BackgroundThe present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.MethodsStudies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.ResultsThis consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.ConclusionsBased on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

Objective To determine the effect of perioperative blocker treatment in patients having non-cardiac surgery. Design Systematic review and meta-analysis. Data sources Seven search strategies, including searching two bibliographic databases and hand searching seven medical journals. Study selection and outcomes We included randomised controlled trials that evaluated blocker treatment in patients having non-cardiac surgery. Perioperative outcomes within 30 days of surgery included total mortality, cardiovascular mortality, non-fatal myocardial infarction, non-fatal cardiac arrest, non-fatal stroke, congestive heart failure, hypotension needing treatment, bradycardia needing treatment, and bronchospasm. Results Twenty two trials that randomised a total of 2437 patients met the eligibility criteria. Perioperative blockers did not show any statistically significant beneficial effects on any of the individual outcomes and the only nominally statistically significant beneficial relative risk was 0.44 (95% confidence interval 0.20 to 0.97, 99% confidence interval 0.16 to 1.24) for the composite outcome of cardiovascular mortality, non-fatal myocardial infarction, and non-fatal cardiac arrest. Methods adapted from formal interim monitoring boundaries applied to cumulative meta-analysis showed that the evidence failed, by a considerable degree, to meet standards for forgoing additional studies. The individual safety outcomes in patients treated with perioperative blockers showed a relative risk for bradycardia needing treatment of 2.27 (95% CI 1.53 to 3.36, 99% CI 1.36 to 3.80) and a nominally statistically significant relative risk for hypotension needing treatment of 1.27 (95% CI 1.04 to 1.56, 99% CI 0.97 to 1.66). Conclusion The evidence that perioperative blockers reduce major cardiovascular events is encouraging but too unreliable to allow definitive conclusions to be drawn.

BackgroundThe present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery.MethodsThe physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care.ResultsThe pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed.ConclusionsEvidence‐based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.

The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

The superior quality of pain relief provided by epidural analgesia had a positive impact on out-of-bed mobilization, bowel function, and intake of food, with long-lasting effects on exercise capacity and health-related quality of life.

In diabetic patients, HbA(1c) levels predict insulin sensitivity during surgery and possibly outcome. Intraoperative insulin resistance is associated with an increased risk of complications, independent of the patient's diabetic state.

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The purpose of this study was to test the hypothesis that epidural blockade with local anesthetic improves the anticatabolic effects of glucose after colorectal surgery. Sixteen patients were randomly assigned to undergo a 6-h stable isotope infusion study (3 h fasted, 3 h glucose infusion at 4 mg. kg(-1). min(-1)) on the second postoperative day with or without perioperative epidural blockade. Protein synthesis, breakdown and oxidation, and glucose production and clearance were assessed by L-[1-(13)C]leucine and [6, 6-(2)H(2)]glucose. Epidural blockade did not affect protein and glucose metabolism in the fasted state. Glucose infusion increased glucose clearance (P < 0.05), accompanied by an increase in the respiratory quotient (P < 0.05) and a decrease in leucine oxidation (P < 0.05) only in the presence of epidural blockade. An inverse correlation (r = -0.74, P < 0.05) between changes in glucose clearance and leucine oxidation was observed. In conclusion, epidural blockade facilitates whole body glucose uptake and inhibits endogenous protein oxidation after abdominal surgery, indicating a shift from a protein to a more glucose-dominated substrate utilization.