Enhanced recovery after surgery (ERAS) in Latin America: The story so far.

Despite modern perioperative care, postoperative complications continue to play a significant role in patient's recovery. Implementation of enhanced recovery pathways has consistently demonstrated better outcomes, reduced complications, and improved length of stay across the globe. However, the literature is scarce with regard to the peaks and valleys encountered during the implementation of these programs in Latin America. The purpose of this review is to shed light on the development and establishment of enhanced recovery pathways in the region. Moreover, it discusses current challenges and future perspectives on perioperative optimization.

Nausea and vomiting in a colorectal ERAS program: Impact on nutritional recovery and the length of hospital stay.

BACKGROUND & AIMS: Postoperative nausea and vomiting (PONV) and its impact on the hospital length of stay (LOS), have been extensively studied. However, most previous publications focused their studies on PONV during the first 24 h, and less is known about this complication during the ensuing days, its impact on nutritional recovery or its relation to other complications and the course of care. METHODS: An observational study involving 806 consecutive patients in a colorectal Enhanced Recovery After Surgery (ERAS) programme was performed. The primary objective was to analyse the incidence of early PONV on the day of surgery and the following 2 postoperative days (late PONV). Secondary objectives included evaluation of the influence of late PONV over the LOS and the nutritional recovery adjusted for confounding factors. RESULTS: PONV tended to increase over time (7% vs 7% and 10%, postop days 0, 1 and 2, respectively; p < 0.05). PONV on day 2 was associated in an adjusted analysis with poor oral intake, delayed solid food tolerance and an average increase in LOS of 2 nights. Risk factors for the presence of PONV on day 2 were the use of opioids on the same day, PONV on the day of the surgery and rectal procedures. CONCLUSIONS: PONV continues to be frequent after the first 24 h in colorectal surgery despite high compliance to current anti emetic recommendations. PONV during day 2 negatively affects the nutritional postoperative recovery and independently prolongs the hospital stay. The findings of the current study highlight the adverse effects of opioids and the need of further discussion on how to best audit, prevent and treat late PONV in ERAS colorectal programmes.

Total intravenous anesthesia with midazolam, remifentanil, propofol and cistracurium in morbid obesity.

BACKGROUND: According to physical impairments of massive obesity, cardiac, respiratory and gastrointestinal physiology must be considered as much as pharmacokinetic behavior. Anesthetic management of morbidly obese patients has to be carefully planned, in order to minimize the increased risks of aspirative pneumonitis, hemodynamic instability and delay in recovery. The ideal anesthesia should provide a smooth and quick induction, allowing rapid airway control, prominent hemodynamic stability, and rapid emergence from anesthesia. To approach these ideal conditions, a Total Intravenous Anesthesia (TIVA) with midazolam, remifentanil, propofol and cisatracurium was designed and analyzed. METHODS: 10 consenting morbidly obese patients scheduled for elective Laparoscopic Adjustable Gastric Banding participated in the study. TIVA with midazolam, remifentanil, propofol and cisatracurium was used in all cases. Time to loss of consciousness, tracheal intubation, perianesthetic physiological parameters and complications, incidence of awareness with recall, recovery times, postoperative analgesia and costs of drugs were evaluated. RESULTS: The analyzed data showed adequate time and physiological conditions for induction and tracheal intubation, stable maintenance with easy handling of deepness, low incidence of perianesthetic complications, excellent recovery performance and institutional efficiency. CONCLUSIONS: TIVA with midazolam, remifentanil, propofol and cisatracurium was found to be effective, secure, predictable and economic for the anesthetic management of morbidly obese patients.