Kühn/Schulz: In Your Opinion, Are There Any Specific Values or Parameters That Disqualify Certain Patients for Enhanced Recovery Programs after Surgery?
No, but ERAS may be limited by comorbidity and impaired mobility – in any case, an individualized approach should be attempted.
Severe neurologic impairment (hemiplegia, severe dementia, advanced M. Parkinson, …) does impose a burden which may exclude patients from participating in ERAS programs. However, this is a general remark and is not based on specific values or parameters. Thus, I propose an individual evaluation of any patients at risk.
No. The components of the ERAS concept are defined in a standardized manner in the respective current guideline. There are patient-specific limitations that exclude patients from single or multiple items from the outset. For example, a patient who does not spend more than 4 h a day out of bed preoperatively is not expected to be able to do so postoperatively. Depending on the preoperative condition, it is possible that patients will not achieve the required 70% overall compliance. In terms of a database, such patients would be formally excluded from the program. Nevertheless, a large part of the program implementation is a culture change in daily clinical care. This means that even for patients outside the pathway, every single item is checked and fulfilled on a patient-specific basis so that such patients are formally treated outside the pathway but in practice receive the same care. Furthermore, these patients are an absolute minority. Even most of the older frail patients have been successfully treated within the pathways.
Kühn/Schulz: Thoracic Epidural Analgesia versus Patient-Controlled Analgesia – What Do You Prefer for Postoperative Pain Management after Major Abdominal Surgery? What Are the Reasons for Your Preference?
Thoracic epidural analgesia (TEA) is the preferred mode in major open abdominal surgery, patient-controlled analgesia (PCA) in laparoscopic surgery. This is in line with the literature. Our experience is good.
Given that there are no contraindications for TEA (anticoagulation, severe communication deficit, language barrier, …), TEA is preferred. The reason for that is the sympathicolysis without systemic opioid therapy. However, TEA must be removed quickly enough in order for patients to benefit from ERAS programs. Therefore, major liver surgery leading to impaired coagulation and consecutive contraindication for TEA removal (low prothrombin time, low platelets, …) in the days following surgery must be evaluated carefully. Prolonged TEA must be carefully balanced against rapid patient discharge to ambulatory care.
In our clinic, we have very good experience using the transverse-abdominal plane block (TAP block). It can be applied safely, especially laparoscopically, but also in open surgery. The data in this respect are more than promising, and a publication is in preparation. It changed our standard procedure for postoperative pain management. Regarding the abovementioned procedures, we prefer intravenous PCA. The major problem with both procedures is the partial immobilization of patients, as wiring of any kind limits mobility. Randomized data related to TEA versus PCA in the context of an ERAS program showed a shorter hospitalization for patients with PCA.
Kühn/Schulz: What Risk Score or Stratification Are You Using to Identify Patients at Higher Postinterventional Risk?
Weight loss >10–15% within 6 months
BMI <18.5 kg/m2
SGA C or NRS >5
Preoperative serum albumin <30 g/L (with no evidence of hepatic or renal dysfunction).
In our department, during the routine preoperative assessment, we use a frailty check consisting of several screening items (i.e., recent weight loss, physical activity [MET] assessment, physical strength assessment, walking speed, and the MiniCog-Test).
It has been shown several times that a trimodal prehabilitation can achieve the best effects. The pillars mentioned here are psychological support, nutritive support, and physical activity. These three cornerstones for risk constellations must be detected. There are validated scores for all areas which represent problems with a good sensitivity. In our own procedure, we use
Nutrition Risk Score (NRS), if necessary, bio-impedance analysis.
Psycho-oncological interview in case of abnormalities Center for Epidemiologic Studies-Depression (CES-D) scale, if necessary, also full geriatric assessment.
Conversation about general everyday coping and if necessary, Short Questionnaire to Assess Health-enhancing Physical Activity (SQUASH).
Kühn/Schulz: What Would a Prehabilitation Program in Your Hospital Look Like? What Measures Would You Apply in Patients with a Significantly Reduced Status?
Shared decision-making regarding risk stratification and potential benefit of prehabilitation. Individualized including oral nutritional supplements and physiotherapy for 4–6 weeks, at least once psychological support.
After identifying patients at risk, measures must be taken in order to reduce postoperative complications for the respective patients. Preventing weight loss, increasing muscle strength, and respiratory training aiming at improving pulmonary function are some of the measures which should be taken in order to optimize patients’ outcome.
Unlike ERAS concepts, a prehabilitation program must be tailored to the individual patient and can range from a full geriatric assessment with preoperative inpatient stay to outpatient nutritional counseling. The vast majority of these patients are treated within the framework of study protocols and real-world data from clinical practice (which must then also reflect economic aspects) remain to be seen. The early identification of high-risk patients with suitable scores, including cognitive function if necessary, is essential. In our own procedure, cognitive function may also be assessed. Some groups perform spiroergometry as a standard procedure, but many high-risk patients cannot be expected to undergo this. Looking at the current literature, only frail patients seem to benefit from prehabilitation in terms of a better postoperative outcome.
Kühn/Schulz: Do You Have a Clear Indication/Cutoff Value for Preoperative Parenteral Nutrition?
According to the ESPEN guideline, preoperative PN shall be administered only in patients with malnutrition or severe nutritional risk, where energy requirement cannot be adequately met by enteral nutrition (A). A time period of 7–14 days is recommended (0).
Since anesthetists mostly see the respective patients on the preoperative day in order to evaluate the patient and obtain informed consent, I am not involved in preoperative parenteral nutrition, and therefore, I do not have a clear cutoff value for preoperative parenteral nutrition. However, low BMI, low serum protein/albumin, low muscle strength/wasting, or inability to ingest enteral nutrition are strongly suggestive for implementing preoperative parenteral nutrition.
As in many aspects, the nutritive status should be as good as possible, and a widely established value is the serum albumin level (>30 mg/dL). The serum albumin level is a clear risk factor for postoperative morbidity, especially for anastomotic leakage. So, if possible, patients with a lower albumin level should receive protein drinks and parenteral nutrition. However, as in many clinical applications, patient-specific target values should be established. Related to what can the patient achieve and what would be specifically desirable for the individual procedure and the underlying disease.
Kühn/Schulz: What Are Your Measures to Address a Higher Comorbidity and Peri-Interventional Risk due to an Aging Society and Increased Frailty?
Awareness for the increased risk, risk assessment including functional scores (Fried frailty, 6MWD), and even cognitive function (Mini Mental Status Test).
Anesthesia must be adapted to the frail population treated in the university hospital setting. Focus must be on the patient’s recovery following surgery. Especially pulmonary complications must be avoided. Therefore, respiratory therapy in combination with potent analgesia are valuable measures in this respect.
Based on our standards, we do not differentiate between patient groups in the baseline assessment. If there are abnormalities in the basic assessment, additional tools are added according to the modular principle. Nevertheless, we implemented a delirium prophylaxes pathway, as this is a main problem in frail patients.
Kühn/Schulz: How Did the Pandemic Change Your Postoperative/Postinterventional Management and How Do You Address the Nursing Staff Shortage in Your Hospital?
No delay for cancer surgery. No change in postoperative interventional management. The nursing staff shortage with turnover leads to a prioritization of duties and is a considerable burden for ERAS including nutritional care.
During the COVID-19 pandemic, ICU beds for non-COVID-19 patients were short. However, the main reason for this dramatic shortage in ICU capacity is the shortage in nursing staff. Therefore, focus must be placed on avoiding fluctuation in nursing staff, holding nurses in their job, and by making this important job by all means attractive. Although the pandemic does not affect the intensive care units at the moment, the shortage in ICU beds persists. Therefore, I give my very best to enable major visceral surgery even without postoperative ICU capacity (prolonged PACU stay, postoperative intermediate care unit rather than ICU, …).
In addition to the positive patient-related aspects of an ERAS program, a major aspect that is important in the current situation is the relief for hospital staff. In the ERAS concept, enlightened and empowered patients become active members of their own treatment through diaries, checklists, and predefined pathways. In addition to the effects of the shorter length of stay, which automatically reduces the hours of care, informed patients are also significantly more independent. Almost all items of the pathway also lead to a reduction in nursing work (drains that are not placed do not have to be taken care, patients who are out of bed can also weigh themselves, etc.). The last point is that the nursing staff started to identify themselves with their daily work again.
Conflict of Interest Statement
Florian Kühn: no conflicts of interest to declare. Christian Schulz: no conflicts of interest to declare. Arved Weimann: lecture fees: Baxter, B. Braun/Melsungen, Fresenius Kabi, Falk Foundation; research grant: B. Braun, Mucos Patrick Scheiermann: no conflicts of interest to declare. Steffen Seyfried: no conflicts of interest to declare. Christoph Reissfelder: no conflicts of interest to declare.
Dr. Florian Kühn
Department of General, Visceral and Transplant Surgery
University Hospital of LMU Munich
81377 Munich, Germany
Prof. Christian Schulz
Medical Department II
University Hospital, LMU Munich
81377 Munich, Germany
Prof. Dr. Arved Weimann
Abteilung für Allgemein-, Viszeral- und Onkologische Chirurgie
Klinikum St. Georg, Leipzig
Delitzscher Str. 141
04129 Leipzig, Germany
Dr. Patrick Scheiermann
Department of Anesthesiology
LMU University Hospital – Campus Großhadern
81377 Munich, Germany
Dr. Steffen Seyfried
Department of Surgery, Universitätsmedizin Mannheim
Medical Faculty Mannheim, Heidelberg University
68167 Mannheim, Germany
Prof. Christoph Reissfelder
Department of Surgery
Universitätsmedizin Mannheim, Medical Faculty Mannheim
68259 Mannheim, Germany