Canadian journal of anaesthesia = Journal canadien d'anesthésie
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Review
Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS).
Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. ⋯ Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and "permissive oliguria" could be tolerated.
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Goal-directed fluid therapy is an integral component of many Enhanced Recovery After Surgery (ERAS) protocols currently in use. The perioperative clinician is faced with a myriad of devices promising to deliver relevant physiologic data to better guide fluid therapy. The goal of this review is to provide concise information to enable the clinician to make an informed decision when choosing a device to guide goal-directed fluid therapy. ⋯ The ERAS protocols typically involve a multipronged regimen to facilitate early recovery after surgery. Optimizing perioperative fluid therapy is a key component of these efforts. While no technology is without limitations, the majority of the currently available literature suggests esophageal Doppler and arterial waveform analysis to be the most desirable choices to guide fluid administration. Their performance is dependent, in part, on the interpretation of dynamic changes resulting from intrathoracic pressure fluctuations encountered during mechanical ventilation. Evolving practice patterns, such as low tidal volume ventilation as well as the necessity to guide fluid therapy in spontaneously breathing patients, will require further investigation.
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Frailty has no single universally accepted definition or method for assessment. It is commonly defined from a physiological perspective as a disruption of homeostatic mechanisms ultimately leading to a vulnerable state. Numerous scoring indices and assessments exist to assist clinicians in determining the frailty status of a patient. The purpose of this review is to discuss the relationship between frailty and perioperative outcomes in surgical patients. ⋯ Patients undergoing surgery who are deemed frail, regardless of the scoring assessment used, have a higher likelihood of experiencing adverse perioperative outcomes. With the lack of a unified definition for frailty, further research is needed to address which assessment method is most predictive of adverse postoperative outcomes.
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Review Case Reports
Prevention of venous thromboembolism in the Enhanced Recovery After Surgery (ERAS) setting: an evidence-based review.
To review the evidence surrounding appropriate prophylaxis for venous thromboembolism (VTE) in patients undergoing surgery. ⋯ Venous thromboembolism is a serious but preventable complication of hospitalization, especially among surgical patients. Historically, it has accounted for a high burden of postoperative morbidity and mortality. In the Enhanced Recovery After Surgery era, our aim should be no less ambitious than the eradication of postoperative VTE.
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Review
Cardiopulmonary exercise testing, prehabilitation, and Enhanced Recovery After Surgery (ERAS).
This review evaluates the current and future role of cardiopulmonary exercise testing (CPET) in the context of Enhanced Recovery After Surgery (ERAS) programs. ⋯ Perioperative CPET is finding an increasing spectrum of roles, including risk evaluation, collaborative decision-making, personalized care, monitoring interventions, and guiding prescription of prehabilitation. These indications are potentially of importance to patients having surgery within an ERAS program, but there are currently few publications specific to CPET in the context of ERAS programs.