Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care.

BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Anaesthesia role in enhanced recovery after surgery: a revolution in care outcomes.

PURPOSE OF REVIEW: Enhanced recovery after surgery (ERAS) has revolutionized care outcomes. The purpose of this review is to provide an overview of how ERAS changed healthcare outcomes. RECENT FINDINGS: Development of multidisciplinary evidence-based ERAS guidelines for specific surgical specialties and systematic implementation of these guidelines resulted in improved healthcare outcomes, reduction in length of stay, reduction in complications and improved survival. The value of audit of the outcomes is essential for implementation and to improve healthcare. Healthcare economics analysis related to the implementation of ERAS showed significant cost savings up to a return to investment ratio of more than seven. SUMMARY: ERAS has revolutionized healthcare by developing evidence-based ERAS guidelines and systematic implementation of these guidelines. Audit of outcomes is essential, not only to improve healthcare but also to significantly save healthcare expenditures.

Mortality and costs associated with acute kidney injury following major elective, non-cardiac surgery.

OBJECTIVE: This study evaluated postoperative AKI severity and its relation to short- and long-term patient outcomes. DESIGN: A retrospective, single-center cohort study of patients undergoing surgery from January 2015 to May 2020. SETTING: An urban, academic medical center. PATIENTS: Adult patients undergoing elective, non-cardiac surgery at our institution with a postoperative length of stay (LOS) of at least 24 h were included. Patients were included in 1-year mortality analysis if their procedure occurred prior to June 2019. INTERVENTIONS: None. MEASUREMENTS: Postoperative AKI was identified and staged using the Kidney Disease Improving Global Outcomes definitions. The outcomes analyzed were in-hospital mortality, LOS, total cost of the surgical hospitalization, and 1-year mortality. MAIN RESULTS: Of the 8887 patients studied, 648 (7.3%) had postoperative AKI. AKI was associated with severity-dependent increases in all outcomes studied. Patients with AKI had rates of in-hospital mortality of 2.0%, 3.8%, and 12.5% for stage 1, 2, and 3 AKI compared to 0.3% for patients without AKI. Mean total costs of the surgical hospitalization were $23,896 (SD $23,736) for patients without AKI compared to $33,042 (SD $27,115), $39,133 (SD $34,006), and $73,216 ($82,290) for patients with stage 1, 2, and 3 AKI, respectively. In the 6729 patients who met inclusion for 1-year mortality analysis, AKI was also associated with 1-year mortality rates of 13.9%, 19.4%, and 22.7% compared to 5.2% for patients without AKI. In multivariate models, stage 1 AKI patients still had a higher probability of 1-year mortality (OR 1.9, 95% CI 1.3-2.6, p < 0.001) in addition to $4391 of additional costs when compared to patients without AKI (95% CI $2498-$6285, p < 0.001). CONCLUSIONS: All stages of postoperative AKI were associated with increased LOS, surgical hospitalization costs, in-hospital mortality, and 1-year mortality. These findings suggest that patients with even a low-grade or stage 1 AKI are at higher risk for short- and long-term complications.

The 'medically unexplained symptoms' syndrome concept and the cognitive-behavioural treatment model.

The American Psychiatric Association's, 2013 DSM-5 abandoned the use of the term 'medically unexplained symptoms' for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.

Enhanced Recovery After Primary Total Hip and Knee Arthroplasty: A Systematic Review.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) has become increasingly implemented to reduce costs, to increase efficiency, and to optimize patient outcomes after a surgical procedure. This study aimed to systematically review the effect of ERAS after primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) on hospital length of stay, total procedure-related morbidity, and readmission. METHODS: A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and with guidance from the Cochrane Handbook for Systematic Reviews of Interventions. MEDLINE, Embase, and Cochrane databases were searched from inception (1946 for MEDLINE and 1974 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date) until January 15, 2020. Prospective nonrandomized cohort studies and randomized controlled trials comparing adult patients undergoing elective primary THA or TKA with ERAS or traditional protocols were included. Articles examining outpatient, nonelective, or revision surgical procedures were excluded. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was length of stay. The secondary outcomes included total procedure-related morbidity and readmission. RESULTS: Of the 1,018 references identified (1,017 identified through an electronic search and 1 identified through a manual search), 9 individual studies met inclusion criteria. Data were reported from 7,789 participants, with 2,428 receiving ERAS and 5,361 receiving traditional care. Narrative synthesis was performed instead of meta-analysis, given the presence of moderate to high risk of bias, wide variation of ERAS interventions, and inconsistent methods for assessing and reporting outcomes among included studies. Adherence to ERAS protocols consistently reduced hospital length of stay. Few studies demonstrated reduced total procedure-related morbidity, and there was no significant effect on readmission rates. CONCLUSIONS: ERAS likely reduced the length of stay after primary elective THA and TKA, with a more pronounced effect in selected healthier patient populations. We found minimal to no impact on perioperative morbidity or readmission. The quality of existing evidence was limited because of study heterogeneity and a significant risk of bias. Further high-quality research is needed to definitively assess the impact of ERAS on total joint arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review.

Importance: Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion. Observations: Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS. Conclusions and Relevance: To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.

VLA4-Targeted Nanoparticles Hijack Cell Adhesion-Mediated Drug Resistance to Target Refractory Myeloma Cells and Prolong Survival.

PURPOSE: In multiple myeloma, drug-resistant cells underlie relapse or progression following chemotherapy. Cell adhesion-mediated drug resistance (CAM-DR) is an established mechanism used by myeloma cells (MMC) to survive chemotherapy and its markers are upregulated in residual disease. The integrin very late antigen 4 (VLA4; α4ß1) is a key mediator of CAM-DR and its expression affects drug sensitivity of MMCs. Rather than trying to inhibit its function, here, we hypothesized that upregulation of VLA4 by resistant MMCs could be exploited for targeted delivery of drugs, which would improve safety and efficacy of treatments. EXPERIMENTAL DESIGN: We synthetized 20 nm VLA4-targeted micellar nanoparticles (V-NP) carrying DiI for tracing or a novel camptothecin prodrug (V-CP). Human or murine MMCs, alone or with stroma, and immunocompetent mice with orthotopic multiple myeloma were used to track delivery of NPs and response to treatments. RESULTS: V-NPs selectively delivered their payload to MMCs in vitro and in vivo, and chemotherapy increased their uptake by surviving MMCs. V-CP, alone or in combination with melphalan, was well tolerated and prolonged survival in myeloma-bearing mice. V-CP also reduced the dose requirement for melphalan, reducing tumor burden in association with suboptimal dosing without increasing overall toxicity. CONCLUSIONS: V-CP may be a safe and effective strategy to prevent or treat relapsing or refractory myeloma. V-NP targeting of resistant cells may suggest a new approach to environment-induced resistance in cancer.

UV-C tower for point-of-care decontamination of filtering facepiece respirators.

BACKGROUND: Filtering facepiece respirators (FFR) are critical for protecting essential personnel and limiting the spread of disease. Due to the current COVID-19 pandemic, FFR supplies are dwindling in many health systems, necessitating re-use of potentially contaminated FFR. Multiple decontamination solutions have been developed to meet this pressing need, including systems designed for bulk decontamination of FFR using vaporous hydrogen peroxide or ultraviolet-C (UV-C) radiation. However, the large scale on which these devices operate may not be logistically practical for small or rural health care settings or for ad hoc use at points-of-care. METHODS: Here, we present the Synchronous UV Decontamination System, a novel device for rapidly deployable, point-of-care decontamination using UV-C germicidal irradiation. We designed a compact, easy-to-use device capable of delivering over 2 J cm2 of UV-C radiation in one minute. RESULTS: We experimentally tested Synchronous UV Decontamination System' microbicidal capacity and found that it eliminates near all virus from the surface of tested FFRs, with less efficacy against pathogens embedded in the inner layers of the masks. CONCLUSIONS: This short decontamination time should enable care-providers to incorporate decontamination of FFR into a normal donning and doffing routine following patient encounters.

The impact of peri-operative intravenous lidocaine on postoperative outcome after elective colorectal surgery: A meta-analysis of randomised controlled trials.

BACKGROUND: There has recently been increasing interest in the use of peri-operative intravenous lidocaine (IVL) due to its analgesic, anti-inflammatory and opioid-sparing effects. However, these potential benefits are not well established in elective colorectal surgery. OBJECTIVES: To examine the effect of peri-operative IVL infusion on postoperative outcome in patients undergoing elective colorectal surgery. DESIGN: A meta-analysis of randomised controlled trials (RCTs) comparing peri-operative IVL with placebo infusion in elective colorectal surgery. The primary outcome measure was postoperative pain scores up to 48 h. The secondary outcome measures included time to return of gastrointestinal function, postoperative morphine requirement, anastomotic leak, local anaesthetic toxicity and hospital length of stay. DATA SOURCES: PubMed, Scopus and the Cochrane Library databases were searched on 5 November 2018. ELIGIBILITY CRITERIA: Studies were included if they were RCTs evaluating the role of peri-operative IVL vs. placebo in adult patients undergoing elective colorectal surgery. Exclusion criteria were paediatric patients, noncolorectal or emergency procedures, non-RCT methodology or lack of relevant outcome measures. RESULTS: A total of 10 studies were included (n = 508 patients; 265 who had undergone IVL infusion, 243 who had undergone placebo infusion). IVL infusion was associated with a significant reduction in time to defecation (mean difference -12.06 h, 95% CI -17.83 to -6.29, I = 93%, P = 0.0001), hospital length of stay (mean difference -0.76 days, 95% CI -1.32 to -0.19, I = 45%, P = 0.009) and postoperative pain scores at early time points, although this difference does not meet the threshold for a clinically relevant difference. There was no difference in time to pass flatus (mean difference -5.33 h, 95% CI -11.53 to 0.88, I = 90%, P = 0.09), nor in rates of surgical site infection or anastomotic leakage. CONCLUSION: This meta-analysis provides some support for the administration of peri-operative IVL infusion in elective colorectal surgery. However, further evidence is necessary to fully elucidate its potential benefits in light of the high levels of study heterogeneity and mixed quality of methodology.

Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications, costs and hospital stay. This concept has been applied for pancreatic surgery since the first published guidelines in 2012. This study presents the updated ERAS recommendations for pancreatoduodenectomy (PD) based on the best available evidence and on expert consensus. METHODS: A systematic literature search was conducted in three databases (Embase, Medline Ovid and Cochrane Library Wiley) for the 27 developed ERAS items. Quality of randomized trials was assessed using the Consolidated Standards of Reporting Trials statement checklist. The level of evidence for each item was determined using the Grading of Recommendations Assessment Development and Evaluation system. The Delphi method was used to validate the final recommendations. RESULTS: A total of 314 articles were included in the systematic review. Consensus among experts was reached after three rounds. A well-implemented ERAS protocol with good compliance is associated with a reduction in medical complications and length of hospital stay. The highest level of evidence was available for five items: avoiding hypothermia, use of wound catheters as an alternative to epidural analgesia, antimicrobial and thromboprophylaxis protocols and preoperative nutritional interventions for patients with severe weight loss (> 15%). CONCLUSIONS: The current updated ERAS recommendations for PD are based on the best available evidence and processed by the Delphi method. Prospective studies of high quality are encouraged to confirm the benefit of current updated recommendations.

Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified.

BACKGROUND: Improving Access to Psychological Therapies is a UK Government funded initiative to widen access to psychological treatment for a range of common mental health complaints, such as depression and anxiety. More recently, the service has begun to treat patients with medically unexplained symptoms. This paper reports on a review of treatment protocols and early treatment data for medically unexplained symptoms, specifically the illness myalgic encephalomyelitis/chronic fatigue syndrome. MAIN TEXT: A series of seven core problems and failings are identified, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. CONCLUSIONS: There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients' physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

AAAPT Diagnostic Criteria for Acute Abdominal and Peritoneal Pain After Surgery.

Abdominal and peritoneal pain after surgery is common and burdensome, yet the lack of standardized diagnostic criteria for this type of acute pain impedes basic, translational, and clinical investigations. The collaborative effort among the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, American Pain Society, and American Academy of Pain Medicine Pain Taxonomy (AAAPT) provides a systematic framework to classify acute painful conditions. Using this framework, a multidisciplinary working group reviewed the literature and developed core diagnostic criteria for acute abdominal and peritoneal pain after surgery. In this report, we apply the proposed AAAPT framework to 4 prototypical surgical procedures resulting in abdominal and peritoneal pain as examples: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection. These diagnostic criteria address the 3 most common surgical procedures performed in the United States, capture diverse surgical approaches, and may also be applied to other surgical procedures resulting in abdominal and peritoneal pain. Additional investigation regarding the validity and reliability of this framework will facilitate its adoption in research that advances our comprehension of mechanisms, deliver better treatments, and help prevent the transition of acute to chronic pain after surgery in the abdominal and peritoneal region. PERSPECTIVE: Using AAAPT, we present key diagnostic criteria for acute abdominal and peritoneal pain after surgery. We provide a systematic classification using 5 dimensions for abdominal and peritoneal pain that occurs after surgery, in addition to 4 specific surgical procedures: cesarean delivery, cholecystectomy, colorectal surgical procedures, and pancreas resection.

Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery.

Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.

Embracing change: the era for pediatric ERAS is here.

The concept of Enhanced Recovery After Surgery (ERAS) has increasingly been embraced by our adult surgical colleagues, but has been slow to crossover to pediatric surgical subspecialties. ERAS® improves outcomes through multiple, incremental steps that act synergistically throughout the entire surgical journey. In practice, ERAS® is a strategy of perioperative management that is defined by strong implementation and ongoing adherence to a patient-focused, multidisciplinary, and multimodal approach. There are increasing numbers of surgical teams exploring ERAS® in children and there is mounting evidence that this approach may improve surgical care for children across the globe. The first World Congress in Pediatric ERAS® in 2018 has set the stage for a new era in pediatric surgical safety.

Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery.

Enhanced recovery after surgery (ERAS) protocols for gynecologic (GYN) surgery are increasingly being reported and may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery, which is a nationwide initiative to disseminate best practices in perioperative care to more than 750 hospitals across five major surgical service lines in a 5-year period. The program is designed to identify evidence-based process measures shown to prevent healthcare-associated conditions and hasten recovery after surgery, integrate those into a comprehensive service line-based pathway, and assist hospitals in program implementation. In conjunction with this effort, we have conducted an evidence review of the various anesthesia components which may influence outcomes and facilitate recovery after GYN surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for preoperative (carbohydrate loading/fasting, multimodal preanesthetic medications), intraoperative (standardized intraoperative pathway, regional anesthesia, protective ventilation strategies, fluid minimization) and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for GYN surgery.