Perioperative surgical home models and enhanced recovery after surgery.

In recent years, numerous initiatives have been introduced to address changes in health-care costs, delivery methods, reimbursements, and the health-care needs of our aging population. The American Society of Anesthesiologists (ASA) defines the Perioperative Surgical Home (PSH) as a patient-centric, team-based model of care to help meet the demands of a rapidly approaching health-care paradigm emphasizing value, patient satisfaction, and a reduction in costs. Enhanced recovery pathways were initially established by a group of surgeons from Europe who formed a research group with the aim to explore the ultimate care pathway for patients undergoing colonic resections. Similar protocols were later expanded to various surgical specialties with promising outcomes. A PubMed and World Wide Web search was performed with the following key words: "ERAS®," "enhanced recovery after surgery," "PSH," "perioperative surgical home," "protocols," "outcomes." Articles found were published over a 20-year time range (1997-2017). In the present investigation, the most common elements of enhanced recovery protocols are reviewed. Review of how existence of a PSH model facilitates the creation of an enhanced recovery protocol and improves cost-efficiency, patient satisfaction, and clinical outcomes observed in enhanced recovery studies that are applicable to health-care systems universally is described.

Essential Elements for Enhanced Recovery After Intra-Abdominal Surgery.

PURPOSE OF REVIEW: Enhanced recovery pathways provide a framework outlining the best perioperative care for intra-abdominal surgical procedures. To date, no evidence-based umbrella guidelines exist for all intra-abdominal surgeries. RECENT FINDINGS: PubMed and worldwide web searches were performed with the keywords: "ERAS," "Enhanced Recovery After Surgery," +/- "protocol." Manuscripts addressing intra-abdominal procedures were selected with the date range 2012-2017. The enhanced recovery philosophy is based in the realization that a traditional hospital works in silos that need to be broken to ensure a care protocol that follows and optimizes the journey the patient makes during the perioperative care. Enhanced recovery interventions can be categorized into preoperative, perioperative, and postoperative interventions. By design each intervention is planned and coordinated by a multidisciplinary ERAS team. The interventions discussed in this manuscript should be applied to patients on an individual basis depending on their needs. In this review, the most common elements of ERAS protocols in intra-abdominal procedures are reviewed, particularly those which provided the best outcomes and are generalized to all intra-abdominal procedures.

Essential Elements for Enhanced Recovery After Intra-abdominal Surgery.

PURPOSE OF REVIEW: Enhanced recovery pathways provide a framework outlining the best perioperative care for intra-abdominal surgical procedures. To date, no evidence-based umbrella guidelines exist for all intra-abdominal surgeries. RECENT FINDINGS: A PubMed and worldwide web search was performed with the keywords: "ERAS," "enhanced recovery after surgery", ± "protocol." Manuscripts addressing intra-abdominal procedures were selected, resulting in studies with the date range: 2012-2017. The basic philosophy behind enhanced recovery is the realization that a traditional hospital works in silos that need to be broken to ensure a care protocol that follows and optimizes the journey the patient makes during the perioperative care. Enhanced recovery interventions can be categorized into preoperative, perioperative, and postoperative interventions. By design, each intervention is planned and coordinated by a multidisciplinary ERAS team. Depending on the particular procedure and patient receiving the interventions, some of the interventions below may be more or less applicable. In this review, the most common elements of ERAS protocols in intra-abdominal procedures are reviewed, particularly those which provided the best outcomes and are most generalizable to all intra-abdominal procedures.

Adverse cardiac events after orthotopic liver transplantation: a cross-sectional study in 389 consecutive patients.

Current American College of Cardiology/American Heart Association guidelines caution that preoperative noninvasive cardiac tests may have poor predictive value for detecting coronary artery disease in liver transplant candidates. The purpose of our study was to evaluate the role of clinical predictor variables for early and late cardiac morbidity and mortality and the predictive values of noninvasive cardiac tests for perioperative cardiac events in a high-risk liver transplant population. In all, 389 adult recipients were retrospectively analyzed for a median follow-up time of 3.4 years (range = 2.3-4.4 years). Overall survival was 83%. During the first year after transplantation, cardiovascular morbidity and mortality rates were 15.2% and 2.8%. In patients who survived the first year, cardiovascular morbidity and mortality rates were 3.9% and 2%, with cardiovascular etiology as the third leading cause of death. Dobutamine stress echocardiography (DSE) and single-photon emission computed tomography had respective sensitivities of 9% and 57%, specificities of 98% and 75%, positive predictive values of 33% and 28%, and negative predictive values of 89% and 91% for predicting early cardiac events. A rate blood pressure product less than 12,000 with DSE was associated with an increased risk for postoperative atrial fibrillation. Correspondence analysis identified a statistical association between nonalcoholic steatohepatitis/cryptogenic cirrhosis and postoperative myocardial ischemia. Logistic regression identified 3 risk factors for postoperative acute coronary syndrome: age, history of coronary artery disease, and pretransplant requirement for vasopressors. Multivariable analysis showed statistical associations of the Model for End-Stage Liver Disease score and the development of acute kidney injury as risk factors for overall cardiac-related mortality. These findings may help in identifying high-risk patients and may lead to the development of better cardiac tests.