Guidelines for Perioperative Care and Enhanced Recovery after Surgery

Introduction

Experts in surgery and medication treat the disease condition, but favorable treatment outcomes are possible with the involvement of perioperative care and enhanced recovery. It is a multidisciplinary approach that considers the primary problem along with any existing secondary diseases or upcoming complications. In addition, specific guidelines to reduce the recovery time have been framed for healthcare professionals to deliver proper medical care to every patient, including the patient's safety during surgery and pain relief during recovery.

What Is the Difference Between Perioperative Care and Enhanced Recovery?

Perioperative care, also known as perioperative medicine, is an integrated, patient-centered practice from the beginning of the treatment until complete recovery. It includes:

• Preoperative, intraoperative, and postoperative care.

• Enabling uninterrupted communication.

• Providing information and support for people undergoing surgery.

Enhanced recovery strives for early recovery by keeping the patient in good health after perioperative care. It includes:

• Proper counseling.

• Providing required nutrition.

• Reducing the stress response after surgery.

What Is Preoperative Care?

It is the medical care taken to prepare the patient for surgery. It involves:

1. Assessments:

• Assessing the surgical risks and medical history. It varies depending on the urgency of the surgery.

• The immediate needs of the patients are met first.

• Review instructions before surgery and check if the patient follows them.

• Assessment of allergies by carrying out specific tests.

• Nutritional assessment by a dietician.

• Assessing the physical status. Patient's ability to communicate, level of consciousness, and vital signs like heart rate, respiratory rate, and blood pressure.

• Psychological assessment: The patient's emotional state and preparation for surgery are monitored.

2. Surgical consent is also understood and signed.

3. Checking blood tests and scans:

• Complete blood count, blood type, urine analysis, chest X-rays, and reports related to heart function.

4. Informing the patient of associated risks with the patient.

• It is advised to teach them about the surgical procedure and their expectations before and after the surgery.

5. Discuss lifestyle modifications (like quitting smoking and alcohol).

6. Managing existing medical conditions, like iron deficiency anemia, venous thromboembolism, and diabetes.

Preoperative care takes the most time, and how long it takes depends on what needs to be done to get the patient ready.

What Is Intraoperative Care?

The medical care provided during the surgery involves the following:

• Management of body fluids (oral or intravenous).

• Monitoring the heart condition (during high-risk surgeries).

• Blood glucose control.

• Maintaining surgical safety.

The intraoperative period begins when the patient is brought to the operating room and ends when they are transferred to the care unit.

What Is Postoperative Care?

It is medical care provided after the surgery. Preoperative care can be provided in a specialist recovery area where pain management is taken care of and the patient is monitored. Symptomatic management with the help of medications is undertaken. For example, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids (to be used as directed by the physician), intravenous Ketamine, and Gabapentin (medicines used to treat seizures).

Postoperative care can be divided into an immediate postoperative period and a later postoperative period. In the first few hours after surgery, a first assessment is done, which includes managing the airway and keeping the vital signs and fluid balance in check. In the later stages of recovery, the patient's heart function, ability to breathe, and level of pain are all checked regularly.

What Are the Consequences of Not Having Perioperative Care?

• The recovery takes a long path without perioperative care.

• The patient has to keep visiting the hospital whenever the problem shows up.

• There is a lot of time and money investment.

What Are the Consequences of Surgical Care?

Because of the holistic approach to treatment, the patient receives all instructions and guidance from healthcare professionals until he or she recovers and is finally discharged from the hospital.

What Are Enhanced Recovery Programs?

Even after perioperative care, certain conditions necessitate extensive care. For such conditions, enhanced recovery programs are set up. Some surgeries follow different protocols in the program. Depending on the complexity, each patient and condition will adhere to specific guidelines. For example:

Guidelines for Enhanced Recovery Programs for Liver Transplant Surgery:

• Preoperative Counseling - Informing the patient about the surgery and the necessary guidelines.

• Prehabilitation - Process of improving functional capacity before surgery.

• Perioperative Fasting and Carbohydrate Loading - A period where the patient is not allowed to take any food before the surgery.

• Antimicrobial and Anticoagulant Prophylaxis - Antimicrobials are medications that reduce infection, and anticoagulants prevent blood clots.

• Perioperative Analgesia - Pain-relieving medications are introduced.

• Fluid Management - The critical aspect of patient care is where necessary fluids are administered.

• Early Oral Nutrition - Nutrition through the oral route is also administered.

• Early Mobilization - The patient is moved out of bed within the first hours of the intensive care stay.

• Glycemic Control - Blood glucose sugar levels are monitored and maintained.

• Postoperative Education - The patient is given the necessary instructions to follow.

Guidelines for Enhanced Recovery Programs for Vascular Surgery:

• Patient information and counseling.

• Screening and assessment.

• Preoperative exercise therapy.

• Perioperative anticoagulation therapy.

• Preoperative fasting and carbohydrate loading.

• Venous thromboembolism.

• Preanesthetic analgesia.

• Antimicrobial agents.

• Prevention of nausea and vomiting.

• Anesthetic protocol.

• Oral feeding.

• Fluid therapy.

• Urinary drainage.

• Glycemic control.

• Postoperative education.

Guidelines for an Enhanced Recovery Program for Gynecologic Oncology (Cancer in Female Reproductive System):

• Patient information and counseling.

• Prehabilitation.

• Preoperative bowel preparation.

• Preoperative fasting and carbohydrate loading.

• Venous thromboembolism prophylaxis (medication to prevent blood clots in veins).

• Surgical site infection reduction.

• Antimicrobial prophylaxis (medication to reduce infection).

• Skin preparation.

• Prevention of hypothermia.

• Controlling perioperative glycemia.

• Standard anesthetic protocol.

• Minimally invasive surgery.

• Fluid management.

• Post operative analgesia.

• Perioperative nutrition.

• Prevention of postoperative ileus.

• Chemotherapy.

• Discharge.

What Are the Benefits of Enhanced Recovery Programs?

Enhanced recovery programs or fast-track programs play a major role after perioperative care. They help in both psychological and physiological responses to surgery. Assist patients in recovering faster and staying in the hospital for a shorter period of time. Early improvements in body function lead to a more normal life.

What Are the Protocols for Enhanced Recovery?

Following enhanced recovery protocols by surgeons ensures that patients get the best possible outcome from their surgery. The following are the protocols:

• Counseling before the surgery.

• Avoid fasting during the entire process (unless mentioned).

• Carbohydrate loading two hours before the surgery.

• Proper anesthetic and analgesics (pain killers) regime.

• Standardized schedule of food.

What Is Included in Enhanced Recovery?

In addition to perioperative care, an enhanced recovery program is initiated in certain complex conditions. The following is an example of an improved recovery program for a surgery that interferes with the patient's feeding.

Enhanced Recovery Before the Day of Surgery:

• Regular breakfast and unrestricted fluid intake.

• Assess psychological responses.

• Encourage self-care.

Enhanced Recovery on the Day of Surgery:

• Maintain ongoing nutrition by parenteral route (through intravenous fluids).

Enhanced Recovery after the Surgery:

• Administer free fluids.

• Referred to a physiotherapist.

• Schedule for return to home.

Conclusion

Perioperative care and enhanced recovery play a vital role in achieving the required outcome of the treatment. Any negligence in following the protocol can result in an adverse outcome for the patient. Hence, it is necessary to avail of the benefits of perioperative care and enhanced recovery to avoid future complications and imbalances. It is also essential for healthcare professionals to detect all the underlying conditions in a patient and treat them in a multidisciplinary way, thereby obtaining the best treatment outcome.