Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology.

INTRODUCTION: Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The "Patient Blood Management" (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM. OBJECTIVE: To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice. MATERIAL AND METHODS: A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety. Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants). In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14). The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations. Statistical treatment: tabulation of mean, median and interquartiles 25-75 of the value of each survey question (Tables 1, 2 and 3). RESULTS: Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into: 1.- "It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients". 2.- "The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition". 3.- "There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8-10g/dL who are candidates for potentially bleeding surgery that cannot be delayed." 4.- "It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients." 5.- "Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term". CONCLUSIONS: There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

Documento de consenso de la Sociedad Española de Trasplante Hepático. Recuperación intensificada en trasplante hepático / Consensus document from the Spanish Society for Liver Transplantation: Enhanced recovery after liver transplantation

La Sociedad Española de Trasplante Hepático tiene como objetivo la promoción y elaboración de documentos de consenso sobre temas de actualidad en trasplante hepático de abordaje multidisciplinario. Para ello, en noviembre de 2022 se celebró la 10.ª Reunión de Consenso, con la participación de representantes de los 26 programas de trasplante hepático españoles autorizados. En esta edición se abordó la recuperación intensificada tras el trasplante hepático y se dividieron las acciones en 3periodos, preoperatorio, intraoperatorio y postoperatorio. Se exponen a continuación las evidencias evaluadas y las consecuentes recomendaciones consensuadas.(AU)

The goal of the Spanish Society for Liver Transplantation (Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses enhanced recovery after liver transplantation, dividing needed actions into 3periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.(AU)

Consensus document from the Spanish Society for Liver Transplantation: enhanced recovery after liver transplantation.

The goal of the Spanish Society for Liver Transplantation (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses Enhanced Recovery After Liver Transplantation, dividing needed actions into three periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.

Consensus document from the Spanish Society for Liver Transplantation: Enhanced recovery after liver transplantation. / Documento de consenso de la Sociedad Española de Trasplante Hepático. Recuperación intensificada en trasplante hepático.

The goal of the Spanish Society for Liver Transplantation (Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, in November 2022, the 10th Consensus Document Meeting was held, with the participation of experts from the 26 authorized Spanish liver transplantation programs. This edition discusses enhanced recovery after liver transplantation, dividing needed actions into 3periods: preoperative, intraoperative and postoperative. The evaluated evidence and the consensus conclusions for each of these topics are described.

Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study / Asociación entre el uso de protocolos de recuperación intensificada y complicaciones postoperatorias tras cirugía gástrica por cáncer (POWER 4): estudio nacional, prospective multicéntrico

Introduction: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. Methods: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). Results: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. Conclusions: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. (AU)

Introducción: La efectividad de los protocolos de recuperación intensificada o ERAS en la cirugía del cáncer gástrico sigue siendo controvertida. Métodos: Estudio de cohortes prospectivo multicéntrico de pacientes intervenidos de cáncer gástrico. Se evaluó la adherencia a 22 elementos ERAS en todos los pacientes, independientemente de la existencia de un protocolo ERAS. Cada centro tuvo un período de reclutamiento de tres meses, con un seguimiento de 30 días. La medida de resultado primario fue el numero de complicaciones posoperatorias moderadas a graves. Las medidas de resultado secundarias fueron el número total de complicaciones, la adherencia a los elementos ERAS, la mortalidad y la estancia. Resultados: Se incluyeron 743 pacientes en 72 hospitales, 211 (28,4 %) en centros ERAS. 245 pacientes (33 %) experimentaron complicaciones posoperatorias, moderadas o graves en 172 (23,1 %). No hubo diferencias en la incidencia de complicaciones moderadas a graves (22,3 % vs. 23,5 %; OR, 0,92 (IC 95 %, 0,59 a 1,41); P = 0,068), o complicaciones posoperatorias totales entre los centros ERAS y no ERAS (33,6 % vs. 32,7 %; OR, 1,05 (IC 95 %, 0,70 a 1,56); P = 0,825). La adherencia a los elementos ERAS fue del 52% [IQR 45 a 60]. No hubo diferencias entre los cuartiles de cumplimiento ERAS más alto (Q1, > 60 %) y más bajo (Q4, ≤ 45 %). Conclusiones: Ni la aplicación parcial de medidas ERAS ni el tratamiento en centros ERAS mejoraron los resultados en pacientes sometidos a cirugía gástrica por cáncer. (AU)

“Optimal recovery” after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation / “Recuperación óptima” tras cirugía por cáncer de colon en el paciente añoso. Resultados de un estudio de cohorte: Cuidados convencionales, Recuperación intensificada y programa de prehabilitación

Background: Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet. Methods: A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models. Results: A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively). Conclusions: PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used. (AU)

Introducción: El cáncer de colon (CC) en pacientes de edad avanzada es un problema creciente por su prevalencia y envejecimiento progresivo de la población. La prehabilitación ha experimentado un gran crecimiento en este campo sin haberse dilucidado si es el mejor estándar de cuidados para estos pacientes. Métodos: Estudio retrospectivo comparativo de cohortes de tres estándares diferentes de cuidados para pacientes mayores de 65 años con CC. Se compararon un programa de prehabilitación (PP) trimodal de cuatro semanas, uno de recuperación intensificada (RI) y cuidados convencionales (CC). Se midieron complicaciones globales, complicaciones mayores (Clavien-Dindo ≥ 3), reintervenciones, mortalidad, reingresos y estancia hospitalaria. La recuperación óptima fue la medida de resultado primaria. La influencia del estándar de atención en la recuperación óptima y los resultados postoperatorios se evaluó con modelos de regresión logística univariante y multivariante. Resultados: Se incluyeron 153 pacientes, 51 por grupo. La edad media fue 77,9 años. La distribución del ASA fue diferente entre los grupos (ASA III–IV: CC 56,9%, RI 25,5%, PP 58,9%; p = 0,014). La tasa de recuperación óptima fue del 55,6% (PP 54,9%, RI 66,7%, CC 45,1%; p = 0,09). No se encontraron diferencias en complicaciones mayores (p = 0,2) ni reintervenciones (p = 0,7). La recuperación sin incidencias favorece a los grupos RI y PP (p = 0,046 y p = 0,049 respectivamente). Conclusiones: PP y RI son seguros y efectivos para pacientes mayores con CC. Las complicaciones generales y reingresos en pacientes con RI y PP fueron menores. Las complicaciones mayores resultaron independientes del estándar de cuidados utilizado. (AU)

Association between use of enhanced recovery after surgery protocols and postoperative complications after gastric surgery for cancer (POWER 4): a nationwide, prospective multicentre study.

INTRODUCTION: The effectiveness of the Enhanced Recovery After Surgery (ERAS) protocols in gastric cancer surgery remains controversial. METHODS: Multicentre prospective cohort study of adult patients undergoing surgery for gastric cancer. Adherence with 22 individual components of ERAS pathways were assessed in all patients, regardless of whether they were treated in a self-designed ERAS centre. Each centre had a three-month recruitment period between October 2019 and September 2020. The primary outcome was moderate-to-severe postoperative complications within 30 days after surgery. Secondary outcomes were overall postoperative complications, adherence to the ERAS pathway, 30 day-mortality and hospital length of stay (LOS). RESULTS: A total of 743 patients in 72 Spanish hospitals were included, 211 of them (28.4 %) from self-declared ERAS centres. A total of 245 patients (33 %) experienced postoperative complications, graded as moderate-to-severe complications in 172 patients (23.1 %). There were no differences in the incidence of moderate-to-severe complications (22.3% vs. 23.5%; OR, 0.92 (95% CI, 0.59 to 1.41); P = 0.068), or overall postoperative complications between the self-declared ERAS and non-ERAS groups (33.6% vs. 32.7%; OR, 1.05 (95 % CI, 0.70 to 1.56); P = 0.825). The overall rate of adherence to the ERAS pathway was 52% [IQR 45 to 60]. There were no differences in postoperative outcomes between higher (Q1, > 60 %) and lower (Q4, ≤ 45 %) ERAS adherence quartiles. CONCLUSIONS: Neither the partial application of perioperative ERAS measures nor treatment in self-designated ERAS centres improved postoperative outcomes in patients undergoing gastric surgery for cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03865810.

"Optimal recovery" after colon cancer surgery in the elderly, a comparative cohort study: Conventional care vs. enhanced recovery vs. prehabilitation.

BACKGROUND: Colon cancer in elderly patients is an increasing problem due to its prevalence and progressive aging population. Prehabilitation has experienced a great grown in this field. Whether it is the best standard of care for these patients has not been elucidated yet. METHODS: A retrospective comparative cohort study of three different standards of care for elderly colon cancer patients (>65 years) was conducted. A four-weeks trimodal prehabilitation program (PP), enhanced recovery program (ERP) and conventional care (CC) were compared. Global complications, major complications (Clavien-Dindo ≥ 3), reinterventions, mortality, readmission and length of stay were measured. Optimal recovery, defined as postoperative course without major complications, no mortality, hospital discharge before the fifth postoperative day and without readmission, was the primary outcome measure. The influence of standard of care in optimal recovery and postoperative outcomes was assessed with univariate and multivariate logistic regression models. RESULTS: A total of 153 patients were included, 51 in each group. Mean age was 77.9 years. ASA Score distribution was different between groups (ASA III-IV: CC 56.9%, ERP 25.5%, PP 58.9%; p = 0.014). Optimal recovery rate was 55.6% (PP 54.9%, ERP 66.7%, CC 45.1%; p = 0.09). No differences were found in major complications (p = 0.2) nor reinterventions (p = 0.7). Uneventful recovery favors ERP and PP groups (p = 0.046 and p = 0.049 respectively). CONCLUSIONS: PP and ERP are safe and effective for older colon cancer patients. Fewer overall complications and readmissions happened in ERP and PP patients. Major complications were independent of the standard of care used.

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Protocolos de recuperación mejorada en cirugía cardiaca. Revisión sistemática con metanálisis de ensayos clínicos aleatorizados / Improved recovery protocols in cardiac surgery: Systematic review with metaanalysis of randomized clinical trails

Introducción: Múltiples son los esfuerzos realizados para incluir los protocolos de recuperación mejorada como un indicador de calidad en la atención al paciente quirúrgico, bajo la premisa de acelerar la recuperación de los enfermos, sin que esto vaya en detrimento del proceso asistencial y obtener su alta satisfacción. Para ello se hace necesario el desarrollo de la investigación avalada por la mejor evidencia científica y práctica. Objetivo: Estimar, a través de la literatura publicada, la efectividad de la aplicación de los protocolos de recuperación precoz sobre la evolución perioperatoria de pacientes a los que se les realizan procedimientos quirúrgicos cardíacos. Método: Se incluyeron ensayos clínicos controlados y aleatorizados, publicados entre enero del año 2013 y mayo de 2020. La revisión sistemática se realizó según las recomendaciones del manual 5.1.0 para revisores de la biblioteca Cochrane. Resultados: Se analizaron 6 estudios (687 pacientes/Grupo estudio=345, Grupo Control=342). La calidad metodológica de la mayoría de las investigaciones evaluadas fue buena. Se muestra una superioridad de los protocolos, ya que se acompañan de una disminución en la incidencia de complicaciones perioperatorias (RR=0,61 [0,40, 0,93]). De forma similar se encuentran relacionados con la disminución la estadía hospitalaria (diferencia de medias, efecto aleatorio, fue de -2,98 [-3,31, -2,65]. Conclusiones: A pesar de los pocos estudios incluidos, la evidencia sugiere que estos programas mejoran la evolución perioperatoria de los pacientes(AU)

Introduction: Multiple efforts are made to include improved recovery protocols as an indicator of quality in care for surgical patients, under the premise of accelerating the recovery of patients, without this being detrimental to the care process, and thus guarantee high patient satisfaction. In view of this, the development of research supported by the best scientific and practical evidence is necessary. Objective: To estimate, through the published literature, the effectiveness of the application of early recovery protocols on the perioperative evolution of patients who undergo cardiac surgical procedures. Method: Randomized controlled clinical trials, published between January 2013 and May 2020, were included. The systematic review was carried out according to the recommendations of the Cochrane Library manual 5.1.0 for reviewers. Results: Six studies were analyzed (687 patients/study group: 345, control group: 342). The methodological quality of most of the researches assessed was good. A superiority of the protocols is shown, since they are accompanied by a decrease in the incidence of perioperative complications (RR=0.61 [0.40, 0.93]). Similarly, they are related to the decrease in hospital stay (mean difference, random effect, was -2.98 [-3.31, -2.65]). Conclusions: Despite the few studies included, the evidence suggests that these programs improve the perioperative outcome of patients(AU)

Multidisciplinary consensus on nutritional and metabolic therapy in enhanced recovery after abdominal surgery programs: NutRICA Project. / Consenso multidisciplinar sobre la terapia nutricional y metabólica en los programas de recuperación intensificada en cirugía abdominal: Proyecto NutRICA.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. OBJECTIVE: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. METHODS: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. RESULTS: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. CONCLUSION: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP) / Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP)

La vía clínica de recuperación intensificada en cirugía cardiaca (RICC) pretende identificar, difundir y favorecer la implementación de las mejores actuaciones basadas en la evidencia científica para disminuir la variabilidad en la práctica clínica. La puesta en marcha de estas prácticas en el proceso clínico global favorecerá la obtención de mejores resultados, acortamiento de estancias hospitalarias y en la Unidad de Cuidados Críticos, lo que permitirá una reducción de costes y una mayor eficiencia. Tras realizar una revisión sistemática en cada uno de los puntos del proceso perioperatorio en cirugía cardiaca, se han redactado recomendaciones basadas en la mejor evidencia científica disponible en la actualidad con el consenso de las sociedades científicas implicadas.(AU)

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.(AU)

Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). / Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP).

The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.

[Is postoperative acute pain control in colorectal surgery better within an enhanced recovery after surgery program (ERAS)?] / ¿Mejora el control del dolor postoperatorio en cirugía colorrectal tras la implementación de un protocolo de rehabilitación intensificada (ERAS)?

BACKGROUND AND OBJECTIVE: A good acute pain control is necessary to achieve the main objective of Enhanced recovery After Surgery (ERAS) programs and accelerate recovery. The study objective is to evaluate postoperative (PO) acute pain, PO opioid consumption, and its association with functional recovery, after implementing a colorectal surgery ERAS program. An analysis was made as regards drugs adverse effects. METHODS: Observational cohort study on scheduled colorectal Surgery: one prospective cohort subjected to the ERAS care program, and one retrospective cohort that received traditional non-standardised care. A record was made of mean pain intensity (measured by a visual analogue scale, which classifies pain intensity from 0 to 10, from lower to higher intensity), as well as the amount of opioid consumption on the day of surgery and on the first three postoperative days, and drugs adverse effects. An analysis was made of the association between PO opioid consumption and ERAS program, and between PO opioid consumption and functional recovery. RESULTS: The study included a total of 410 patients (313 in the ERAS group and 97 in the control group). In the ERAS group, it was observed that the mean visual analogue scale was less than 2, with a smaller amount of PO opioid consumption, on each single day and the accumulated amount of the four days (4 [0-24] vs. 0 [0-4], P<.001). PO opioid consumption was associated with functional recovery (OR 0.97 [95% CI; 0.96-0.99], P=.011). No drugs adverse effects were observed. CONCLUSIONS: After implementing a colorectal Surgery ERAS program, good pain control was achieved, as well as a reduction in PO opioid consumption, which is associated with functional recovery. No drugs adverse effects were observed.

Enhanced recovery after bariatric surgery. / Rehabilitación multimodal en cirugía bariátrica.

Enhanced recovery after surgery (ERAS) protocols are care programs based on scientific evidence and focused on postoperative recovery. They encompass all aspects of patient care and require multidisciplinary management, with the participation of diverse specialists. The implementation of these protocols is being extended to several abdominal and extra-abdominal surgeries, including bariatric approaches. Diverse specialists with wide experience in the management of morbidly obese patients have taken part in the working group that developed this protocol. A bibliographic search about ERAS in bariatric surgery in several databases was performed to evaluate the current scientific evidence, establishing evidence levels and recommendations according to the GRADE methodology. The items included in this protocol are separated into preoperative, perioperative and postoperative guidelines.

Nursing role on rapid recovery programmes fast-track. / Rol de enfermería en los programas de recuperación intensificada (fast-track).

Rapid recovery (RR) or fast-track programmes are aimed at reducing surgical stress, leading to a reduction in nurse workload, costs and hospital stay, greater patient empowerment, early post-surgical recovery and reduced morbidity and mortality. These new protocols require the coordinated participation of a multidisciplinary team. Based on an integrative review of the literature, this paper aims to define the concept of a RR or fast track programme and show the existing evidence on the implementation of these programmes in nursing. The benefits and low incidence of damage of RR programmes in nursing justify their implementation. The programmes require greater support and diffusion in order to develop, as well as more research to increase the evidence on the effectiveness and efficiency of the protocols.

Enhanced recovery after surgery in gastric resections. / Rehabilitación multimodal en la cirugía de resección gástrica.

INTRODUCTION: Enhanced recovery after surgery is a modality of perioperative management with the purpose of improving results and providing a faster recovery of patients. This kind of protocol has been applied frequently in colorectal surgery, presenting less available experience and evidence in gastric surgery. METHODS: According to the RICA guidelines published in 2015, a review of the bibliography and the consensus established in a multidisciplinary meeting in Zaragoza on the 9th of October 2015, we present a protocol that contains the basic procedures of fast-track for resective gastric surgery. RESULTS: The measures to be applied are divided in a preoperative, perioperative and postoperative stage. This document provides recommendations concerning the appropriate information, limited fasting and administration of carbohydrate drinks 2hours before surgery, specialized anesthetic strategies, minimal invasive surgery, no routine use of drainages and tubes, mobilization and early oral tolerance during the immediate postoperative period, as well as criteria for discharge. CONCLUSIONS: The application of a protocol of enhanced recovery after surgery in resective gastric surgery can improve and accelerate the functional recovery of our patients, requiring an appropriate multidisciplinary coordination, the evaluation of obtained results with the application of these measures and the investigation of controversial topics about which we currently have limited evidence.

Impact of an enhanced recovery after surgery programme in radical cystectomy. A cohort-comparative study. / Impacto de un programa de recuperación intensificada en cistectomía radical. Estudio comparativo de cohortes.

OBJECTIVE: To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital. MATERIAL AND METHODS: A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared. RESULTS: No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001). CONCLUSION: Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.

Spanish survey on enhanced recovery after surgery. / Encuesta nacional sobre cirugía con recuperación intensificada.

INTRODUCTION: The aim of this study was to determine the interest in ERAS protocols, and the extent to which clinicians are familiar with and apply these protocols during perioperative care. MATERIALS AND METHODS: Free access survey hosted on the Spanish Society of Anesthesiology and Critical Care; Spanish Association of Surgeons and Spanish Society of Enteral and Parenteral nutrition and ERAS Spain (GERM) websites conducted between September and December 2014. RESULTS: The survey was answered by 272 professionals (44.5% anaesthetists, 45.2% general surgeons) from 110 hospitals, 73% of whom had experience in ERAS protocols. Most (86.1%) had specific knowledge of ERAS protocols, whereas only 50.9% were familiar with ERAS recommendations and 42.4% with GERM recommendations. Most (73.1%) respondents reported that ERAS protocols are performed in their hospitals, mainly in colorectal surgery (93%), and 52.2% reported that GERM/ERAS recommendations are followed. Nearly all (95.5%) would be interested in the development of multidisciplinary national guidelines. Less than half (46.6%) perform preoperative nutritional assessment, albeit without a universal malnutrition screening method (56.8%). Preoperative loading with carbohydrate drinks is carried out in only 51.4% of cases; nasogastric tube and drainage are avoided (79.3%), prophylaxis for postoperative nausea and vomiting (73.4%), goal directed fluid therapy (73.3%), and active normothermia maintenance (87.4%) are performed. In most cases, mobilization (90.1%) and early feeding (87.9%) are performed. The leading causes of protocol failure are postoperative nausea and vomiting (46.5%) and ileus (58.9%). CONCLUSION: Clinicians in Spain are familiar with fast track protocols, although there is no overall consensus, and hospitals do not adhere to existing guidelines. Overall compliance with the items of the protocol is adequate, although perioperative nutritional management is poor.