I. Enhanced recovery: more than just reducing length of stay?

Abstract

The concept of enhanced recovery (ER) after surgery is not new. It was pioneered in Denmark in the 1990s and in that time has been practiced under various names, including fasttrack surgery and accelerated recovery. Currently, NHS improvement is leading a major initiative in the UK to implement ER across a number of specialities, including colorectal, musculoskeletal, urology, gynaecology, and breast surgery (http:// www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/ @en/@ps/documents/digitalasset/dh_115156.pdf). The major evidence base to date is from colorectal surgery. It is noteworthy that in spite of anaesthesia having a pivotal role in driving ER forward, many of the publications are found in surgical journals. There are many traditionally perceived benefits from ER, for patients, healthcare professionals, and hospital managers. Patients recover from surgery more swiftly and are able to resume their normal lifestyle more quickly. For healthcare professionals and managers, patients spend less time in hospital resulting in either more capacity or a reduced requirement for hospital beds and therefore cost. Of the many criteria used to judge ER, length of stay (LOS) is the most commonly used. It is widely collected and allows easy comparisons between units. Dramatic reductions in LOS have been described including 23 h stay laparoscopic colectomy. However, there are several pitfalls associated with LOS. Time fit for medical discharge is probably a better marker but may not be the same in all hospitals and is not always the same as LOS, as it is recognized that patients may remain in hospital for reasons other than medical ones. In addition, some use the mean LOS, while others use the median LOS. This can be misleading; for example, in a group of patients in which a small number have a very prolonged LOS, the median LOS effectively ignores these patients. Despite these points, LOS (mean or median) is still so widely used that a reduction in LOS is almost seen as the raison d’etre of ER. There are, however, potentially more benefits other than having patients in hospital for less time. ER allows patients to recover quicker, using a number of techniques including preoperative carbohydrate loading, small incision surgery, reduced tubes, drains, etc., minimal use of opioid analgesia, avoidance of sodium and/or fluid overload, early resumption of enteral feeding, and early mobilization. This has been encompassed into a protocol-driven care pathway ensuring great consistency in patient treatment, from the preoperative phase through to discharge. Importantly, it has been demonstrated that the greater adherence to ER protocols, the greater the improvement in clinical outcome. Of all the steps that are important in colorectal surgery (some 20 in all), we have simplified them to analgesia, goal-directed fluid therapy (GDFT), and ‘all the others’ in the ER pathway and have termed this the trimodal approach. Perioperative analgesia and i.v. fluid therapy are generally under the control of the anaesthetist. The rewards are great if these processes are performed well but can be disastrous for patients if they are poorly conducted. Inadequate analgesia can result in poor mobilization, sleep deprivation, and ultimately an exaggerated stress response, or side-effects from excessive or inappropriate medication. The optimum analgesic regimen for many types of surgery is often contested. Volume 109, Number 5, November 2012