Acta Anaesthesiol Scand 2014; 58: 639–641 Printed in Singapore. All rights reserved
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12324
Editorial
Recovery after anaesthesia and surgery O. Ljungqvist1 and L. S. Rasmussen2
1 Department of Surgery, Karolinska Institutet, Örebro University Hospital, Örebro, Sweden and 2Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
W
ith the continuous improvement in anaesthesia and surgery, the focus of interest for outcomes has shifted dramatically in the last few decades. Senior surgeons and anaesthesiologists of today were trained in an era when mortality was still a clear concern after, for instance, major vascular surgery. Today, surgery for aortic aneurysms is mostly performed using minimal invasive techniques, and even as same day surgery, with a low risk of major complications. Alongside major improvements in surgical techniques, anaesthesia has also improved, and there has been a shift of focus from obvious and crude outcomes to other measures. This necessitates accurate, easy to use measures that are relevant in determining multiple aspects of recovery. There is a clear need for multiple specialties to come together to agree on useful outcome measures that reflect not only an individual specialty, but rather all relevant aspects from the patient perspective. This approach, especially concerning longer term outcome measures, is rarely part of clinical scientific reports.1 In the current issue of Acta Anaesthesiologica Scandinavica, Royse et al. present data on a new and promising tool for following recovery, the Patient Quality Recovery Scale (PQRS).2 The measurement of accurate and meaningful recovery is the key to further development of surgical and anaesthesia care. Despite programmes such as the enhanced recovery after surgery (ERAS), the science of determination of recovery is still in its infancy, and is in need of further development and spread. A recent review on this concerns enhanced recovery.1 The ERAS programmes (http:// www.erassociety.org) are multi-modal, multidisciplinary, and should encompass the whole experience for the patient’s hospital care up to and
including 30 day follow-up after hospital discharge. This type of assessment does not limit itself to only what has happened in the operating room.3 Interest in this extended recovery concept has become more widespread in recent years, with more than 1600 publications on the subject in PubMed. A common motivation is interest in reducing the need for hospital care and reduction in complications. These concepts have been tested not only in colorectal surgery4 but also in general surgical patient populations.5 In a situation where there is need for both better care and lower health-care costs, these programs can play a key role in supporting health-care management and planning.6 Recovery, in scientific reports, is not always well defined. Surgeons traditionally tend to focus on surgical outcomes, and in particular issues related to the specific surgical procedure. These include blood loss and complications such as anastomotic leaks, reoperations, and more. In the long term, other outcomes are very relevant, including cure from cancer and need for revision surgery. Surgeons share with nurses interest in issues such as food tolerance, postoperative ileus, pain, and mobility. Anaesthesiologists often focus on matters related to the immediate postoperative phase such as haemodynamic, pulmonary, and renal function, but also pain, nausea, and vomiting. Recently, also cognitive function has received much interest.7 Other stakeholders focus on other outcomes. Managers look at hospital length of stay, costs for complications, and factors related to logistics.8 For patients, some of these outcomes are the same as for the professionals. Patients want cure first and foremost, but avoiding nausea and pain are high priorities in the early postoperative phase, as is return of certain bodily functions. It is worth noting that return of bodily function as
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O. Ljungqvist and L. S. Rasmussen
viewed by health-care professionals is often not the same as that for the patient and their families. While the surgical professional may consider that ‘sufficient’ recovery is reached when the patient has been able to eat one or two consecutive meals, has normal bowel function, pain ‘under control’, or that the patient is sufficiently mobile to manage their normal basic daily needs does not mean that recovery is complete. It just means that the patient has recovered enough to not be in immediate need of care on a surgical ward. For the patient undergoing major surgery, just being able to move from the surgical ward after surgery is still far from what the patient may experience as being recovered. Especially in elderly patients, it may take 3 to 6 months or even a year to recover their physical ability completely following major surgery.1 Still, when studying endpoints for recovery, even in the era of ERAS, the medical profession often thinks in terms of hospital length of stay or possibly a 30-day perspective. This may encompass the most obvious, and for the profession most relevant complications, but it does not facilitate study of complete recovery of patients in many cases. A key aspect is how to define and determine recovery. Despite popularity for ERAS protocols, the term ‘recovery’ itself has no universally accepted definition. Determining recovery is difficult for many reasons. Many different methods to identify recovery have been developed and used. Subjective measures are mixed with more objective measures. Different scales and grading systems have been used and combined in different ways. Some disparity or diversity in these definitions is understandable, since recovery from an orthopaedic operation will differ from that after, for instance, a low anterior rectal resection. With higher expectations in the field of enhanced recovery, there will be an increasing need for definitions of recovery in general, as well as some special definitions related to specific procedures. What about reporting outcomes from the patients view point? These are uncommon, unfortunately. It is more difficult to follow patients over many months than over a shorter period of time. Some aspects of recovery may not be in the immediate interest of the researcher. Many methods include subjective measures, and this approach can be different from more objective measures commonly used in clinical medicine. Lastly, as the patient moves away from the hospital to primary care for later follow-up and care, they may be lost for follow-up by the team in the hospital. Hence, the
640
insight of the long-term quality of life is usually not as strong as the knowledge about the short-term outcomes. In the current issue of Acta Anaesthesiologica Scandinavica, Royse et al.2 report on the PQRS. This system assesses recovery in five different dimensions: physiological, nociceptive – pain and nausea, emotive – anxiety and depression, activities of daily living, and cognition. The basic principle is that for these domains, recovery is achieved when each of them has returned to preoperative levels (or near preoperative values).9 This scale is easy to grasp both from a clinical and a research point of view. In addition, it helps to identify where recovery may be slower domains in one domain or faster in another. It also identifies recovery aspects that may not be obvious for the patient’s surgeon but are highly relevant for the patient. This may involve, for example, cognitive aspects of recovery, which are often not part of outcome measures in surgical literature.1 The PQRS holds promise to be a useful tool for larger clinical studies, and it may even be useful in clinical practice to detect potential slow recovery already at an early stage. For example, this study2 showed poorer recovery after knee replacement surgery in nearly all aspects compared with knee arthroscopy.2 This demonstrates that this tool is capable of discriminating important outcomes. Interest in collaborative work between surgery, anaesthesia, and other professions is increasing. This is necessary in order to advance and optimize today’s perioperative care. It is time to break down the ‘silos’ where departments and sections in hospital could work to a large extent in isolation. From this limited perspective, it is not possible to understand an entire patient perioperative ‘journey’ to full recovery. A more collaborative perspective with better assessment tools will enable us to see what actually improves outcomes. We may then identify our own specific contributions to such improvements. In achieving these goals, it is imperative to agree on outcomes for recovery, how to define and measure, and finally (and not the least important) how to achieve recovery from the patient’s own perspective. Conflict of interest: Authors declare no conflicts of interest.
References 1. Neville A, Lee L, Antonescu I, Mayo NE, Vassiliou MC, Fried GM, Feldman LS. Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 2014; 101: 159–71.
Recovery after anaesthesia and surgery 2. Royse CF, Williams Z, Ye G, Wilkinson D, Steiger RD, Richardson M, Newman S. Quality of recovery after knee surgery: a discriminant validation study comparing age and complexity of surgery using the Postoperative Quality of Recovery Scale. Acta Anaesthesiol Scand 2014; 58: 660–7. 3. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: 466–77. 4. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin Nutr 2010; 29: 434–40. 5. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AP. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014; 101: 172–88. 6. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 2010; 123: 61–70.
7. Krenk L, Rasmussen LS, Kehlet H. New insights into the pathophysiology of postoperative cognitive dysfunction. Acta Anaesthesiol Scand 2010; 54: 951–6. 8. Fiore JF, Faragher IG, Bialocerkowski A, Browning L, Denehy L. Time to readiness of discharge is a valid and reliable measure of short-term recovery after colorectal surgery. World J Surg 2013; 37: 2927–34. 9. Lindqvist M, Royse C, Brattwall M, Warrén-Stomberg M, Jakobsson J. Post-operative Quality of Recovery Scale: the impact of assessment method on cognitive recovery. Acta Anaesthesiol Scand 2013; 57: 1308–12.
Address: Olle Ljungqvist Department of Surgery, Karolinska Institutet Örebro University Hospital 701 85 Örebro Sweden e-mail: [email protected]
641
© 2014 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd ACTA ANAESTHESIOLOGICA SCANDINAVICA
doi: 10.1111/aas.12324
Editorial
Recovery after anaesthesia and surgery O. Ljungqvist1 and L. S. Rasmussen2
1 Department of Surgery, Karolinska Institutet, Örebro University Hospital, Örebro, Sweden and 2Department of Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
W
ith the continuous improvement in anaesthesia and surgery, the focus of interest for outcomes has shifted dramatically in the last few decades. Senior surgeons and anaesthesiologists of today were trained in an era when mortality was still a clear concern after, for instance, major vascular surgery. Today, surgery for aortic aneurysms is mostly performed using minimal invasive techniques, and even as same day surgery, with a low risk of major complications. Alongside major improvements in surgical techniques, anaesthesia has also improved, and there has been a shift of focus from obvious and crude outcomes to other measures. This necessitates accurate, easy to use measures that are relevant in determining multiple aspects of recovery. There is a clear need for multiple specialties to come together to agree on useful outcome measures that reflect not only an individual specialty, but rather all relevant aspects from the patient perspective. This approach, especially concerning longer term outcome measures, is rarely part of clinical scientific reports.1 In the current issue of Acta Anaesthesiologica Scandinavica, Royse et al. present data on a new and promising tool for following recovery, the Patient Quality Recovery Scale (PQRS).2 The measurement of accurate and meaningful recovery is the key to further development of surgical and anaesthesia care. Despite programmes such as the enhanced recovery after surgery (ERAS), the science of determination of recovery is still in its infancy, and is in need of further development and spread. A recent review on this concerns enhanced recovery.1 The ERAS programmes (http:// www.erassociety.org) are multi-modal, multidisciplinary, and should encompass the whole experience for the patient’s hospital care up to and
including 30 day follow-up after hospital discharge. This type of assessment does not limit itself to only what has happened in the operating room.3 Interest in this extended recovery concept has become more widespread in recent years, with more than 1600 publications on the subject in PubMed. A common motivation is interest in reducing the need for hospital care and reduction in complications. These concepts have been tested not only in colorectal surgery4 but also in general surgical patient populations.5 In a situation where there is need for both better care and lower health-care costs, these programs can play a key role in supporting health-care management and planning.6 Recovery, in scientific reports, is not always well defined. Surgeons traditionally tend to focus on surgical outcomes, and in particular issues related to the specific surgical procedure. These include blood loss and complications such as anastomotic leaks, reoperations, and more. In the long term, other outcomes are very relevant, including cure from cancer and need for revision surgery. Surgeons share with nurses interest in issues such as food tolerance, postoperative ileus, pain, and mobility. Anaesthesiologists often focus on matters related to the immediate postoperative phase such as haemodynamic, pulmonary, and renal function, but also pain, nausea, and vomiting. Recently, also cognitive function has received much interest.7 Other stakeholders focus on other outcomes. Managers look at hospital length of stay, costs for complications, and factors related to logistics.8 For patients, some of these outcomes are the same as for the professionals. Patients want cure first and foremost, but avoiding nausea and pain are high priorities in the early postoperative phase, as is return of certain bodily functions. It is worth noting that return of bodily function as
639 bs_bs_banner
O. Ljungqvist and L. S. Rasmussen
viewed by health-care professionals is often not the same as that for the patient and their families. While the surgical professional may consider that ‘sufficient’ recovery is reached when the patient has been able to eat one or two consecutive meals, has normal bowel function, pain ‘under control’, or that the patient is sufficiently mobile to manage their normal basic daily needs does not mean that recovery is complete. It just means that the patient has recovered enough to not be in immediate need of care on a surgical ward. For the patient undergoing major surgery, just being able to move from the surgical ward after surgery is still far from what the patient may experience as being recovered. Especially in elderly patients, it may take 3 to 6 months or even a year to recover their physical ability completely following major surgery.1 Still, when studying endpoints for recovery, even in the era of ERAS, the medical profession often thinks in terms of hospital length of stay or possibly a 30-day perspective. This may encompass the most obvious, and for the profession most relevant complications, but it does not facilitate study of complete recovery of patients in many cases. A key aspect is how to define and determine recovery. Despite popularity for ERAS protocols, the term ‘recovery’ itself has no universally accepted definition. Determining recovery is difficult for many reasons. Many different methods to identify recovery have been developed and used. Subjective measures are mixed with more objective measures. Different scales and grading systems have been used and combined in different ways. Some disparity or diversity in these definitions is understandable, since recovery from an orthopaedic operation will differ from that after, for instance, a low anterior rectal resection. With higher expectations in the field of enhanced recovery, there will be an increasing need for definitions of recovery in general, as well as some special definitions related to specific procedures. What about reporting outcomes from the patients view point? These are uncommon, unfortunately. It is more difficult to follow patients over many months than over a shorter period of time. Some aspects of recovery may not be in the immediate interest of the researcher. Many methods include subjective measures, and this approach can be different from more objective measures commonly used in clinical medicine. Lastly, as the patient moves away from the hospital to primary care for later follow-up and care, they may be lost for follow-up by the team in the hospital. Hence, the
640
insight of the long-term quality of life is usually not as strong as the knowledge about the short-term outcomes. In the current issue of Acta Anaesthesiologica Scandinavica, Royse et al.2 report on the PQRS. This system assesses recovery in five different dimensions: physiological, nociceptive – pain and nausea, emotive – anxiety and depression, activities of daily living, and cognition. The basic principle is that for these domains, recovery is achieved when each of them has returned to preoperative levels (or near preoperative values).9 This scale is easy to grasp both from a clinical and a research point of view. In addition, it helps to identify where recovery may be slower domains in one domain or faster in another. It also identifies recovery aspects that may not be obvious for the patient’s surgeon but are highly relevant for the patient. This may involve, for example, cognitive aspects of recovery, which are often not part of outcome measures in surgical literature.1 The PQRS holds promise to be a useful tool for larger clinical studies, and it may even be useful in clinical practice to detect potential slow recovery already at an early stage. For example, this study2 showed poorer recovery after knee replacement surgery in nearly all aspects compared with knee arthroscopy.2 This demonstrates that this tool is capable of discriminating important outcomes. Interest in collaborative work between surgery, anaesthesia, and other professions is increasing. This is necessary in order to advance and optimize today’s perioperative care. It is time to break down the ‘silos’ where departments and sections in hospital could work to a large extent in isolation. From this limited perspective, it is not possible to understand an entire patient perioperative ‘journey’ to full recovery. A more collaborative perspective with better assessment tools will enable us to see what actually improves outcomes. We may then identify our own specific contributions to such improvements. In achieving these goals, it is imperative to agree on outcomes for recovery, how to define and measure, and finally (and not the least important) how to achieve recovery from the patient’s own perspective. Conflict of interest: Authors declare no conflicts of interest.
References 1. Neville A, Lee L, Antonescu I, Mayo NE, Vassiliou MC, Fried GM, Feldman LS. Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg 2014; 101: 159–71.
Recovery after anaesthesia and surgery 2. Royse CF, Williams Z, Ye G, Wilkinson D, Steiger RD, Richardson M, Newman S. Quality of recovery after knee surgery: a discriminant validation study comparing age and complexity of surgery using the Postoperative Quality of Recovery Scale. Acta Anaesthesiol Scand 2014; 58: 660–7. 3. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: 466–77. 4. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized trials. Clin Nutr 2010; 29: 434–40. 5. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AP. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014; 101: 172–88. 6. Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 2010; 123: 61–70.
7. Krenk L, Rasmussen LS, Kehlet H. New insights into the pathophysiology of postoperative cognitive dysfunction. Acta Anaesthesiol Scand 2010; 54: 951–6. 8. Fiore JF, Faragher IG, Bialocerkowski A, Browning L, Denehy L. Time to readiness of discharge is a valid and reliable measure of short-term recovery after colorectal surgery. World J Surg 2013; 37: 2927–34. 9. Lindqvist M, Royse C, Brattwall M, Warrén-Stomberg M, Jakobsson J. Post-operative Quality of Recovery Scale: the impact of assessment method on cognitive recovery. Acta Anaesthesiol Scand 2013; 57: 1308–12.
Address: Olle Ljungqvist Department of Surgery, Karolinska Institutet Örebro University Hospital 701 85 Örebro Sweden e-mail: [email protected]
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