Enhanced Recovery (ER) after Surgery (or Fast Track) is a bundle of ‘best evidence based practices’ delivered by a multi-professional health care team, with the intention of helping patients recover faster after surgery [1]. Professor Henrik Kehlet, a surgeon from Denmark, pioneered the concept more than a decade ago but practitioners in the UK remained sceptical of his amazing results and adoption in the National Health Service (NHS) had been slow [1,2]. The Enhanced Recovery Partnership Programme (ERPP) was set up by the Department of Health in England in May 2009, to encourage the widespread adoption of ER with the aim of improving recovery from major surgery [1,3]. The Programme initially concentrated on elective major surgery in four specialities (Colorectal, Musculoskeletal, Gynaecology and Urology). Audit of ER practice by the early adopters demonstrated greater than 80% compliance with the majority of elements recommended by the ERPP. However, perioperative fluid management including the administration of pre-operative carbohydrate drinks and individualised goal directed fluid management guided by advanced haemodynamic monitoring (e.g. Oesophageal Doppler) had lower levels of compliance [3]. A pilot study using Commissioning for Quality and Innovation (CQUIN) to encourage practice change showed a dramatic improvement in outcomes in North Central London with very high levels of compliance with the ERPP recommended principles of perioperative fluid management, in particular goal directed fluid management [4]. The National Programme has evolved into the Enhanced Recovery Partnership (ERP), and the most recent guide published by the ERP includes evidence of widespread adoption of ER in the NHS in England and achievement of stated goals i.e. reduced length of hospital stay after surgery resulting in more operations being performed despite fewer bed days, no increase in readmissions and high levels of patient satisfaction [5]. Perioperative fluid management is at the heart of Enhanced Recovery and the use of intra-operative fluid management technology, such as Oesophageal Doppler, is supported by the ERP in line with the National Institute of Clinical Excellence (NICE) Guidance (MTG3), the NHS Operating Framework 2012–13 and the Department of Health Innovation Health and Wealth Review 2011 [5-7]. Despite concordance in the guidelines, the veracity of the evidence has been challenged [8,9]. The ERP thought it was timely to produce a consensus statement from the National Clinical Leads and Specialist Advisors within the specific context of Enhanced Recovery and, for the purpose of widespread dissemination, the general principles and key recommendations outlined in the latest guide are reiterated in this article [5]. Of note, no particular evidence based methodology was used aside from seeking unanimous agreement from the authors. A practical and pragmatic set of guidelines and recommendations was the aim. The conclusions do align with the GIFTASUP guidelines and NICE guidance where established EBM methodologies were utilised [6,8,10]. In making this consensus statement we agree that larger, more definitive studies of perioperative fluid management and, in particular, the relative contribution of haemodynamic monitoring compared with fluid restriction would be welcomed [11,12]. However, to be useful, such studies must be conducted in the context of a fully implemented Enhanced Recovery Program.
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Apr 1, 2016
Mingkwan Wongyingsinn + 3
