Enhanced recovery: joining the dots

Abstract

Eight years ago, we wrote an editorial for the British Journal of Anaesthesia exploring whether rapid, uncomplicated recovery after surgery would have downstream benefits other than just reduction in hospital length of stay (LOS).1Fawcett W.J. Mythen M.G. Scott M.J.P. Enhanced recovery—more than just reducing length of stay?.Br J Anaesth. 2012; 109: 671-674Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar At that time, the concept of Enhanced Recovery After Surgery (ERAS®) was more than 15 yr old (and had been practised under various names, such as fast-track surgery or accelerated recovery); yet, its uptake was initially sporadic. National implementation measures across the UK (such as NHS Improvement and the Enhanced Recovery Partnership) meant most hospitals and departments had adopted some form of a standardised care pathway by 2012. At that stage, established ERAS units recognised that there were very large potential gains to be had for patients undergoing major elective surgery. Many of the benefits arose from the evidenced-based, multimodal, multidisciplinary management of patients undergoing major surgery, creating a pathway that optimised patients preoperatively, minimised injury and stress at the time of surgery, and protocolised de-escalation of care to accelerate return of functional recovery. Here, we explore the evidence and developments in this field, why ERAS pathways have not been universally implemented, and their relevance in current healthcare during the coronavirus disease 2019 (COVID-19) pandemic. A key driver of the implementation of ERAS across the UK was to release bed capacity, and therefore, the easy-to-measure endpoint LOS was historically used to compare and judge the success of ERAS programmes. Recording LOS still has merit; not least as remaining in a hospital environment is not risk free, and associated with fasting, sleep disturbance, immobilisation, infection, and medication errors.2Rasmussen L.S. Jørgensen C.C. Kehlet H. Enhanced recovery programmes for the elderly.Eur J Anaesthesiol. 2016; 33: 391-392Crossref PubMed Scopus (6) Google Scholar However, measurement of LOS on its own is a somewhat limited metric for assessing the efficacy of patient-centred care, as there are other potential consequences for ERAS patients. Other areas have been studied and recorded in ERAS patients, including reduced pathophysiological responses with reduced organ dysfunction, quicker return of metabolic function, reduced complications and readmissions, improved cancer survival, reduced costs, improving patient satisfaction, and faster return to preoperative function.3Ljungqvist O. Scott M. Fearon K.C. Enhanced recovery after surgery: a review.JAMA Surg. 2017; 152: 292-298Crossref PubMed Scopus (1224) Google Scholar Moreover, with more than 10 million operations performed in the NHS annually and more than 300 million worldwide (with both rising annually),4Abbott T.E. Fowler A.J. Dobbs T.D. Harrison E.M. Gillies M.A. Pearse R.M. Frequency of surgical treatment and related hospital procedures in the UK: a national ecological study using hospital episode statistics.Br J Anaesth. 2017; 119: 249-257Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar harnessing these potential gains for patients on ERAS pathways is enormous. Since 2012, many of these proposed benefits have been realised, many from formal ERAS programmes. With good compliance to these programmes, not only does LOS decrease, but readmissions are usually reduced or unchanged, but not increased, which is a valid concern when attempting to reduce LOS.5ERAS Compliance GroupThe impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry.Ann Surg. 2015; 261: 1153-1159Crossref PubMed Scopus (384) Google Scholar Readmissions are a key area, as early hospital discharge without sufficient recovery can increase both patient and family anxiety, and increase the risk of hospital readmission. It is noteworthy that when readmissions do occur, they are associated with more challenging patients, such as ASA physical status of 3 or more, surgical complexity, and operation times in excess of 6 h in colorectal surgery,6Bennedsen A.L. Eriksen J.R. Gögenur I. Prolonged hospital stay and readmission rate in an enhanced recovery after surgery cohort undergoing colorectal cancer surgery.Colorectal Dis. 2018; 20: 1097-1108Crossref PubMed Scopus (9) Google Scholar such that caution should be taken in the early discharge of patients identified at higher risk. A recent retrospective analysis has shown that greater use of enhanced recovery elements in hip or knee arthroplasty was associated with fewer complications and shorter LOS.7Memtsoudis S.G. Fiasconaro M. Soffin E.M. et al.Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study.Br J Anaesth. 2020; 124: 638-647Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Whilst reducing LOS and readmissions is important, it is the reduction in complications for surgical patients that is recognised as a key metric within healthcare systems, as it impacts on both short- and long-term outcomes.8Khuri S.F. Henderson W.G. DePalma R.G. et al.Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.Ann Surg. 2005; 242: 326-341Crossref PubMed Scopus (923) Google Scholar It has been estimated that all-cause postoperative deaths are the third biggest cause of mortality in the USA following heart disease and cancer.9Bartels K. Karhausen J. Clambey E.T. Grenz A. Eltzschig H.K. Perioperative organ injury.Anesthesiology. 2013; 119: 1474-1489Crossref PubMed Google Scholar Non-fatal complications not only reduce patient satisfaction, but may impact patients permanently in terms of disability-free survival, functional recovery, and health-related quality of life, with an enormous associated socio-economic impact. ERAS pathways have consistently been shown to reduce complications, such as a surgical site infection and acute kidney injury, with strict pathway adherence promoting the greatest reduction in complications (both surgical and especially medical).3Ljungqvist O. Scott M. Fearon K.C. Enhanced recovery after surgery: a review.JAMA Surg. 2017; 152: 292-298Crossref PubMed Scopus (1224) Google Scholar A recent systematic review and meta-analysis of RCTs to examine perioperative prevention of postoperative pulmonary complications found that the most benefit was conferred by patients enrolled in ERAS pathways,10Odor P.M. Bampoe S. Gilhooly D. Creagh-Brown B. Moonesinghe S.R. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis.BMJ. 2020; 368: m540Crossref PubMed Scopus (34) Google Scholar rather than a single targeted respiratory intervention. ERAS also confers procedure-specific benefits; for example, in joint replacement surgery, it is possible to demonstrate reductions in a variety of common complications, such as postoperative delirium and cognitive dysfunction.11Petersen P.B. Jørgensen C.C. Kehlet H. et al.Delirium after fast-track hip and knee arthroplasty—a cohort study of 6331 elderly patients.Acta Anaesthesiol Scand. 2017; 61: 767-772Crossref PubMed Scopus (26) Google Scholar In another study of hip or knee arthroplasty, omission of venous thromboembolism (VTE) prophylaxis is proposed without apparently increasing the incidence of VTE and its complications.12Wainwright T.W. Kehlet H. Fast-track hip and knee arthroplasty—have we reached the goal?.Acta Orthop. 2019; 90: 3-5Crossref PubMed Scopus (27) Google Scholar Early data supported the concept that colorectal cancer patients receiving an ERAS protocol may have improved disease-free survival,13Gustafsson U.O. Hausel J. Thorell A. et al.Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery.Arch Surg. 2011; 146: 571-577Crossref PubMed Scopus (521) Google Scholar which is supported by more recent data from the same group showing that good adherence to the ERAS pathways (>70%) lowered the risk of 5 yr cancer-specific death by 42%.14Gustafsson U.O. Oppelstrup H. Thorell A. Nygren J. Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study.World J Surg. 2016; 40: 1741-1747Crossref PubMed Scopus (188) Google Scholar The factors involved are multifactorial and may include reduction of perioperative stress, preoperative nutrition, pre-habilitation, anaesthetic technique, reduction in complications, improved immune function with earlier commencement of other therapies (such as chemotherapy), etc.; a feature of such ERAS protocols is the difficulty in singling out the critical intervention(s). ERAS has shown to be cost-effective in spite of the initial financial outlay (e.g. reorganising healthcare delivery, equipment, and training minimal access surgery). Data support sustained but varied reduction in costs (up to $7000 per patient in direct cost),15Thiele R.H. Rea K.M. Turrentine F.E. et al.Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery.J Am Coll Surg. 2015; 220: 430-443Abstract Full Text Full Text PDF PubMed Scopus (244) Google Scholar with a return on investment of $3.8 (range $2.4–$5.1) for every $1 invested in ERAS.16Thanh N.X. Chuck A.W. Wasylak T. et al.An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta.Can J Surg. 2016; 59: 415-421Crossref PubMed Scopus (67) Google Scholar However, even if LOS is reduced, it must be borne in mind that there may be significant post-discharge spending required for implementation.17Bozic K.J. Ward L. Vail T.P. Maze M. Bundled payments in total joint arthroplasty: targeting opportunities for quality improvement and cost reduction.Clin Orthop Relat Res. 2014; 472: 188-193Crossref PubMed Scopus (280) Google Scholar Some studies take this spending into account in their calculations, with the inclusion of primary care spending,16Thanh N.X. Chuck A.W. Wasylak T. et al.An economic evaluation of the Enhanced Recovery After Surgery (ERAS) multisite implementation program for colorectal surgery in Alberta.Can J Surg. 2016; 59: 415-421Crossref PubMed Scopus (67) Google Scholar whilst others appear not to.15Thiele R.H. Rea K.M. Turrentine F.E. et al.Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery.J Am Coll Surg. 2015; 220: 430-443Abstract Full Text Full Text PDF PubMed Scopus (244) Google Scholar ERAS has spread to many other surgical specialties from the original four (colorectal, gynaecology, musculoskeletal, and urology) to practically every surgical specialty, including cardiac, thoracic, neurological, vascular, paediatric, head and neck and bariatric surgery, and obstetrics,18ERAS® SocietyERAS/guidelines/list of guidelines.https://erassociety.org/guidelines/list-of-guidelines/Date accessed: August , 2020Google Scholar with others in development, such as spinal fusion surgery, vulvar and vaginal surgery, and cytoreductive surgery, with or without hyperthermic intraperitoneal chemotherapy. ERAS has also achieved marked successes in older patients.2Rasmussen L.S. Jørgensen C.C. Kehlet H. Enhanced recovery programmes for the elderly.Eur J Anaesthesiol. 2016; 33: 391-392Crossref PubMed Scopus (6) Google Scholar The principles have also been applied to emergency general surgery,19Jordan L.C. Cook T.M. Cook S.C. et al.Sustaining better care for patients undergoing emergency laparotomy.Anaesthesia. 2020; 75: 1321-1330Crossref PubMed Scopus (2) Google Scholar and there has been great success globally, not only for higher-income countries, but also for low- and middle-income countries.18ERAS® SocietyERAS/guidelines/list of guidelines.https://erassociety.org/guidelines/list-of-guidelines/Date accessed: August , 2020Google Scholar In spite of its many successes, ERAS still has a number of issues that need addressing in the future. A paradox encompasses the term ‘enhanced recovery’ inasmuch that the definition of what constitutes recovery after surgery is not universal. Only recently has due focus centred on this crucial area. Only as recently as 2015 have standardised outcome measures been defined and formalised in perioperative medicine.20Jammer I. Wickboldt N. Sander M. et al.Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures.Eur J Anaesthesiol. 2015; 32: 88-105Crossref PubMed Scopus (321) Google Scholar Classically, recovery has been divided into three phases21Bowyer A.J. Royse C.F. Postoperative recovery and outcomes—what are we measuring and for whom?.Anaesthesia. 2016; 71: 72-77Crossref PubMed Scopus (61) Google Scholar familiar to all anaesthetists: (i) restoration of biological and physiological parameters, such as adequate ventilation, BP, oxygen delivery (if measured), urine output (if measured and more rarely used as guide to early patient management), and temperature in the postanaesthetic care unit; (ii) a symptom-based approach to recovery treating pain, gastrointestinal function, and the ability to perform basic activities before leaving hospital; and (iii) possibly most importantly and definitely the most neglected in the past, resumption of full functional activities and prior quality of life. This last area has been the subject of much interest, as it can take well more than 6 months for patients undergoing colorectal surgery to return to baseline physical capacity,22Miller T.E. Mythen M. Successful recovery after major surgery: moving beyond length of stay.Perioper Med (Lond). 2014; 3: 4Crossref PubMed Google Scholar and in the latest Perioperative Quality Improvement Programme (PQIP) report only 60% of patients resumed usual activities in this time frame.23Periopertive Quality Improvement Programmehttps://pqip.org.uk/pages/ar2019Date accessed: August , 2020Google Scholar There are many measures described for assessing these latter stages of recovery, including patient-reported outcomes and quality of recovery scores.24Kingsley C. Patel S. Patient-reported outcome measures and patient-reported experience measures.BJA Educ. 2017; 17: 137-144Abstract Full Text Full Text PDF Scopus (167) Google Scholar A useful, simple, and widely used measurement is ‘days at home up to 30 days after surgery’, a patient-centred outcome measure that is easy to measure and a useful marker of postoperative complications.25Myles P.S. More than just morbidity and mortality—quality of recovery and long-term functional recovery after surgery.Anaesthesia. 2020; 75: e143-e150Crossref PubMed Scopus (31) Google Scholar,26Jørgensen C.C. Petersen P.B. Kehlet H. Lundbeck Foundation Center for Fast-track Hip and Knee Replacement Collaborative Group. Days alive and out of hospital after fast-track total hip and knee arthroplasty: an observational cohort study in 16 137 patients.Br J Anaesth. 2019; 123: 671-678Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The advent of perioperative medicine pioneered at the Royal College of Anaesthetists embraces and complements many themes of ERAS. Perioperative medicine itself has driven improvements and led to other initiatives within the UK healthcare system. There are many common to the ERAS philosophy, including strict pathway adherence with no variation, and high-quality data collection, audit, and analysis to drive improvement. For example, the UK PQIP includes enhanced recovery within its ‘Top 5 National Improvement Priorities for 2019–20’,23Periopertive Quality Improvement Programmehttps://pqip.org.uk/pages/ar2019Date accessed: August , 2020Google Scholar and the concept of drinking, eating, and mobilising is very similar to ERAS principles.27Levy N. Mills P. Mythen M. Is the pursuit of DREAMing (drinking, eating and mobilising) the ultimate goal of anaesthesia?.Anaesthesia. 2016; 71: 1008-1012Crossref PubMed Scopus (32) Google Scholar However, ERAS differs from many perioperative programmes in the close involvement of many members of the perioperative team: primary care, surgeons, nurses, pharmacists, physiotherapists, dietitians, etc., in addition to anaesthetists.3Ljungqvist O. Scott M. Fearon K.C. Enhanced recovery after surgery: a review.JAMA Surg. 2017; 152: 292-298Crossref PubMed Scopus (1224) Google Scholar Although there is still substantial heterogeneity in ERAS protocols studied to date, pre-optimisation; injury and stress reduction; rapid de-escalation; and transition to baseline preoperative functions of drinking, eating, mobilising, and sleeping are constant themes. Finally, the balance between individualised, patient-tailored medicine must be weighed against the value of standardisation of care characterised in ERAS pathways. Although attempts have been made to standardise the writing of ERAS pathways28Brindle M. Nelson G. Lobo D.N. Ljungqvist O. Gustafsson U.O. Recommendations from the ERAS® Society for standards for the development of enhanced recovery after surgery guidelines.BJS Open. 2020; 4: 157-163Crossref PubMed Scopus (42) Google Scholar for different surgeries, research outcomes and pathway authorship have resulted in a large and varied number of required elements, often in excess of 20, that are seen as daunting.18ERAS® SocietyERAS/guidelines/list of guidelines.https://erassociety.org/guidelines/list-of-guidelines/Date accessed: August , 2020Google Scholar Many of these are now standards of care. This has generated a few practical issues concerning both attaining compliance and posing the question ‘Which elements are really necessary?’ Whilst it is recognised that compliance and outcome are closely related, analogous to a dose–response curve, it also recognised (and would be most unlikely) that not all components carry the same weight in terms of patient benefit.13Gustafsson U.O. Hausel J. Thorell A. et al.Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery.Arch Surg. 2011; 146: 571-577Crossref PubMed Scopus (521) Google Scholar Moreover, some elements of care are covered in the WHO checklist (such as maintenance of euglycaemia, avoidance of hypothermia, and administration of antibiotics), whereas others are viewed as generic standards of care (such as avoiding fluid excess, ensuring multimodal analgesia, etc.). It is therefore logical that we direct focus to other major modifiable elements that confer the most benefits. This area has recently been the subject of papers and editorials from which two major themes emerge. Firstly, the concepts described by Kehlet29Kehlet H. ERAS implementation—time to move forward.Ann Surg. 2018; 267: 998-999Crossref PubMed Scopus (39) Google Scholar more than 25 yr ago and reiterated in a recent editorial that re-emphasise his view that a return to the five early principles approach is required. This includes preoperative patient information, thoracic epidural anaesthesia in open (but not laparoscopic) colon surgery, avoidance of both fluid overload and hypovolaemia, avoidance of a nasogastric tube, and early oral feeding with mobilisation. In addition, there has recently been focus on the importance of postoperative elements, which, although often difficult to implement, are strongly associated with the greatest impact on optimal recovery. These include early removal or avoidance of urinary catheters, assistance with patient ambulation, and early feeding.30Aarts M.A. Rotstein O.D. Pearsall E.A. et al.Postoperative ERAS interventions have the greatest impact on optimal recovery: experience with implementation of ERAS across multiple hospitals.Ann Surg. 2018; 267: 992-997Crossref PubMed Scopus (80) Google Scholar A recurring theme within ERAS poses why there appear to be barriers to both implementation of and subsequent adherence to proven evidenced-based pathways. This concept, referred to as the ‘knowing–doing gap’, continues to be a major obstacle in delivering ERAS.31Kehlet H. Fast-track colonic surgery and the ‘knowing–doing’ gap.Nat Rev Gastroenterol Hepatol. 2011; 8: 539-540Crossref PubMed Scopus (19) Google Scholar These include patient, healthcare professional, and institutional barriers, with many reasons, such as ERAS programmes not meeting patient expectations and perspectives, issues related to medical and nursing staff (resistance to change, staff turnover and workload, and inadequate training and support) and institutional reasons, such as poor leadership, inadequate funding, and importantly a lack of good data collection that will in turn not allow reliable auditing and implementation of continuous feedback.32Tanious M.K. Ljungqvist O. Urman R.D. Enhanced Recovery After Surgery: history, evolution, guidelines, and future directions.Int Anesthesiol Clin. 2017; 55: 1-11Crossref PubMed Scopus (15) Google Scholar One issue that is seen as fundamental to benchmarking ERAS units and judging the success of ERAS as a whole is good-quality data collection. Contemporaneous good-quality data collection and analysis are required, which can then be benchmarked against other centres and compared over time. Where data are collected, such as ERAS Interactive Audit System or PQIP (vide supra), valuable data are produced to drive change in the future, for example, in the form of a live dashboard or regular updates.23Periopertive Quality Improvement Programmehttps://pqip.org.uk/pages/ar2019Date accessed: August , 2020Google Scholar,33Currie A. Soop M. Demartines N. Fearon K. Kennedy R. Ljungqvist O. Enhanced Recovery After Surgery interactive audit system: 10 years’ experience with an international web-based clinical and research perioperative care database.Clin Colon Rectal Surg. 2019; 32: 75-81Crossref PubMed Scopus (16) Google Scholar With increasing adoption of standardised electronic patient records, there is the huge potential to harness outcome data across health systems to improve data collection and drive necessary outcome changes. The issue of conducting high-quality research in perioperative medicine is frustrated by a marked variation in practice between centres, often investigating several interventions within the ERAS elements.34Kehlet H. Enhanced postoperative recovery: good from afar, but far from good?.Anaesthesia. 2020; 75: e54-61Crossref PubMed Scopus (52) Google Scholar This often results in losing any potential signal in improvement. The emphasis is thus moving towards much more tightly controlled patient-specific and procedure-specific interventions.35Joshi G.P. Alexander J.C. Kehlet H. Large pragmatic randomised controlled trials in peri-operative decision making: are they really the gold standard?.Anaesthesia. 2018; 73: 799-803Crossref PubMed Scopus (15) Google Scholar Moreover, the need for standardising patient-centred outcomes to facilitate comparison is viewed as fundamental in perioperative medicine trials.36Moonesinghe S.R. Jackson A.I. Boney O. et al.Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine initiative: patient-centred outcomes.Br J Anaesth. 2019; 123: 664-670Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar A number of patients do not fit the usual postoperative trajectory. Whilst much of ERAS focuses on procedure-specific issues, there are nevertheless patient-specific issues that will pose a clinical challenge, for example, an exaggerated stress response (both neuroendocrine and inflammatory). This area has been recently reviewed.37Manou-Stathopoulou V. Korbonits M. Ackland G.L. Redefining the perioperative stress response: a narrative review.Br J Anaesth. 2019; 123: 570-583Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar In particular, the neuroendocrine response, which is affected by the relative expression of glucocorticoid and mineralocorticoid receptors, determined genetically, can be further modified by illness, age, and deconditioning. These changes are associated with a number of common postoperative conditions, including cognitive dysfunction, myocardial injury, acute kidney injury, immunosuppression and infection, and muscle wasting, all of which will slow the expected progress of an ERAS patient.37Manou-Stathopoulou V. Korbonits M. Ackland G.L. Redefining the perioperative stress response: a narrative review.Br J Anaesth. 2019; 123: 570-583Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Other patients include those who are receiving long-term high-dose opioid, or who are pain catastrophisers that will need their analgesic pathways planned and modified in advance.34Kehlet H. Enhanced postoperative recovery: good from afar, but far from good?.Anaesthesia. 2020; 75: e54-61Crossref PubMed Scopus (52) Google Scholar Our 2012 editorial1Fawcett W.J. Mythen M.G. Scott M.J.P. Enhanced recovery—more than just reducing length of stay?.Br J Anaesth. 2012; 109: 671-674Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar focused on a trimodal approach: analgesia, goal-directed fluid therapy (GDFT), and ‘all the others’. At that time, analgesia and GDFT appeared to be pivotal in delivering ERAS; however, recent advances in these two areas have been modest: analgesia is delivered on a procedure-specific basis,38European Society of Regional Anaesthesia & Pain TherapyBetter postoperative pain management.https://esraeurope.org/prospect/Date accessed: August , 2020Google Scholar moving away from central neuraxial block (in spite of good early pain control) because of the associated problems of hypotension, immobility, and need for a urinary catheter. Although spinal anaesthesia can reduce LOS and modify the physiological response,39Levy B.F. Scott M.J. Fawcett W.J. Rockall T.A. 23-hour stay laparoscopic colectomy.Dis Colon Rectum. 2009; 52: 1239-1243Crossref PubMed Scopus (99) Google Scholar,40Day A.R. Smith R.V.P. Scott M.J.P. Fawcett W.J. Rockall T.A. Randomized clinical trial of spinal versus intravenous morphine on postoperative neuroendocrine responses.Br J Surg. 2015; 102: 1473-1479Crossref PubMed Scopus (23) Google Scholar many are now using more peripherally sited blocks, combined with regularly administered multimodal analgesia. Similarly, whilst fluid balance endpoints are agreed, avoiding too little or too much fluid administration (with patients at highest risk and least cardiac reserve probably benefiting the most), the optimal way of delivering this endpoint is still debated. It seems likely that timing of fluid administration is as crucial as the volume administered. Recent evidence from the FEDORA trial suggests that using goal-directed haemodynamic therapy for low- to moderate-risk patients undergoing intermediate risk surgery reduces complications and LOS, even if it does not reduce overall mortality.41Calvo-Vecino J.M. Ripolles-Melchor J. Mythen M.G. et al.Effect of goal-directed haemodynamic therapy on postoperative complications in low–moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial).Br J Anaesth. 2018; 120: 734-744Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Overall, many patients arrive relatively euvolaemic for theatre because of carbohydrate loading, reduced fasting, and reduced need for bowel preparation, and thus, the main aims are to replace ongoing requirements and losses. Recent studies have also shown the importance of maintaining perfusion pressure and optimizing flow.42Futier E. Lefrant J.Y. Guinot P.G. et al.Effect of individualized vs standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: a randomized clinical trial.JAMA. 2017; 318: 1346-1357Crossref PubMed Scopus (282) Google Scholar Although other intraoperative interventions have produced some encouraging results, such as total intravenous anaesthesia (in an attempt to reduce long-term cancer recurrence),43Wigmore T.J. Mohammed K. Jhanji S. Long-term survival for patients undergoing volatile versus IV anesthesia for cancer surgery: a retrospective analysis.Anesthesiology. 2016; 124: 69-79Crossref PubMed Scopus (237) Google Scholar deep neuromuscular block (to allow reduction in intra-abdominal pressures during minimally invasive surgery), and opioid-free anaesthesia (to reduce postoperative nausea and vomiting), they have yet to find a clear, evidence-based established place. An area of practice that requires renewed attention is ensuring that neuromuscular block is adequately reversed at the end of surgery, as the incidence is of postoperative residual curarisation and the associated sequalae are still high, although it is reduced by the use of quantitative neuromuscular monitoring.44Carvalho H. Verdonck M. Cools W. Geerts L. Forget P. Poelaert J. Forty years of neuromuscular monitoring and postoperative residual curarisation: a meta-analysis and evaluation of confidence in network meta-analysis.Br J Anaesth. 2020; 125: 466-482Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The focus for perioperative physicians will direct attention to other areas, such as patient blood management, nutrition, pre-habilitation, and glycaemic control, to early recognition and management of postoperative organ dysfunction and perioperative opioid stewardship (to minimise risks of opioid-related harm). The current COVID-19 pandemic has significantly reduced our ability to carry out major elective surgery. With reduced operating theatre capacity and bed availability, together with inevitable financial constraints that will face global economies, the scenario is set for ERAS to flourish, delivering high-quality care at reduced costs. In addition, early discharge may well reduce COVID-19 infection risk (from nosocomial and staff transmission). Some aspects of the ERAS pathway may have to be delivered remotely (such as preoperative and postoperative consultations and advice), the emphasis must be on delivering high-quality care (including minimal access surgery where appropriate), all conducted in a safe environment of patient testing, isolation, and optimal personal protective equipment. So, how do we join the dots for the future? If the benefits outlined here from ERAS were a single intervention, such as a drug or a procedure, ERAS would represent probably the biggest advance in medicine for years, and its implementation would be mandated. ERAS does not make bad surgery good, but it does make good surgery optimal. Yet, for a multistep pathway, there will always be the temptation to bypass many of the elements, hoping for the same benefits. The future of ERAS lies perhaps not so much in tweaks to existing clinical pathways, but rather in more strategic concepts:(i)Defining what endpoint(s) constitute recovery(ii)Instituting, optimising, and maintaining ERAS programmes in different specialties and healthcare systems(iii)Producing the best-quality research and other clinical evidence to direct simplified and the most important clinical care pathways, with a focus on patient-centred outcomes(iv)Producing the best-quality contemporaneous institutional outcome data to allow benchmarking, the incidence of complications (e.g. via use of dashboards) thus rapidly directing local changes in practice where unwanted variation in best practice occurs(v)Recognition by healthcare funders of the importance of optimal perioperative care, and their engagement in future planning Leaders of ERAS programmes must work with patients, managers, and healthcare funders to promote the importance of delivering optimal, evidence-based, and continuously audited care for all patients undergoing major surgery. To date, many dots have already been joined to create Kehlet's45Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.Br J Anaesth. 1997; 78: 606-617Abstract Full Text PDF PubMed Scopus (1610) Google Scholar goal of ‘pain and risk-free operation’, but it is not yet a continuous line, so we should not put away our pencils. WJF has received speaker, travel, and advisor honoraria from Grünenthal, Baxter, Merck, and Smiths. He is website editor and executive committee member of the ERAS Society. MGM is an editorial board member of the British Journal of Anaesthesia, consultant for Edwards Lifesciences, and consultant for Deltex Medical. MJS has received speaker, travel, and advisor honoraria from Edwards Lifesciences, Baxter, and Merck; is education chair and executive committee member of the ERAS Society; and is president-elect of ERAS USA.