetic drugs, using nonemetogenic anesthetics (i.e., propofol/total intravenous anesthesia [TIVA] technique) and regional techniques. Another highlight of the World Congress was session 5, which discussed “hot” topics in ERAS. Internationally renowned expert in ER, Dr. Henrik Kehlet, led the session describing the future challenges in ERAS. Dr. Kehlet described how high-dose steroids have shown promise in the decreasing of pain, PONV, and fatigue. In a fully developed ERAS program, immune function should be better than in the non-ERAS population, but there are very few studies that have fully implemented the ERAS programs. One area of interest is postoperative orthostatic intolerance, which prevents patients from initiating rehabilitation therapy. This is not a problem of fluid or general anesthesia but rather likely related to the synpathovagal response, which may be related to heart rate variability. In terms of delirium, the data have shown that on postoperative day 1, the patient does not experience rapid eye movement sleep. However, administration of a sleep aid such as zolpidem, although not producing rapid eye movement sleep, does result in less fatigue, better sleep quality, and less arousals. In terms of blood management, 3 strategies were described: optimize preoperative hematocrit, minimize blood loss, and optimize patient’s response to anemia. The postdischarge outcome is often subjective, but there is a dire need for objective end points for determining postdischarge outcomes. Dr. Lawrence Lee’s lecture focused on 3 phases of recovery: early (from operating room to the patient ward, inclusive of PACU stay), which is measured by biologic and physiologic markers, intermediate (which is the time in the hospital from the end of the PACU stay to the end of the hospital ward stay), which is defined by the activities of daily living, and late (which is from when the patient leaves the hospital to when they return to baseline and is determined by the function and quality of life). Thus far, we have been measuring inappropriate outcomes, and there is a need to develop core outcome sets. For example, many institutions measure hospital LOS as a “core outcome” of assessing the efficacy of the ERAS program. However, the discharge criteria from patients undergoing surgery vary from hospital to hospital. Thus, rather than measure “hospital LOS,” programs should measure pain relief (as evidenced by patient self-reporting and ingestion of oral pain meds), time to oral intake, attainment of certain physical milestones, and baseline activities. Dr. Nicolaus Demartines rounded out the session discussing ERAS in emergency surgery. In a true emergent situation, certain elements of ERAS such as patient education and carbohydrate loading cannot be done, but other aspects, which can be done such as PONV prophylaxis, is often excluded. PONV prophylaxis includes avoidance of emetogenic drugs and administration of antiemetic drugs. Of note, the compliance during the postoperative phase of patient care to an ERAS protocol may be the lowest from an anecdotal standpoint, resulting in the LOS of 8 days in patients who undergo “emergency” surgery (within the ERAS pathway) versus 5 days in patients who undergo nonemergency surgery (within the ERAS pathway). Sessions 6, 7, and 8 focused on the patient’s condition, the great world fluid debate evidence, and contentious points, as well as findings from large multicenter perioperative clinical trials. Dr. Gan reviewed non-opioid adjunctive analgesia to reduce opioid-related side effects, such as postoperative ileus, nausea and vomiting, and urinary retention. Dr. Franco Carli presented data on preoperative habilitation (or prehabilitation) to better prepare patients for surgical trauma and the management of physiologic and psychologic stress of surgery. Dr. Andrew Shaw spoke on the topic of the future of perioperative medicine in the United States and predicted that genomics will be increasingly used to predict the risk of perioperative outcomes. Dr. Paul Myles from Australia who had conducted a number of large international clinical trials presented a topic entitled “Big trials—what we know and what is in the pipeline?” where he reviewed recent and ongoing large perioperative trials. The main points from the colloid debate were that physiologically colloids have been shown to stay in the circulation longer than crystalloids, and therefore, as a physiologic concept colloids should be superior to crystalloids for the treatment of hypovolemia. However, there is no clinical evidence from outcome studies that colloids are superior to crystalloids. Perioperatively, there is no evidence of harm or benefit with colloids. The consensus in the debate was that colloids are probably overused currently, but they still have a place as an option when plasma volume expansion is needed. The main points from the goal-directed fluid therapy (GDFT) debate were that GDFT has been shown to decrease hospital LOS and complications after major surgery. However, in the setting of a “good” ER program, this benefit may be less in magnitude than in older studies when crystalloid excess in the control group was the norm. The consensus of the debate was that GDFT should be considered based on institutional, surgical, and patient factors. In top performing programs, GDFT have been adopted in all patients. However, some recent studies have not shown a reduction in LOS when GDFT was universally adopted in an ERAS setting. In conclusion, the speakers agreed that a properly instituted ER program does lead to the delivery of a higher quality care and a decrease in complication rate in patients. Elements of such a program should include proper coordination of care between anesthesia, surgery, nursing, and the patient. The importance of education for both the staff and the patient cannot be understated. Patients should be allowed to drink clear liquids up to 2 hours before surgery, and carbohydrate loading may be beneficial. Multimodal pain management with opioid adjuncts and multimodal PONV reduction strategies are important. However, despite the presentation of guidelines and promising data from around the world, challenges remain, which include ensuring proper compliance with ERAS regimens, determination of adequate end points for recovery, and measurement of proper outcome metrics. During the congress, an educational initiative on perioperative fluid management was launched with the acronym CHEERS-DREAM. Patients after elective surgery should be Carbohydrate loaded (not hungry), Hydrated (not thirsty), Euvolemic (the right amount of fluid), Eunatremic (the right amount of salt), Ready to Start DRinking, EAting and Mobilizing (www.cheers-dream.com). Future directions with ER should be focused on addressing the challenges facing each program and coordinating multicenter trials to evaluate the strength of the various evidenced-based elements of the ER pathways. In addition, audit on compliance of the ER protocol should be part of the process. The next US Enhanced Recovery and Perioperative Management Congress will be held in Washington DC in April 2016; ERAS Society Congress in Portugal in April 2016; and EBPOM in London in July 2016. APPENDIX 1 Conference Presenters C. Scott Brudney, USA C. Canfield, Canada Franco Carli, Canada Mink Chawla, USA Nicolas Demartines, Switzerland Tonia M. Young-Fadok, USA Bill Fawcett, United Kingdom Ken Fearon, United Kingdom Lee A. Fleisher, USA Christopher Gallagher, USA T. J. Gan, USA Stuart Grant, USA Michael P. W. Grocott, United Kingdom Ruchir Gupta, USA Ulf Gustafsson, Sweden Mark Hamilton, United Kingdom Dorthe Hjort, Denmark Henrik Kehlet, Denmark John Kellum, USA Lawrence Lee, Canada Olle Ljungqvist, Sweden Dileep N. Lobo, United Kingdom Timothy E. Miller, USA Paul Myles, Australia Michael (Monty) G. Mythen, United Kingdom Sreekumaran Nair, USA G. Nelson, Canada Arthur Revhaug, Norway Mike Scott, United Kingdom Anthony Senagore, USA Andrew Shaw, USA Roy Soto, USA Julie Thacker, USA A. Thorell, Sweden Deborah Watson, Canada Tracy Wasylak, Canada RECUSE NOTE Dr. Tong Joo Gan is the Section Editor for Ambulatory Anesthesiology and Perioperative Management for Anesthesia & Analgesia. This manuscript was handled by Dr. Eugene Hessel, Section Editor for Media Reviews, and Dr. Gan was not involved in any way with the editorial process or decision. Ruchir Gupta, MD Tong Joo Gan, MD, MHS, FRCA Department of Anesthesiology Stony Brook School of Medicine Stony Brook, New York [email protected] Monty G. Mythen, MBBS, MD, FRCA, FFICL, FCAI (Hon) Department of Anaesthesia and Critical Care University College London Hospitals London, England Olle Ljungqvist, MD, PhD Faculty of Medicine and Health School of Health and Medical Sciences Department of Surgery Örebro University Örebro, Sweden

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