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Invited Commentary
May 4, 2019

The Enhanced Recovery After Surgery in Cardiac Surgery Revolution

Author Affiliations
  • 1School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
JAMA Surg. 2019;154(8):767. doi:10.1001/jamasurg.2019.1154

In this issue of JAMA Surgery, the Enhanced Recovery After Surgery (ERAS) in Cardiac Surgery recommendations are published as a joint effort between the ERAS Cardiac Surgery (http://www.erascardiac.org) and the ERAS Society (http://www.erassociety.org).1 This is another step in a transformation of care that is sweeping across the world with the adoption of the principles of ERAS within another important area of surgery,2 cardiac surgery.

The reasons for the success of ERAS lie in the outstanding results that can be achieved by using the principles of ERAS: multiprofessional and multidisciplinary teamwork, an application of evidence-based best practices of care (guidelines), continuous audits of outcomes and processes, and a readiness to make the next change.2 Applying ERAS principles results in a 30% to 40% reduction in the number of complications reported in several surgeries, shortening recovery time and ultimately freeing up hospital beds to save costs for payers.2 New data are also suggesting survival benefits.3

While this guideline is a milestone for ERAS in cardiac surgery, it is just a beginning. Enhanced Recovery After Surgery guidelines need to be updated as new information emerges. Enhanced Recovery After Surgery is not another static surgical or anesthesia guideline. It is a new approach to care that will change surgery at its roots. The fundamental approach of ERAS will transform surgery.

The ERAS guidelines are based on the evidence available for the entire care process. This means that everyone involved caring for the patient (ie, surgery, anesthesia, nursing, physiotherapy, and nutritional aspects) helps establish basic perioperative care principles that are needed worldwide. The variation in care delivery is substantial everywhere, and this helps explain the marked variation in outcomes. This variation exists not only between high-income and low-income countries, but also within countries4 and even within the same institutions.5 The reason for the variation is the uneven and the slow adoption of new care elements and principles that improves outcomes.

For this reason, ERAS goes beyond guidelines by also driving implementation. The ERAS Society is training units worldwide to improve their clinical outcomes by examining the processes behind their outcomes and continuously motivating toward increased compliance to the guidelines through audits. Through this process, ERAS introduces a new way to manage the care of the patient undergoing surgery. The modern surgeon is performing excellent surgery within a working team that represents all categories of health care clinicians. The ERAS team has the mission to keep up with modern care principles by using audits and feedback and to lead to make the next change.

This guideline is an important starting point for cardiac surgery. Better knowledge of what should be done makes it hard to find excuses not to do it.

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Article Information

Corresponding Author: Olle Ljungqvist, MD, PhD, School of Health and Medical Sciences, Department of Surgery, Örebro University Hospital Örebro, SE-701 85 Örebro, Sweden (olle.ljungqvist@oru.se).

Published Online: May 4, 2019. doi:10.1001/jamasurg.2019.1154

Conflict of Interest Disclosures: Dr Ljungqvist reports nonfinancial support from the Enhanced Recovery After Surgery Society and is a shareholder and founder of Encare AB.

References
1.
Engelman  DT, Ben Ali  W, Williams  JB,  et al.  Guidelines for perioperative care in cardiac surgery: Enhanced Recovery After Surgery Society recommendations [published online May 4, 2019].  JAMA Surg. doi:10.1001/jamasurg.2019.1153Google Scholar
2.
Ljungqvist  O, Scott  M, Fearon  KC.  Enhanced recovery after surgery: a review.  JAMA Surg. 2017;152(3):292-298. doi:10.1001/jamasurg.2016.4952PubMedGoogle ScholarCrossref
3.
Gustafsson  UO, Oppelstrup  H, Thorell  A, Nygren  J, Ljungqvist  O.  Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study.  World J Surg. 2016;40(7):1741-1747. doi:10.1007/s00268-016-3460-yPubMedGoogle ScholarCrossref
4.
Pearse  RM, Moreno  RP, Bauer  P,  et al; European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology.  Mortality after surgery in Europe: a 7 day cohort study.  Lancet. 2012;380(9847):1059-1065. doi:10.1016/S0140-6736(12)61148-9PubMedGoogle ScholarCrossref
5.
Lilot  M, Ehrenfeld  JM, Lee  C, Harrington  B, Cannesson  M, Rinehart  J.  Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis.  Br J Anaesth. 2015;114(5):767-776. doi:10.1093/bja/aeu452PubMedGoogle ScholarCrossref
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