1. Enhanced Recovery Principles and Practice
Julie Marosky Thacker, MD, FACS, FASCRS
ASER-EPBOM, April 2016

2. Disclosures
Merck Edwards LifeScience Cheetah Medical Covidien-Medtronic Premier Abbott Nutritional

4. 20072016

5. Lassen, BMJ 2005 Response Sweden Norway Range NG is removed in OR 75
Scotland
Netherlands
Sweden
Norway
Denmark
Range
NG is removed in OR 75 22 83 82 85
22-85%
Epidural analgesia is used routinely on general ward 11 93 89 96
11-96%
Resume clear fluids day of surgery 38 58 71
38-96%
Resume oral intake at will by POD1 27 46 44 53
27-85%
Lassen, BMJ 2005

6. Enhanced Recovery Publications-SOURCE 2010
Thacker, ACS NSQIP 2015

7. Enhanced Recovery Publications-TOPIC 2010
Thacker, ACS NSQIP 2015

8. Enhanced Recovery Publications-SOURCE 2015
Thacker, ACS NSQIP 2015

9. US Enhanced Recovery Publications-Combined Effort, 2015
Thacker, ACS NSQIP 2015

10. Enhanced Recovery Publications-TOPIC 2015
Thacker, ACS NSQIP 2015

11. Lassen, BMJ 2005 Response Sweden Norway Range NG is removed in OR 75
Scotland
Netherlands
Sweden
Norway
Denmark
Range
NG is removed in OR 75 22 83 82 85
22-85%
Epidural analgesia is used routinely on general ward 11 93 89 96
11-96%
Resume clear fluids day of surgery 38 58 71
38-96%
Resume oral intake at will by POD1 27 46 44 53
27-85%
Lassen, BMJ 2005

12. Gustaffson, WJS 2016

13. Principles and Practice, 2016
Differentiate
Care ELEMENTS
PRINCIPLES of enhanced recovery
Discuss US perioperative medicine in practice

14. Elements and Principles
7 ELEMENTS of ART
7 PRINCIPLES of DESIGN
Line Shape Form Color Value Texture Space
Balance Movement Rhythm Contrast Emphasis Pattern Unity

15. Elements and Principles
7 ELEMENTS of Care
7 PRINCIPLES of
Enhanced Recovery
Education Preop Fluids Analgesia GDIVF PONV prophylaxis MIS Order set
Engaged Euvolemic Euglycemic Drinking Eating Sleeping Satisfied

16. Elements and Principles
7 ELEMENTS of ART
7 PRINCIPLES of DESIGN
Line Shape Form Color Value Texture Space
Balance Movement Rhythm Contrast Emphasis Pattern Unity

17. Elements and Principles
7 ELEMENTS of Care
7 PRINCIPLES of
Enhanced Recovery
Education Preop Fluids Analgesia GDIVF PONV prophylaxis MIS Order set
Engaged Euvolemic Euglycemic Drinking Eating Sleeping Satisfied

18. Elements and Principles
7 ELEMENTS of Care
7 PRINCIPLES of
Enhanced Recovery
Education Preop Fluids Analgesia GDIVF PONV prophylaxis MIS Order set
Engaged Euvolemic Euglycemic Drinking Eating Sleeping Satisfied

19. The elements of design, The principle into practice
Always wonder… is every little thing you do or don’t do for your patient, the right thing for that person at that time?

20. Principle of Enhanced Recovery
Consider EACH care point, from diagnosis to full recovery
Implement the evidence for best outcomes
If there is inadequate evidence, study it.

21. Common elements to multiple patient populations and operations
PREOP
Education
Optimization
Specialty Teaching
Liberal Preop Fluid
INTRAOP
PONV prevention
Opioid sparing,
Multimodal analgesia
Cognitive protection
Intentional Fluid Use
POSTOP
Judicious IVF
Multimodal analgesia
Food
Exercise
Progress audits and teaching
Defined discharge criteria

22. serge de Nîmes

23. What US perioperative medicine currently is
Limited by specialty and surgeon specifics
Being adapted to local environments
Limited by fee for service, breakdown of fee for service, and by divisive societies and goals
Variably used to improve surgical outcomes

24. What enhanced recovery in the US is becoming
Patient centric
Collaborative
Uniquely implemented for each system
Expansive by principle, rather than elements

25. ASER MISSION Advance enhanced recovery perioperative medicine
Foster education
Fund and lead research
Participate in public policy creation
Build relationships with patients and providers
IHI, CMS, BXBS
ASER-EPBOM
ASER-ASA_ACS-NSQIP