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Surgery_Schwartz. that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less expensive, more widely available technology or process. The ability for disruptive innovations to transform products and services into affordable realities requires three main factors: a sophisticated technology that simplifies, a low-cost business model, and an economically coherent value network (Fig. 49-34).195Regulations and standards that vary between countries and locales can facilitate or impede disruptive change. While disrup-tions often are not qualitatively superior to the status quo, they make the process both less expensive and more accessible, and through multiple iterations, ultimately improve quality as they cycle through the transformative process.Decentralizing education, laboratory testing, and medical records have been made possible through free and open-source software, apps,


Surgery_Schwartz

Surgery_Schwartz. improve quality as they cycle through the transformative process.Decentralizing education, laboratory testing, and medical records have been made possible through free and open-source software, apps, and devices such as smart phones, tablets, and laptop computers. Monitoring and imaging devices and lapa-roscopic instruments designed for low resource environments have the potential to not only improve accessibility in poor countries but also to radically reduce surgical costs in wealthy ones.196THE FUTURE FOR GLOBAL SURGERYSurgeons of the future will need to educate themselves in areas that have not historically been taught in surgical curricula. Beyond the technical aspects of surgical practice, there is a complex ecosystem that supports surgical care. Surgeons must become more aware of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience, rather than focusing


Surgery_Schwartz

Surgery_Schwartz. of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience, rather than focusing primarily on a narrow view of what surgery might have to offer. Surgeons must engage in policy development and advocate for affordable and accessible surgical care without sacrificing quality. Thoughtful technology design can focus on improving quality and on decreasing cost, both in poor and wealthy countries. Building surgical capac-ity through a health systems-focused approach, with robust data collection, and establishment of global surgery centers of Telementoring in Global SurgeryOne excellent example of successful telementoring in surgery is a program started by Allan Okrainec, MD, a minimally invasive surgeon at the University of Toronto, and Georges Azzie, MD, a pediatric surgeon at Toronto’s Hospital for Sick Children. In the mid-2000s, the two imagined utilizing laparoscopic box


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Surgery_Schwartz. invasive surgeon at the University of Toronto, and Georges Azzie, MD, a pediatric surgeon at Toronto’s Hospital for Sick Children. In the mid-2000s, the two imagined utilizing laparoscopic box trainers and videoconferencing technology via Skype to teach minimally invasive techniques to surgeons in LMICs.192 As part of the “Go Global” Initiative of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dr. Okrainec’s team traveled to Botswana in 2007 to teach a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in person. Although only two of twenty surgeons achieved certification, average posttest scores showed promising improvement.Realizing that continued mentorship promotes success, Dr. Okrainec’s team reconfigured their teaching model to include telesimulation. In 2009, they carried out an 8-week course in FLS, with weekly meetings via videoconference and real-time simulation demonstration and feedback between Botswana and Toronto. This time, 100% of


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Surgery_Schwartz. In 2009, they carried out an 8-week course in FLS, with weekly meetings via videoconference and real-time simulation demonstration and feedback between Botswana and Toronto. This time, 100% of participants in the tele-simulation group attained certification.193 Subsequently, the team expanded its program to Colombia, with similar success in skill acquisition.194 Since 2009, the program has expanded to 15 countries, with satellite telesimulation sites in Colombia and Ukraine. They have trained more than 300 individuals in FLS skills around the world.Brunicardi_Ch49_p2077-p2112.indd 210613/02/19 5:54 PM 2107GLOBAL SURGERYCHAPTER 49excellence will stimulate improvements in the provision of sur-gical and anesthesia services.197 Further integration of surgical care into national health plans of governments should encour-age increased investments and political will necessary to create capacity, leading to timely, quality surgical care to all without risk of financial ruin.16,91 Our


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Surgery_Schwartz. plans of governments should encour-age increased investments and political will necessary to create capacity, leading to timely, quality surgical care to all without risk of financial ruin.16,91 Our colleagues in public health and the World Bank, Paul Farmer and Jim Kim, have challenged us: “We need our surgical colleagues to speak fluently about rebuilding infrastructure, training, personnel, and delivering high-quality care to the very poorest.”106REFERENCESEntries highlighted in bright blue are key references. 1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspec-tive. Lancet Glob Health. 2015;3(suppl 2):S8-S9. 2. Weiser TG, Regenbogen SE, Thompson KD, et al. An esti-mation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-144. 3. Chang L, Lacy BE, Spiegel BM. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J


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Surgery_Schwartz. strategy based on available data. Lancet. 2008;372(9633):139-144. 3. Chang L, Lacy BE, Spiegel BM. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J Surg. 2011;35(2):272-279. 4. Contini S, Taqdeer A, Cherian M, et al. Emergency and essen-tial surgical services in Afghanistan: still a missing challenge. World J Surg. 2010;34(3):473-479. 5. Choo S, Perry H, Hesse AA, et al. Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hos-pitals using a WHO assessment tool. Trop Med Int Health. 2010;15(9):1109-1115. 6. Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anes-thesia in 8 lowand middle-income countries. Arch Surg. 2010;145(2):154-159. 7. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery. Disease Control Priori-ties. 3rd ed. Vol 1. Washington, DC: World Bank; 2015. doi:


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Surgery_Schwartz. Surg. 2010;145(2):154-159. 7. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery. Disease Control Priori-ties. 3rd ed. Vol 1. Washington, DC: World Bank; 2015. doi: 10.1596/978-1-4648-0346-8. 8. Alkire BC, Shrime MG, Dare AJ, Vincent JR, Meara JG. Global economic consequences of selected surgical diseases: a modeling study. Lancet Glob Health. 2015;3:S21-S27. 9. deVries C, Price RR. Global Surgery and Public Health: A New Paradigm. 1st ed. Sudbury, MA: Jones and Bartlett Learning; 2012:300. 10. Debas HT. Surgery. In: Jamison DT, ed. Disease Control Pri-orities in Developing Countries. 2nd ed. New York: Oxford University Press; 2006:1245-1259. 11. Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of sur-gery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health. 2014;2(6):e334-e345. 12. Grimes CE, Henry JA, Maraka J, et al. Cost-effectiveness of surgery in lowand middle-income countries: a systematic


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Surgery_Schwartz. a systematic review and analysis. Lancet Glob Health. 2014;2(6):e334-e345. 12. Grimes CE, Henry JA, Maraka J, et al. Cost-effectiveness of surgery in lowand middle-income countries: a systematic review. World J Surg. 2014;38(1):252-263. 13. International Finance Corporation. The Business of Health in Africa: Partnering with the Private Sector to Improve Peo-ple’s Lives. Available at: https://www.unido.org/sites/default/files/2016-01/IFC_HealthinAfrica_Final_0.pdf. Accessed August 22, 2018. 14. Central Intelligence Agency. CIA World Fact Book. 2018. Available at: https://www.cia.gov/library/publications/the-world-factbook/. Accessed August 22, 2018. 15. World Health Organization. World Health Statistics 2012. Available at: http://www.who.int/gho/publications/world_health_statistics/2012/en/. Accessed August 22, 2018. 16. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet.


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Surgery_Schwartz. Accessed August 22, 2018. 16. Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624. 17. Casey KM. Putting the “global” back in global health. Arch Surg. 2012;147(5):404-407. 18. Copenhagen Consensus Center. Nobel Laureates: More should be spent on hunger, health: top economists identify the smart-est investments for policy-makers and philanthropists. 2012. Available at: https://www.copenhagenconsensus.com/sites/default/files/CC12+Results+Press+Release+Final_0.pdf. 19. Kydland F, Stokey N, Schelling T, et al. Post-2015 consensus. Copenhagen Consensus Available at: http://www.copenhagen-consensus.com/sites/default/files/outcomedocument_col.pdf. Accessed August 22, 2018. 20. Lancet Commissioners. The Lancet Commission on global surgery, 2015. Available at: http://www.lancetglobalsurgery .org/lancet-commissioners. Accessed August 22, 2018. 21. 68th World Health


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Surgery_Schwartz. 2018. 20. Lancet Commissioners. The Lancet Commission on global surgery, 2015. Available at: http://www.lancetglobalsurgery .org/lancet-commissioners. Accessed August 22, 2018. 21. 68th World Health Assembly. Emergency and Essential Surgi-cal Care, World Health Organization. Available at: http://who .int/surgery/wha-eb/en/ 22. Dare AJ, Grimes CE, Gillies R, et al. Global Surgery: defining an emerging global health field. Lancet. 2014;384:2245-2247. 23. deVries CR, Rosenberg JS. Global surgical ecosys-tems: a need for systems strengthening. Ann Glob Health. 2016;82(4):605-613. 24. Chu K, Rosseel P, Gielis P, Ford N. Surgical task shifting in Sub-Saharan Africa. PLoS Med. 2009;6:e1000078. 25. Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: role of surgeons and other providers. Adv Surg. 2008;42:63-85. 26. Crisp N, Chen L. Global supply of health professionals. New Engl J Med. 2014;370:950-957. 27. Mkandawire N, Ngulube C, Lavy C.


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Surgery_Schwartz. role of surgeons and other providers. Adv Surg. 2008;42:63-85. 26. Crisp N, Chen L. Global supply of health professionals. New Engl J Med. 2014;370:950-957. 27. Mkandawire N, Ngulube C, Lavy C. Orthopaedic clinical officer program in Malawi: a model for providing orthopaedic care. Clin Orthop Relat Res. 2008;466(10):2385-2391. 28. Pereira C, Cumbi A, Malalane R, et al. Meeting the need for emergency obstetric care in Mozambique: work performance and histories of medical doctors and assistant medical officers trained for surgery. BJOG. 2007;114(12):1530-1553. 29. Kruk ME, Pereira C, Vaz F, Bergström S, Galea S. Economic evaluation of surgically trained assistant medical officers in performing major obstetric surgery in Mozambique. BJOG. 2007;114(10):1253-1260. 30. Sherwood KL, Price RR, White TW, Stevens MH, Van Boerum DH. A role in trauma care for advanced practice clinicians. JAAPA. 2009;22(6):33-36, 41. 31. Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s neglected surgical


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Surgery_Schwartz. .pdf?ua=. Accessed August 22, 2018. 96. Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening surgical services at the Soum (First-referral) hos-pital: the WHO emergency and essential surgical care (EESC) program in Mongolia. World J Surg. 2012;36(10):2359-2370. 97. Indicators of Surgical Operation (Mongolia 2001-2009). 2010 [cited 2017 March 25]; Available from: www.doh.gov.mn. 98. World Health Organization. Injury and violence: the facts. Available at: http://www.who.int/violence_injury_preven-tion/key_facts/VIP_key_facts.pdf?ua=1. Accessed August 22, 2018. 99. The United Nations. United Nations Road Traffic Collabo-ration: UN General Assembly adopts a resolution “Improv-ing global road safety.” Available at: http://www.who.int/violence_injury_prevention/media/news/2016/15_04/en/. Accessed August 22, 2018. 100. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global popula-tion. N Engl J Med.


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Surgery_Schwartz. Accessed August 22, 2018. 100. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global popula-tion. N Engl J Med. 2009;360(5):491-499. 101. World Health Organization. WHO guidelines for safe surgery 2009: Safe surgery saves lives. Available at: http://apps.who .int/iris/bitstream/handle/10665/44185/9789241598552_eng .pdf?sequence=1. Accessed August 22, 2018. 102. World Health Organization WHO surgical safety checklist. Available at: http://www.who.int/patientsafety/safesurgery/checklist/en/. Accessed August 22, 2018. 103. Peden M, McGee K, Krug E. Injury: A Leading Cause of the Global Burden of Disease. Geneva: World Health Organiza-tion; 2002. 104. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLOS Med. 2005;3(5):e226. 105. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of


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Surgery_Schwartz. intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLOS Med. 2005;3(5):e226. 105. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14:2361-2370. 106. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32(4):533-536. 107. Learmonth J. The Contributions of Surgery to Preven-tive Medicine. London: Oxford University Press, Geoffrey Cumberlege, Publisher to the University; 1951:55. 108. Brigham and Women’s Hospital. Center for Surgery and Pub-lic Health. Available at: http://www.brighamandwomens.org/research/labs/CenterforSurgeryandPublicHealth/default.aspx. Accessed August 22, 2018. 109. UC San Diego School of Medicine, Department of Surgery. Available at: https://medschool.ucsd.edu/som/surgery/educa-tion/Pages/Global-Surgery.aspx 110. Riviello R, Meara JG, Rogers SO. Commentary: cancer care and


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Surgery_Schwartz. School of Medicine, Department of Surgery. Available at: https://medschool.ucsd.edu/som/surgery/educa-tion/Pages/Global-Surgery.aspx 110. Riviello R, Meara JG, Rogers SO. Commentary: cancer care and control—the role of surgery. Global Surgery and Anes-thesia 2010. Available at: http://www.ghdonline.org/surgery/discussion/cancer-care-and-control-the-role-of-surgery/. Accessed August 22, 2018. 111. Mock C, Cherian M, Juillard C, et al. Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy. World J Surg, 2010;34(3):381-385. 112. Mock C, Lormand JD, Goosen J, Joshipura M, Peden M, Guidelines for Essential Trauma Care. Geneva: World Health Organization; 2004:106. 113. Sixtieth World Health Assembly. Health systems: emergency-care systems. Available at: http://www.wpro.who.int/mnh/A60_R22-en.pdf. Accessed August 22, 2018. 114. Mock C. WHA resolution on trauma and emergency care ser-vices. Inj Prev.


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Surgery_Schwartz. systems: emergency-care systems. Available at: http://www.wpro.who.int/mnh/A60_R22-en.pdf. Accessed August 22, 2018. 114. Mock C. WHA resolution on trauma and emergency care ser-vices. Inj Prev. 2007;13(4):285-286. 115. Haider AH, Hashmi ZG, Gupta S, et al. Benchmark-ing of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB). World J Surg. 2014;38(8):1882-1891.Brunicardi_Ch49_p2077-p2112.indd 210913/02/19 5:54 PM 2110SPECIFIC CONSIDERATIONSPART II 116. Mann NC, Mullins RJ, MacKenzie EJ, et al. Systematic review of published evidence regarding trauma system effectiveness. J Trauma. 1999;47(3 suppl):S25-S33. 117. O’Reilly GM, Joshipura M, Cameron PA, Gruen R. Trauma registries in developing countries: a review of the published experience. Injury. 2013;44(6):713-721. 118. Stelfox HT, Joshipura M, Chadunchachai W, et al. Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg.


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Surgery_Schwartz. HT, Joshipura M, Chadunchachai W, et al. Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg. 2012;36(8):1978-1992. 119. Gosselin R, Charles A, Joshipura M, et al. Surgery and Trauma Care. Disease Control Priorities. 3rd ed. Vol 1. New York: World Bank; 2015. 120. Mock C, Joshipura M, Arreola-Risa C, Quansah R. An esti-mate of the number of lives that could be saved through improvements in trauma care globally. World J Surg. 2012;36(5):959-963. 121. Liberman M, Mulder D, Lavoie A, et al. Implementation of a trauma care system: evolution through evaluation. J Trauma. 2004;56:1330-1335. 122. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066-1074. 123. World Health Organization. Maternal mortality fact sheet. 2016 Available at: http://www.who.int/mediacentre/factsheets/fs348/en/index.html. Accessed August 22,


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Surgery_Schwartz. Lancet. 2006;367(9516):1066-1074. 123. World Health Organization. Maternal mortality fact sheet. 2016 Available at: http://www.who.int/mediacentre/factsheets/fs348/en/index.html. Accessed August 22, 2018. 124. Corlew DS. Perspectives on plastic surgery and global health. Ann Plast Surg. 2009;62(5):473-477. 125. Smile Train. 2017. Available at: http://www.smiletrain.org/. Accessed August 22, 2018. 126. Operation Smile. 2017. Available at: http://www.operations-mile.org/. Accessed August 22, 2018. 127. ReSurge International. 2016. Available at: http://resurge.org/home/home.cfm. Accessed August 22, 2018. 128. World Blindness Overview. 2017. Available at: http://www .cureblindness.org/world-blindness/. Accessed August 22, 2018. 129. Nepal. 2017. Available at: http://www.cureblindness.org/where/himalayas/nepal/. Accessed August 22, 2018. 130. Tilganga Eye Centre. 2017. Available at: http://www.cureblindness.org/what/infrastructure/specialty-hospitals/ tilganga/. Accessed August 22,


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Surgery_Schwartz. Accessed August 22, 2018. 130. Tilganga Eye Centre. 2017. Available at: http://www.cureblindness.org/what/infrastructure/specialty-hospitals/ tilganga/. Accessed August 22, 2018. 131. HCP’s Eye Care Model. 2017. Available at: http://www.cure-blindness.org/what/hcp-eye-care-model/. Accessed August 22, 2018. 132. Kushner A. Malawi esophageal cancer palliative care program. In: Kingham P, ed. Quarterly Newsletter, Society of Interna-tional Humanitarian Surgeons. New York; Society of Interna-tional Humanitarian Surgeons: 2009. 133. Agarwal G, Ramakant P, Forgach ER, et al. Breast cancer care in developing countries. World J Surg. 2009;33(10):2069-2076. 134. Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries: 2017 Available at: http://gtfccc.harvard.edu/icb/icb.do?keyword=k69586&tabgroupid= icb.tabgroup132925. Accessed August 22, 2018. 135. Ozgediz D, Riviello R. The “other” neglected diseases in global public health: surgical conditions in sub-Saharan


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Surgery_Schwartz. icb.tabgroup132925. Accessed August 22, 2018. 135. Ozgediz D, Riviello R. The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. 2008;5(6):e121. 136. Shillcutt SD, Clarke MG, Kingsnorth AN. Cost-effectiveness of groin hernia surgery in the Western Region of Ghana. Arch Surg. 2010;145(10):954-961. 137. Gosselin RA, Heitto M. Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World J Surg. 2008;32(11):2450-2453. 138. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribu-tion of different services? World J Surg. 2006;30(4):505-511. 139. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet. 2003;81(1):83-92. 140. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara JG. Obstructed labor and caesarean delivery: the cost and benefit of surgical


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Surgery_Schwartz. care. Int J Gynaecol Obstet. 2003;81(1):83-92. 140. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara JG. Obstructed labor and caesarean delivery: the cost and benefit of surgical intervention. PLoS One. 2012;7(4):e34595. 141. Murray CJ. Quantifying the burden of disease: the techni-cal basis for disability-adjusted life years. Bull World Health Organ. 1994;72:429-445. 142. Shillcutt SD, Sanders DL, Teresa Butrón-Vila M, Kingsnorth AN. Cost-effectiveness of inguinal hernia surgery in north-western ecuador. World J Surg. 2013;37(1):32-41. 143. Tongaonkar RR, et al. Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg. 2003;65(1):89-95. 144. Alkire BC, Shrime MG, Dare AJ, et al. The global economic consequences of selected surgical diseases: a modelling study. Lancet Glob Health. 2015;3(suppl 2):S21-S27. 145. United Nations Population Fund (UNFPA); Providing emer-gency obstetric and newborn care to all in need.


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Surgery_Schwartz. surgical diseases: a modelling study. Lancet Glob Health. 2015;3(suppl 2):S21-S27. 145. United Nations Population Fund (UNFPA); Providing emer-gency obstetric and newborn care to all in need. Available at: http://www.unfpa.org/public/mothers/pid/4385. Accessed August 22, 2018. 146. Marseille E, Larson B, Kazi DS, et al. Thresholds for the cost-effectiveness of interventions: alternative approaches. Bull World Health Organ. 2015;93:118-124. 147. Price R, Sergelen O, Unursaikhan C. Improving surgical care in Mongolia: a model for sustainable development. World J Surg. 2012;37:1492-1499. 148. Gunsentsoodol B, Nachin B, Dashzeveg T. Surgery in Mongo-lia. Arch Surg. 2006;141(12):1254-1257. 149. List of countries by total health expenditure per capita. Avail-able at: http://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_%28PPP%29_per_capita. Accessed August 22, 2018. 150. Health Indicators 2007, National Center for Health Development:Ulaanbataar. Ministry of Health,


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Surgery_Schwartz. Accessed August 22, 2018. 150. Health Indicators 2007, National Center for Health Development:Ulaanbataar. Ministry of Health, Mongolia. Available at: http://www.chd.mohs.mn/images/pdf/sma/uzuulelt/ENGLISH2007.pdf. Accessed October 30, 2018. 151. Rusher AH. Outreach surgery. Surgical technology arrives in Mongolia. Bull Am Coll Surg. 1999;84(3):21-25. 152. Sergelen O. Development of laparoscopic surgery in Mongolia. 2006. Available at: http://www.gfmer.ch/Medical_education_En/PGC_RH_2006/Reviews/pdf/Orgoi_laparoscopy_2006.pdf. Accessed August 22, 2018. 153. Straub CM, Price RR, Matthews D, Handrahan DL, Sergelen D. Expanding laparoscopic cholecystectomy to rural Mongo-lia. World J Surg. 2011;35(4):751-759. 154. Wells KM, Lee YJ, Erdene S, et al. Building operative care capacity in a resource limited setting: the Mongolian model of the expansion of sustainable laparoscopic cholecystectomy. Surgery. 2016;160(2):509-517. 155. Manning RG, Azziz AQ. Should laparoscopic cholecystec-tomy be


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Surgery_Schwartz. limited setting: the Mongolian model of the expansion of sustainable laparoscopic cholecystectomy. Surgery. 2016;160(2):509-517. 155. Manning RG, Azziz AQ. Should laparoscopic cholecystec-tomy be practiced in the developing world? The experience of the first training program in Afghanistan. Ann Surg. 2009; 249(5):794-798. 156. Contini S, Taqdeer A, Gosselin RA. Should laparoscopic cho-lecystectomy be practiced in the developing World? The expe-rience of the first training program in Afghanistan. Ann Surg. 2010;251(3):574; author reply 575. 157. Alfa-Wali M, Antoniou A. Should laparoscopic cholecys-tectomy be practiced in the developing world? Ann Surg. 2010;251(2):387; author reply 387-388. 158. Castadot RG, Magarick RH, Sheppard L, Burkman RT. A review of ten years’ experience with surgical equipment in international health programs. Int J Gynaecol Obstet. 1986;24(1):53-60.Brunicardi_Ch49_p2077-p2112.indd 211013/02/19 5:54 PM 2111GLOBAL SURGERYCHAPTER 49 159. Udwadia TE.


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Surgery_Schwartz. surgical equipment in international health programs. Int J Gynaecol Obstet. 1986;24(1):53-60.Brunicardi_Ch49_p2077-p2112.indd 211013/02/19 5:54 PM 2111GLOBAL SURGERYCHAPTER 49 159. Udwadia TE. Navigating laparoscopic surgery into the next decade in developing countries—a personal perspec-tive. Langenbecks Arch Surg. 2007;392(1):99-104. 160. Udwadia TE. One world, one people, one surgery. Surg Endosc. 2001;15(4):37-343. 161. Vargas G, Price RR, Sergelen O, Lkhagvabayar B, Batcholuun P, Enkhamagalan T. A successful model for laparoscopic train-ing in Mongolia. Int Surg. 2012;97(4):363-371. 162. Clegg-Lamptey JN, Amponsah G. Laparoscopic cholecystec-tomy at the Korle Bu Teaching Hospital, Accra, Ghana: an initial report. West Afr J Med. 2010;29(2):113-116. 163. Baigrie RJ, Stupart D. Introduction of laparoscopic colorectal cancer surgery in developing nations. Br J Surg. 2010;97(5):625-627. 164. Udwadia TE. Low-cost laparoscopic cholecystectomy. (Br J Surg. 2002; 89:1602-1607). Br J


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Surgery_Schwartz. of laparoscopic colorectal cancer surgery in developing nations. Br J Surg. 2010;97(5):625-627. 164. Udwadia TE. Low-cost laparoscopic cholecystectomy. (Br J Surg. 2002; 89:1602-1607). Br J Surg. 2003;90(6):761. 165. Piukala S. Laparoscopic cholecystectomy: complications and experiences in Tonga. Pac Health Dialog. 2006;13(2): 107-110. 166. Udwadia TE, Udwadia RT, Menon K, et al. Laparoscopic sur-gery in the developing world. An overview of the Indian scene. Int Surg. 1995;80(4):371-375. 167. Akporiaye L. Trigen survey: West African College of Sur-geons. Trigen, Lagos, Nigeria. Unpublished data. 2010. 168. Al-Bazzaz PH. Kidney transplantation in Erbil, Iraq: a single-center experience. Saudi J Kidney Dis Transpl. 2010;21(2):359-362. 169. Basinda SL, Maro EE, McLarty DG, Young AE, Wing AJ. Ten Tanzanian transplants: problems and perspectives. Postgrad Med J. 1988;64(756):778-782. 170. Korle-Bu to begin kidney transplant in last quarter. 2012. Available at:


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Surgery_Schwartz. DG, Young AE, Wing AJ. Ten Tanzanian transplants: problems and perspectives. Postgrad Med J. 1988;64(756):778-782. 170. Korle-Bu to begin kidney transplant in last quarter. 2012. Available at: http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=238839. Accessed August 22, 2018. 171. Kumar A, Dubey D, Gogoi S, Arvind NK. Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries. J Endourol. 2002;16(3):155-159. 172. Kumar A, Chaudhary H, Srivastava A, Raghavendran M. Laparoscopic live-donor nephrectomy: modifications for developing nations. BJU Int. 2004;93(9):1291-1295. 173. Simforoosh N, Basiri A, Tabibi A, Shakhssalim N. Laparo-scopic donor nephrectomy—an Iranian model for developing countries: a cost-effective no-rush approach. Exp Clin Trans-plant. 2004;2(2):249-253. 174. Wells KM, Price RR, Finlayson SG, deVries CR. Fundamen-tals for establishing and maintaining an academic centre for global surgery: the University of


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Surgery_Schwartz. Exp Clin Trans-plant. 2004;2(2):249-253. 174. Wells KM, Price RR, Finlayson SG, deVries CR. Fundamen-tals for establishing and maintaining an academic centre for global surgery: the University of Utah Experience. Lancet Glob Health. 2014;2(S47):47. 175. Price RR, Butler MW, deVries CR, Abdullah F. Promoting, developing, and sustaining academic global surgery programs. In: Swaroop M, Krishnaswami S, eds. Academic Global Surgery. New York: Springer International Publishing; 2016. 176. Banerjee A. Medical electives: a chance for international health. J R Soc Med. 2010;103(1):6-8. 177. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volun-teerism. J Am Coll Surg. 2009;208(2):304-312. 178. Baker TD, Weisman C, Piwoz E. U.S. physicians in international health. Report of a current survey. JAMA. 1984;251(4):502-504. 179. Busnaina I. Medical school admissions doctor. 2012.


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Surgery_Schwartz. TD, Weisman C, Piwoz E. U.S. physicians in international health. Report of a current survey. JAMA. 1984;251(4):502-504. 179. Busnaina I. Medical school admissions doctor. 2012. Available at: https://www.usnews.com/education/blogs/medical-school-admissions-doctor/2012/04/09/medical-students-should-consider-overseas-clinical-experience. 180. Provenzano AM, Graber LK, Elansary M, Khoshnood K, Rastegar A, Barry M. Short-term global health research projects by U.S. medical students: ethical challenges for partnerships. Am J Trop Med Hyg. 2010;83(2):211-214. 181. University of Utah Health: Transforming Healthcare through Innovation: Center for Medical Innovation. Available from: http://healthsciences.utah.edu/center-for-medical-innovation/ 182. Stanford University: Extreme: Design for Extreme Affordabil-ity. Available at: https://extreme.stanford.edu.) 183. Busse H, Azazh A, Teklu S, et al. Creating change through collaboration: a twinning partnership to strengthen emergency medicine at


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Surgery_Schwartz. Affordabil-ity. Available at: https://extreme.stanford.edu.) 183. Busse H, Azazh A, Teklu S, et al. Creating change through collaboration: a twinning partnership to strengthen emergency medicine at Addis Ababa University/Tikur Anbessa Special-ized Hospital—a model for international medical education partnerships. Acad Emerg Med. 2013;20(12):1310-1318. 184. Blair KJ, Paladino L, Shaw PL, Shapiro MB, Nwomeh BC, Swaroop M. Surgical and trauma care in lowand middle-income countries: a review of capacity assessments. J Surg Res. 2017;210:139-151. 185. Carlson LC, Lin JA, Ameh EA, et al. Moving from data col-lection to application: a systematic literature review of surgi-cal capacity assessments and their applications. World J Surg. 2015;39(4):813-821. 186. Cancedda C, Riviello R, Wilson K, et al. Building workforce capacity abroad while strengthening global health programs at home: participation of seven Harvard-affiliated institutions in a health professional training initiative in


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Surgery_Schwartz. K, et al. Building workforce capacity abroad while strengthening global health programs at home: participation of seven Harvard-affiliated institutions in a health professional training initiative in Rwanda. Acad Med. 2017;92(5):649-658. 187. Sztajnkrycer MD, Madsen BE, Alejandro Báez A. Unstable ethical plateaus and disaster triage. Emerg Med Clin North Am. 2006;24(3):749-768. 188. Ramsey KM, Weijer CR. Ethics of surgical training in devel-oping countries. World J Surg. 2007;31(11):2067-2069; discussion 2070-2071. 189. Zumla A, Costello A. Ethics of healthcare research in develop-ing countries. J R Soc Med. 2002;95(6):275-276. 190. Kushner AL, Kyamanywa P, Adisa CA, et al. Editorial policy on co-authorship of articles from lowand middle-income countries. World J Surg, 2011;35:2367-2368. 191. Cameron JS, Hoffenberg R. The ethics of organ transplanta-tion reconsidered: paid organ donation and the use of executed prisoners as donors. Kidney Int. 1999;55(2):724-732. 192. International


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Surgery_Schwartz. JS, Hoffenberg R. The ethics of organ transplanta-tion reconsidered: paid organ donation and the use of executed prisoners as donors. Kidney Int. 1999;55(2):724-732. 192. International Surgery Canada. Telementoring in Botswana. Available at: http://internationalsurgerycanada.com/telemen-toring-in-botswana. Accessed August 22, 2018. 193. Okrainec A, Henao O, Azzie G. Telesimulation: an effec-tive method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc. 2010;24(2):417-422. 194. Henao O, Escallon J, Green J, et al. Fundamentals of lapa-roscopic surgery in Colombia using telesimulation: an effective educational tool for distance learning. Biomedica. 2013;33(1):107-114. 195. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription. New York: McGraw-Hill; 2009:441. 196. Beck M. New low-cost surgical tool could help patients in third world. The Wall Street Journal. September 23, 2016. 197. Ng-Kamstra JS, Greenberg SLM, Abdullah F,


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Surgery_Schwartz. York: McGraw-Hill; 2009:441. 196. Beck M. New low-cost surgical tool could help patients in third world. The Wall Street Journal. September 23, 2016. 197. Ng-Kamstra JS, Greenberg SLM, Abdullah F, et al. Global Surgery 2030: a Roadmap for high income country actors. BMJ Global Health. 2016;1(1):e000011.Brunicardi_Ch49_p2077-p2112.indd 211113/02/19 5:54 PM


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Surgery_Schwartz. ENHANCED RECOVERY AFTER SURGERYHistory and Overview of Enhanced RecoveryAs anesthetic techniques, antibiotics, and minimally invasive surgery have improved surgical care over the centuries, fur-ther strategies to continue to improve patient outcomes have emerged. A novel perioperative regimen for patients following colon surgery using early oral nutrition, early mobilization, and epidural analgesia was first described in 1995 by Professor Hen-rik Kehlet from Copenhagen, Denmark in a small group of nine patients.1 He subsequently outlined a more detailed multimodal approach to perioperative care in 1997, reducing length of stay to a median of 2 days following sigmoid resection, and thus, has been described as the founder of enhanced recovery after surgery (ERAS).2,3 Soon thereafter, several others duplicated that applying standard perioperative care protocols could reduce length of stay following colon surgery.4The ERAS Study Group was founded in 2001 by Professor Ken Fearon and


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Surgery_Schwartz. several others duplicated that applying standard perioperative care protocols could reduce length of stay following colon surgery.4The ERAS Study Group was founded in 2001 by Professor Ken Fearon and Professor Olle Ljungqvist to further expand on the ideas proposed by Professor Kehlet. As there was a great discrepancy between actual practices and evidence-based best practices, as well as geographical and practitioner variations in care, the group desired to create a consensus on best practices with guidelines that could be employed in the clinical arena. The primary goal of ERAS is to treat the surgical patient in a multidisciplinary team approach throughout the perioperative course with the unified goal of accelerating functional recov-ery and optimizing patient outcomes based on evidence-based medicine (Fig. 50-1).In order to develop the key tenets of ERAS, the details of preoperative care, intraoperative surgical and anesthetic tech-nique, and postoperative care were scrutinized


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Surgery_Schwartz. medicine (Fig. 50-1).In order to develop the key tenets of ERAS, the details of preoperative care, intraoperative surgical and anesthetic tech-nique, and postoperative care were scrutinized and standards for each facet of care were developed (Fig. 50-2).ERAS and its associated principles truly represented a paradigm shift in perioperative care, breaking from the clas-sical teaching of prolonged fasting postoperatively until signs of bowel function, excessive fluid administration, and delayed postoperative mobilization. Instead, mitigating the metabolic and stress responses to surgery through multimodal care and uti-lizing evidenced based medicine allows for “fast-track” recov-ery and improved outcomes.Each facet of perioperative care may have modest benefit to the patient when applied alone, but when an integrated, mul-timodal enhanced recovery pathway (ERP) is used, the benefi-cial effects become synergistic. Patients return to presurgical functional states faster, spend less time in


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Surgery_Schwartz. but when an integrated, mul-timodal enhanced recovery pathway (ERP) is used, the benefi-cial effects become synergistic. Patients return to presurgical functional states faster, spend less time in the hospital, and expe-rience less morbidity.5 Furthermore, resource utilization is reduced, healthcare system cost is less, and societal cost is lower with faster return to work and reduced homecare needs.6 Though initial studies of ERP were primarily performed for colorectal surgery, ERP can be applied to a wide variety of specialties in the inpatient and outpatient setting including urology, orthopedics, and gynecology. Preoperative OptimizationFirst proposed in 1949 by the anesthesiologist, Dr. J. Albert Lee, a preanesthetic and presurgical evaluation by an anesthesiolo-gist is associated with improved outcomes for the efficiency of the operating room, the hospital, and most importantly, the patient.7 The use of a preoperative evaluation results in identify-ing patients at elevated


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Surgery_Schwartz. with improved outcomes for the efficiency of the operating room, the hospital, and most importantly, the patient.7 The use of a preoperative evaluation results in identify-ing patients at elevated respiratory risk, a 55% decrease in pre-operative testing, an 88% reduction in case cancellations, reduction in day of surgery delays, reduced total length of stay, a positive impact on hospital finances with cost reduction, and lower in-hospital mortality.8-13 Therefore, while it is very impor-tant for the surgeon to see the patient prior to a surgery, it is also 1Optimizing Perioperative Care: Enhanced Recovery and Chinese MedicineJennifer Holder-Murray, Stephen Esper, Zhiliang Wang, Zhigang Cui, and Xima Wang 50chapterEnhanced Recovery after Surgery 2113History and Overview of Enhanced Recovery / 2113Preoperative Optimization / 2113Metabolic Stress Response to Surgery / 2116Preoperative Fasting and Preoperative Carbohydrate Loading / 2117Intraoperative Considerations / 2117Perioperative


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Surgery_Schwartz. / 2113Preoperative Optimization / 2113Metabolic Stress Response to Surgery / 2116Preoperative Fasting and Preoperative Carbohydrate Loading / 2117Intraoperative Considerations / 2117Perioperative Pain Management / 2119Postoperative Nausea and Vomiting Prevention / 2121Early Nutrition and Postoperative Ileus Prevention / 2121Mobilization / 2122ERAS in CRS / 2122ERAS in Hepatopancreaticobiliary Surgery / 2123ERAS in Gastrectomy and Esophagectomy / 2123ERAS in Bariatric Surgery / 2123ERAS in Other Surgical Specialties / 2123Setting Up an ERAS Program / 2124Traditional Chinese Medicine in Surgical Patients 2124History of Traditional Chinese Medicine / 2124Preoperative Nutritional Optimization / 2126Bowel Preparation for Surgery / 2126Preoperative Optimization During Sepsis and Infection / 2126Perioperative Pain Management / 2127Postoperative Nausea and Vomiting Prevention / 2127Early Nutrition and Postoperative Ileus Prevention / 2127Traditional Chinese Medicine in Common Surgical


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Surgery_Schwartz. / 2126Perioperative Pain Management / 2127Postoperative Nausea and Vomiting Prevention / 2127Early Nutrition and Postoperative Ileus Prevention / 2127Traditional Chinese Medicine in Common Surgical Conditions / 2127Brunicardi_Ch50_p2113-p2136.indd 211301/03/19 9:39 AM 2114Key Points1 Enhanced recovery after surgery (ERAS) is a paradigm shift in the surgical care of patients. As a multimodal, integrated, evidence-based care pathway, ERAS optimizes patient care in the preoperative, intraoperative, and post-operative setting in order to achieve best patient outcomes. Patients recover faster, experience less physiological stress, enjoy shorter stays in the hospital, and have fewer complications.2 Setting appropriate expectations, optimizing nutritional and physical status through prehabilitation, and treating medical comorbidities optimizes patients before surgery.3 Achieving normovolemia both intraoperatively and post-operatively is important in order to maintain perfusion without


Surgery_Schwartz

Surgery_Schwartz. and treating medical comorbidities optimizes patients before surgery.3 Achieving normovolemia both intraoperatively and post-operatively is important in order to maintain perfusion without volume overload, as hypervolemia and hypovo-lemia are both associated with significant complications. Goal-directed therapy approaches maintain normovolemia with zero fluid balance.4 Intravenous normal saline administration results in hyper-chloremia, which has been associated with increased mor-tality and morbidity.5 As pain is a subjective response and cannot therefore be experienced while unconscious, the use of opioids intraop-eratively should generally be avoided in order to minimize the multiorgan system side effects of these medications. Additionally, avoiding intraoperative opioids actually improves postoperative pain scores and reduces the need for postoperative opioids.6 Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce


Surgery_Schwartz

Surgery_Schwartz. improves postoperative pain scores and reduces the need for postoperative opioids.6 Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce postoperative physiological stress and decrease complica-tions associated with surgery as part of a pain management regimen. Multimodal analgesia has been shown to reduce the number of opioids required for analgesia.7 The strategies for avoiding postoperative nausea and vom-iting include the avoidance of general anesthesia, the use of totally intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and postoperative opioids, and adequate hydration.8 Enhanced recovery after surgery care pathways can be applied to numerous types of surgery including colorectal, liver, pancreas, bariatric, gynecologic, and urologic sur-gery with success.9 Traditional Chinese medicine has been practiced for thou-sands of years and serves as a distinct cultural heritage


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Surgery_Schwartz. liver, pancreas, bariatric, gynecologic, and urologic sur-gery with success.9 Traditional Chinese medicine has been practiced for thou-sands of years and serves as a distinct cultural heritage of China. Its unique theories and methods are still applied widely in the practice of modern medicine, including dis-ease prevention, disease treatment, and perioperative management.10 Acupuncture and transcutaneous electroacupuncture can reduce the number of opioids utilized in the perioperative setting. Additionally, acupuncture, transcutaneous elec-troacupuncture, and some Chinese herb decoctions are effective in the prevention and treatment of postoperative nausea and vomiting.highly important for the patient to have an opportunity to dis-cuss the upcoming perisurgical and perianesthetic experience with a physician that is trained in the realm of periopera-tive optimization. Setting Expectations and Patient Education. Setting expectations in the preoperative clinic helps to orient patients


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Surgery_Schwartz. with a physician that is trained in the realm of periopera-tive optimization. Setting Expectations and Patient Education. Setting expectations in the preoperative clinic helps to orient patients regarding the entire surgical experience, from what they are expected to do at home before the surgery to the entire length of the recovery both in the hospital and at home. Information on the procedure and typical recovery should be clear, well defined, and consistently reinforced from all healthcare person-nel that interact with the patient. Clear expectations of goals prior to surgery, in the hospital, and after discharge should be communicated long before the surgery. Expected length of stay and disposition should also be clearly communicated in order to optimize timely discharge. The preoperative clinic helps in this role and to establish the patient as the leader in his or her own care. The patient must understand that his or her active partici-pation throughout the perioperative


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Surgery_Schwartz. clinic helps in this role and to establish the patient as the leader in his or her own care. The patient must understand that his or her active partici-pation throughout the perioperative experience will facilitate the recovery. A surgeon can do an operation. An anesthesiologist can keep a patient alive while the patient asleep. However, in reality, it is up to the patient to make his or her own care a prior-ity. If individuals train for a race, should they not also prepare for their procedure so that the recovery is swift? The optimiza-tion for success at surgery begins preoperatively with smoking cessation, exercise, and nutrition, but it also continues in the hospital and after discharge with pain control, physical activ-ity, discharge planning, and returning to daily activities. Clear expectations at each point in the perioperative continuum, which are communicated to the patient, will improve the perioperative experience for the patient and the provider.According to Costa,


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Surgery_Schwartz. Clear expectations at each point in the perioperative continuum, which are communicated to the patient, will improve the perioperative experience for the patient and the provider.According to Costa, “Evidence shows that patients suffer needlessly due to inadequate preoperative preparation and lack of information regarding their postoperative course as indicated by reports of unexpected pain, fatigue, and the inability to care for oneself.”14 Patients enter physician offices and procedures with a great deal of fear and anxiety related to the identification of a disease, the consequences of treatment of this disease, and/or the fear of death. Eliciting the patient’s concerns and provid-ing optimal communication and education can allay much of this fear and anxiety. There is a substantial perioperative cul-ture change that is brought about by the elements of ERAS, and many patients have personally had or have had a close relative that has experienced surgery that likely did not include


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Surgery_Schwartz. cul-ture change that is brought about by the elements of ERAS, and many patients have personally had or have had a close relative that has experienced surgery that likely did not include many 2ERAS: Team-centered approachPatientSurgical teamPreoperative nursing teamAnesthesiology teamPACU nursing teamInpatient nursing teamOffice/clinic teamERAS educatorPharmacyERAS project managerInformation technological teamFigure 50-1. Enhanced recovery multidisciplinary team. ERAS = enhanced recovery after surgery; PACU = postanesthesia care unit.Brunicardi_Ch50_p2113-p2136.indd 211401/03/19 9:39 AM 2115OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50components of ERAS. Therefore, this culture change must be clearly disseminated to the patients and include new fasting guidelines, analgesic management, and patient participation in preoperative optimization. Patients can then anticipate and plan for certain events and sensations, such as what and when to eat and


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Surgery_Schwartz. guidelines, analgesic management, and patient participation in preoperative optimization. Patients can then anticipate and plan for certain events and sensations, such as what and when to eat and drink, how to exercise, what medications will be used, what tubes or lines will be present, and what criteria are used for dis-charge and return to daily activities. This kind of teaching has been defined as a therapeutic communication to help the patient face and cope with the surgical procedure in a calm manner.15Approximately 90 million people have difficulty under-standing and subsequently acting upon health information dis-tributed to them.16 Further, the ability of patients to process and understand basic information to make appropriate health decisions is directly related to socioeconomic status and to Caucasian race; furthermore, the readability of patient-directed healthcare material may be too advanced for comprehension by much of the surgical population.17,18 Thus, it is


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Surgery_Schwartz. status and to Caucasian race; furthermore, the readability of patient-directed healthcare material may be too advanced for comprehension by much of the surgical population.17,18 Thus, it is appropriate for patient information material to be at no higher than a sixth grade reading level, friendly, clear, concise, and simply designed. The employment of audiovisual aids may assist some patients as well.Nutrition. Surgery results in a significant catabolic stress response on the body, triggering inflammation and nutrient depletion. This stress response results in downstream effects on numerous organ systems and can lead to a higher risk of post-operative complications. Ensuring preoperative adequate nutri-tion is imperative before a large surgical procedure in order to mitigate adverse outcomes.While enteral or parenteral nutritional supplementation can be considered for the most nutritionally compromised patient, the enteral route is always preferred if clinically appropriate and can be


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Surgery_Schwartz. enteral or parenteral nutritional supplementation can be considered for the most nutritionally compromised patient, the enteral route is always preferred if clinically appropriate and can be adequately achieved in a timely fashion. Two main approaches to preoperative enteral nutrition include standard oral nutrition supplements and immunonutrition supplements, each providing extra protein and calories to supplement the diet. There is no statistical difference in infections, complications, and length of hospital stay between patients given standard oral versus immunonutrition supplements.19Standard oral nutrition products are high in protein, contain vitamins and minerals, and are widely available. Immunonutrition supplements usually similarly contain high protein, vitamins, and minerals, but they also have the addition of arginine to improve immunity and tissue repair and omega-3 fatty acids to mediate the inflammatory response.19 The exact dosage of arginine and omega-3 fatty acids


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Surgery_Schwartz. but they also have the addition of arginine to improve immunity and tissue repair and omega-3 fatty acids to mediate the inflammatory response.19 The exact dosage of arginine and omega-3 fatty acids that contribute to improved outcomes is not known. Standard oral nutrition prod-ucts may contain no or lesser quantities of arginine and omega-3 fatty acids when compared to immunonutrition supplements. The exact duration and frequency of supplementation have not been established; however, it is clear that the use of standard oral nutrition products has a positive impact on surgical out-comes by reducing postsurgical complications.19Exercise and Prehabilitation. Prehabilitation is defined as “the process of enhancing the functional capacity of the indi-vidual to enable him or her to withstand a stressful event.”20,21 Both exercise and prehabilitation, which have, heretofore, focused on cardiopulmonary rehabilitation prior to surgery, are very important to optimization of patient outcomes.


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Surgery_Schwartz. a stressful event.”20,21 Both exercise and prehabilitation, which have, heretofore, focused on cardiopulmonary rehabilitation prior to surgery, are very important to optimization of patient outcomes. Peri-operative cardiopulmonary exercise testing and prehabilitation in relation to ERAS programs around the world have been ana-lyzed, and it is noted that a reduction in fitness prior to sur-gery is associated with increased mortality and morbidity in the postoperative arena.22 Patients who actively exercise even when suffering from documented coronary artery disease, heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, depression, dementia, cancer, and stroke have better outcomes.23-36 Furthermore, other literature supports the signifi-cant merits of exercise therapy and cardiopulmonary exercise therapy before and after major surgery, with the ability to reduce infection, hospital-associated complications, length of stay, and postoperative mortality.37There is a


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Surgery_Schwartz. and cardiopulmonary exercise therapy before and after major surgery, with the ability to reduce infection, hospital-associated complications, length of stay, and postoperative mortality.37There is a significant amount of evidence indicating that exercise training is feasible and safe in patients with a spec-trum of severe cardiac and pulmonary diseases as many of these patients require surgery to manage other disease processes. A randomized controlled trial involving 246 low-risk patients undergoing cardiac surgery reported a 1-day reduction in ICU stay and a reduced hospital length of stay in the intervention group.38 Cardiopulmonary fitness was found to be a strong independent predictor of survival after lung surgery, especially for non–small cell lung cancer.39 Preliminary nonrandomized Preoperative phasePatient education & set expectationsSmoking & alcohol cessationPrehabilitation with diet & exerciseShortened fastingAntimicrobial prophylaxisVTE prophylaxisMinimize bowel


Surgery_Schwartz

Surgery_Schwartz. Preoperative phasePatient education & set expectationsSmoking & alcohol cessationPrehabilitation with diet & exerciseShortened fastingAntimicrobial prophylaxisVTE prophylaxisMinimize bowel preparationIntraoperative phasePain blocksMinimally invasive surgeryGoal-directed fluid therapyMultimodal pain reliefPrevention of PONVAvoidance of tubes, drains, linesNormothermiaPostoperative phaseGoal-directed fluid therapyPrevention of PONVEarly ambulationEarly feedingMultimodal pain reliefEarly urinary catheter removalDefined discharge criteriaFigure 50-2. Phases and components of an enhanced recovery after surgery pathway. VTE = venous thromboembolism; PONV = postopera-tive nausea and vomiting.Brunicardi_Ch50_p2113-p2136.indd 211501/03/19 9:39 AM 2116SPECIFIC CONSIDERATIONSPART IIdata from patients undergoing elective rectal cancer surgery within an ERAS program have shown the feasibility of provid-ing a cardiopulmonary exercise interval training program that is delivered three times per


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Surgery_Schwartz. undergoing elective rectal cancer surgery within an ERAS program have shown the feasibility of provid-ing a cardiopulmonary exercise interval training program that is delivered three times per week for 6 weeks in a hospital setting after neoadjuvant chemoradiotherapy and before surgery.40 The interval following neoadjuvant therapy offers a unique window of time to improve the fitness and nutrition of many oncologic patients, which is especially important as these patients can often be some of the most debilitated.The addition of physical fitness and activity to a preopera-tive regimen for elderly patients undergoing major abdominal surgery significantly improved mortality, discharge to home versus a care facility, and length of stay.41 While this study showed that patients benefited from 60-minute sessions 2 to 4 weeks prior to surgery, even brief therapy before surgery, ranging from 1 day to 7 days before major abdominal surgery, have been associate with a significant decrease in


Surgery_Schwartz

Surgery_Schwartz. 60-minute sessions 2 to 4 weeks prior to surgery, even brief therapy before surgery, ranging from 1 day to 7 days before major abdominal surgery, have been associate with a significant decrease in postopera-tive complications.42,43 Therefore, some oncologic or semiurgent patients may actually benefit from preoperative cardiopulmo-nary exercise programs.Smoking Cessation. Clearly tobacco use, especially smok-ing, has been well documented across all surgical specialties to increase postoperative mortality, as well as increase postopera-tive complications including prolonged ventilation, pneumonia, deep venous thrombosis, wound infection, delayed wound heal-ing, and reduced bone fusion.44-47 Physiologically, the carbon monoxide and nicotine from tobacco products increase heart rate and blood pressure and the body’s demand for oxygen. Nic-otine also causes vasoconstriction, reducing perfusion to many tissue beds. Obviously, it is advantageous for patients to cease smoking preoperatively.


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Surgery_Schwartz. pressure and the body’s demand for oxygen. Nic-otine also causes vasoconstriction, reducing perfusion to many tissue beds. Obviously, it is advantageous for patients to cease smoking preoperatively. There is debate about the duration of the nicotine free days needed preoperatively to offer best out-comes, though the literature suggests that the longer duration of smoking cessation prior to surgery portends better outcomes.48 This is likely to allow for bronchiolar and collagen remodeling and the several weeks following last exposure that are needed to achieve blood free of nicotine and its derivatives.Metabolic Stress Response to SurgeryMultiple organ systems interact in numerous metabolic and inflammatory cascades following the stress response to surgery leading to insulin resistance and protein catabolism (Fig. 50-3). Neuroendocrine responses, stress hormones cascades, activation of cytokine, and immune reactions all occur, leading to a cata-bolic state.49 Central to this metabolic


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Surgery_Schwartz. protein catabolism (Fig. 50-3). Neuroendocrine responses, stress hormones cascades, activation of cytokine, and immune reactions all occur, leading to a cata-bolic state.49 Central to this metabolic and inflammatory cas-cade is the development of insulin resistance, whereby a normal insulin concentration results in a subnormal biologic response. As insulin is the main anabolic hormone involved in glucose control, fat metabolism, and protein balance, insulin resistance disrupts many metabolic pathways.Hyperglycemia from insulin resistance results from an increase in glucose production and a decrease in glucose uptake by the periphery. In a fed state, insulin levels surge to 6 to 8 times basal levels, which stops glucose production and increases peripheral glucose uptake threeto fourfold.50 When fasting, insulin levels remain in a relative steady state with minimal effects on glucose and protein metabolism. Even when insulin levels increase to three times basal levels, there is no


Surgery_Schwartz

Surgery_Schwartz. When fasting, insulin levels remain in a relative steady state with minimal effects on glucose and protein metabolism. Even when insulin levels increase to three times basal levels, there is no increase in peripheral glucose uptake. Therefore, in the postoperative fast-ing state, without the assistance of exogenous insulin, peripheral Counterregulatory hormonescytokinesGlycogenolysisGlucoseLipolysisInsulinresistanceWhole-bodyprotein catabolismGluconeogenesisHypothalamusPituitaryGlycerolAmino acidsAcute-phaseproteinsHyperglycemiaPyruvateGlycolysisProteolysisLactateInjury siteAfferentsensorynervesSympathetic nervesHumoral agentsNeural impulsesFigure 50-3. Metabolic stress response to surgery results in insulin resistance. (Reproduced with permission from McGill University Health Center Patient Education Office, Montreal, Quebec, Canada.)Brunicardi_Ch50_p2113-p2136.indd 211601/03/19 9:39 AM 2117OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50glucose


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Surgery_Schwartz. Education Office, Montreal, Quebec, Canada.)Brunicardi_Ch50_p2113-p2136.indd 211601/03/19 9:39 AM 2117OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50glucose uptake is reduced. The resulting hyperglycemia can be corrected, however, with the use of exogenous insulin, and when normoglycemia is achieved in the perioperative period, the main components of metabolism also normalize.51The preoperative and postoperative fasting state triggers insulin resistance resulting in a catabolic state with gluconeo-genesis and protein breakdown. Following prolonged fasting states with stress such as following surgery, protein catabolism can be increased several fold over baseline. As less glycogen is stored in the muscle and loss of lean body mass occurs, there is less muscle function and therefore less capacity to mobilize.In addition to the typical metabolic effects of surgery, pain has been demonstrated to increase insulin resistance. In healthy male volunteers


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Surgery_Schwartz. muscle function and therefore less capacity to mobilize.In addition to the typical metabolic effects of surgery, pain has been demonstrated to increase insulin resistance. In healthy male volunteers undergoing painful stimulation, glucose uptake was reduced as a direct result of decreased insulin sensitivity.52 In addition, serum cortisol, epinephrine, and free fatty acids were all increased following painful stimulation.Elective surgery results in a state of insulin resistance, with the magnitude of surgery corresponding to a decrease in insulin sensitivity.53 For example, the difference in insulin sen-sitivity following laparoscopic cholecystectomy versus open cholecystectomy is 2.5-fold. More complex abdominal surgery such as an open colorectal resection results in a 3.5-fold increase in insulin resistance over laparoscopic cholecystectomy. As lev-els of insulin resistance increase, complications also increase.54 In addition to an association with complications, insulin resis-tance


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Surgery_Schwartz. insulin resistance over laparoscopic cholecystectomy. As lev-els of insulin resistance increase, complications also increase.54 In addition to an association with complications, insulin resis-tance has been shown to be an independent predictor of length of stay.53The increased postoperative complications associated with insulin resistance may be not only from the direct meta-bolic effects of insulin on glucose but also from free radical formation. In peripheral tissues that are independent of insulin metabolism, and therefore do not store glycogen, the increased plasma glucose levels result in greater glycolysis and oxygen free radical formation. This leads to alterations in gene expres-sion, which in turn propagates a cycle of increased inflamma-tion causing even more insulin resistance.55 Elective surgery has been implicated in increased inflammatory gene pathways and changes in insulin signaling genes in both adipose and skeletal muscle tissues.56,57Components of an ERP may offset


Surgery_Schwartz

Surgery_Schwartz. Elective surgery has been implicated in increased inflammatory gene pathways and changes in insulin signaling genes in both adipose and skeletal muscle tissues.56,57Components of an ERP may offset the metabolic and stress responses of surgery. Preoperative carbohydrate supple-mentation has been shown to counter the catabolic effects of the fasted state by stimulating glucose uptake and transition-ing metabolism to a more anabolic state with improved insulin sensitivity.58 Preoperative carbohydrate supplementation also reduces protein loss and improves muscle strength postopera-tively.59-61 When preoperative carbohydrate supplementation is added to epidural analgesia, there is even greater improvement in insulin resistance.62Preoperative Fasting and Preoperative Carbohydrate LoadingTraditionally, patients have been instructed to fast for 6 to 12 hours before surgery to reduce the risk of aspiration of gastric contents during the induction of anesthesia. This fasting state results in a


Surgery_Schwartz

Surgery_Schwartz. patients have been instructed to fast for 6 to 12 hours before surgery to reduce the risk of aspiration of gastric contents during the induction of anesthesia. This fasting state results in a prolonged period without nutrients or hydration prior to and during surgery, and it can lead to insulin resistance, hyper-glycemia, failure to achieve a postsurgical anabolic state, and sometimes, the need for insulin. Both European and American Societies of Anesthesiology guidelines have supported the use of clear liquid oral intake up to 2 hours prior to surgery with the exception of patients with gastroparesis, intestinal obstruction, or dysphagia.63-65 Carbohydrate oral intake up to 2 hours prior to surgery does not increase aspiration in healthy adults under-going elective surgery and in fact reduces preoperative hunger, thirst, anxiety, and nausea.66,67 In addition, a fasting time of 2 to 4 hours versus more than 4 hours actually results in smaller gastric volume and a higher gastric pH


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Surgery_Schwartz. reduces preoperative hunger, thirst, anxiety, and nausea.66,67 In addition, a fasting time of 2 to 4 hours versus more than 4 hours actually results in smaller gastric volume and a higher gastric pH value.68-75 Nevertheless, prior to the introduction of ERAS, the dogma of prolonged nothing-by-mouth status widely adopted many decades ago had little advocacy to change, despite evidence supporting more lib-eral fasting parameters. Current guidelines support fasting from clear liquids for 2 hours and solid food for 6 hours.Preoperative carbohydrate loading prior to surgery in the form of a carbohydrate rich clear liquid improves patient nausea and discomfort over preoperative water hydration or a prolonged fasting state.76 It may also have further benefits over low carbohydrate clear liquid beverages or fasting by changing the overnight fasting state to a fed state and thus altering glu-cose, protein, and fat metabolism by increasing postoperative insulin sensitivity.77-79 Furthermore, in


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Surgery_Schwartz. or fasting by changing the overnight fasting state to a fed state and thus altering glu-cose, protein, and fat metabolism by increasing postoperative insulin sensitivity.77-79 Furthermore, in patients whose expected length of stay is greater than 2 days, there is a significant length of stay reduction in patients that receive preoperative carbohy-drate loading.80 The best carbohydrate loading drink is unclear as studies are heterogeneous and the carbohydrate content is variable. Nevertheless, the carbohydrate drink should be hypo-osmolar for faster gastric emptying, result in a fed state with full glycogen stores, and reduce postoperative insulin resis-tance. The most commonly studied carbohydrate loading drink includes 100 g of carbohydrate the evening prior and 50 g of carbohydrate 2 to 3 hours prior to surgery.Intraoperative ConsiderationsSurgical Considerations. Prevention of surgical site infection consists of the use of mechanical, chemical, and/or antimicro-bial modalities.


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Surgery_Schwartz. to 3 hours prior to surgery.Intraoperative ConsiderationsSurgical Considerations. Prevention of surgical site infection consists of the use of mechanical, chemical, and/or antimicro-bial modalities. Mechanical and chemical methods include the use of patient bathing preoperatively and skin preparation with betadine, chlorhexidine, or similar chemical in order to limit the microbial content of the skin. Additionally, the appropriate use of antimicrobial prophylaxis should be employed and follow guidelines specific to the type of surgery and for duration of antibiotic prophylactic administration.Minimally invasive surgical approaches should be con-sidered as minimally invasive techniques have demonstrated improved outcomes across surgical specialties, including reduc-tions in length of stay and postoperative complications. Addi-tionally, the use of catheters or drains should be limited unless necessary, as these hinder the patient’s perceived ability for ambulation.81-84Hypothermia


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Surgery_Schwartz. stay and postoperative complications. Addi-tionally, the use of catheters or drains should be limited unless necessary, as these hinder the patient’s perceived ability for ambulation.81-84Hypothermia Prevention. Hypothermia is a common periop-erative problem. Up to 90% of all patients undergoing elective surgery suffer from inadvertent postoperative hypothermia.85,86 Those at highest risk include patients over the age of 60 years, and/or patients that have malnourishment, preexisting hypo-thermia, preexisting medical comorbidities that impair body temperature regulation (including advanced diabetes with neu-ropathy and hypothyroidism), who are undergoing general anes-thesia, and who are undergoing a major long surgery. Further, in patients who experience hypothermia, surgical complications are increased, including impaired wound healing, wound infec-tion, pressure ulcers, cardiac disorders including arrhythmia and infarction, as well as increased bleeding requiring blood transfu-sion


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Surgery_Schwartz. are increased, including impaired wound healing, wound infec-tion, pressure ulcers, cardiac disorders including arrhythmia and infarction, as well as increased bleeding requiring blood transfu-sion (Table 50-1).Brunicardi_Ch50_p2113-p2136.indd 211701/03/19 9:39 AM 2118SPECIFIC CONSIDERATIONSPART IITable 50-1Relative risk of elective surgical complications secondary to hypothermia86 RELATIVE RISK95% CONFIDENCE INTERVALSImpaired wound healing3.251.35–7.84Cardiac disorders4.491–20.16Blood transfusion1.331.06–1.66The reasons for hypothermia are multifactorial. Radiation, the transfer of heat by electromagnetic waves through space without a medium, accounts for 50% to 70% of heat loss. Con-vection, the loss of heat through ambient air stream, accounts for 15% to 25% of heat loss. Evaporation accounts for 5% to 20%, and conduction accounts for 3% to 5%.85 Temperature reduction can also be accelerated by cold intravenous fluids, low operating room temperatures, and a decreased


Surgery_Schwartz

Surgery_Schwartz. Evaporation accounts for 5% to 20%, and conduction accounts for 3% to 5%.85 Temperature reduction can also be accelerated by cold intravenous fluids, low operating room temperatures, and a decreased thermoregu-latory threshold, which occurs during the administration of gen-eral anesthesia. Further, the ability to compensate for reduction in body temperature is also compromised by muscle relaxation and anesthesia in general, as these processes impair shivering and thermoregulatory vasoconstriction.87 There are steps to take to prevent this hypothermia including active, convective heating using clean, filtered, forced-air warming blankets in patients in the preoperative area (prewarming) and also during anesthesia; thermal insulation; warmer ambient operating room tempera-tures, warmed irrigation solutions during surgery; and warmed infusions and blood products.88-99Venous Thromboembolism Prophylaxis. Venous throm-boembolism (VTE), which includes deep venous thrombosis (DVT) and


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Surgery_Schwartz. irrigation solutions during surgery; and warmed infusions and blood products.88-99Venous Thromboembolism Prophylaxis. Venous throm-boembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is the number one cause of potentially preventable death in common but preventable causes of morbidity and mortality in the perioperative patient. Several national quality improvement organizations have cited VTE prophylaxis for patients at risk as a priority for individual physicians and for hospitals because this intervention reduces adverse patient outcomes and hospital costs.Surgical patients have increased risk for VTE due to advanced age, multiple medical comorbidities, prolonged pro-cedure times, the inflammatory and hypercoagulable state of surgery, and immobility. Specific risk factors include major general, vascular, or orthopedic surgery; lower extremity paral-ysis due to spinal cord injury; fracture of the pelvis, hip, or long bones; multiple trauma;


Surgery_Schwartz

Surgery_Schwartz. Specific risk factors include major general, vascular, or orthopedic surgery; lower extremity paral-ysis due to spinal cord injury; fracture of the pelvis, hip, or long bones; multiple trauma; cancer; prior VTE; age 40 years and higher; obesity; immobility; oral contraceptive use; hypervis-cosity syndromes; and severe cardiopulmonary disease (prior myocardial infarction, congestive heart failure, chronic obstruc-tive pulmonary disease).Postoperative DVT is usually asymptomatic, and fatal PE can often be the first sign of VTE. DVT occurs after approxi-mately 25% of all major surgeries without prophylaxis, and PE occurs after 7%. Since screening modalities (such as venous duplex imaging) in asymptomatic patients have low sensitivity to detect clot, the best approach is to systematically apply pre-vention strategies to all patients undergoing surgery, with treat-ment choices based on patient-related and procedure-related risks.VTE prophylaxis is therefore an important component in


Surgery_Schwartz

Surgery_Schwartz. apply pre-vention strategies to all patients undergoing surgery, with treat-ment choices based on patient-related and procedure-related risks.VTE prophylaxis is therefore an important component in optimal perioperative care and current surgical practice and should be included in all practice guidelines. Appropriate VTE prophylaxis should be given preoperatively, intraopera-tively, and postoperatively based upon current guidelines for the surgery type.100 Examples of nonpharmacologic methods include early ambulation, graduated compression stockings, and intermittent pneumatic compression devices. Pharmaco-logic methods include the use of low dose unfractionated hepa-rin, low molecular weight heparin, and in some case, factor Xa inhibitors.Perioperative Fluid Management. Current and traditional fluid management strategies, which are based on a fixed fluid requirement per patient per case, have failed to improve out-comes. More modern goal-directed therapy (GDT) intravenous fluid


Surgery_Schwartz

Surgery_Schwartz. traditional fluid management strategies, which are based on a fixed fluid requirement per patient per case, have failed to improve out-comes. More modern goal-directed therapy (GDT) intravenous fluid approaches rely on the use of advanced medical devices, including esophageal Doppler monitors and other noninvasive cardiac output or bioimpedence models to determine whether or not patients are “fluid responsive” during surgery.101 In the setting of a normal ejection fraction, fluid is only administered when the expectation is that cardiac output will increase, and vasopressors are utilized if the aforementioned devices show fluid will not increase cardiac output. Excess fluid in certain general surgical cases can cause ileus and bowel edema, and in cardiac cases, it can cause hemodilution. Patients random-ized to restricted and liberal fluid resuscitation strategies found a clear linear relationship between total fluids administered (and weight gain) and complications following


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Surgery_Schwartz. Patients random-ized to restricted and liberal fluid resuscitation strategies found a clear linear relationship between total fluids administered (and weight gain) and complications following colorectal surgery including pulmonary edema and tissue-healing complications.102 Further multiple studies exist demonstrating fewer complica-tions with normovolemia than with liberal strategies of fluid resuscitation.102-108It must be understood that goal-directed therapy does, in no way, mean reduction in fluid administration. For some pro-cedures, it may be necessary to administer more than anticipated fluid volumes (orthopedics), while for others, the opposite may be true (abdominal). Normovolemia is important to maintain perfusion without volume overload. Thus, the idea behind goal-directed therapy is to maintain zero fluid balance coupled with minimal weight gain or loss. Hypovolemia is associated with reduced circulating blood volume, decreased renal perfusion, altered coagulation,


Surgery_Schwartz

Surgery_Schwartz. therapy is to maintain zero fluid balance coupled with minimal weight gain or loss. Hypovolemia is associated with reduced circulating blood volume, decreased renal perfusion, altered coagulation, microcirculation compromise, and endothe-lial dysfunction, among other processes. Hypervolemia is asso-ciated with splanchnic edema, decreased pulmonary gas exchange secondary to pulmonary edema, impaired wound heal-ing, anastomotic dehiscence, decreased mobility, altered coagu-lation, and endothelial dysfunction, amidst others processes109 (Fig. 50-4). Esophageal Doppler is a mode by which ultrasound is used to monitor and guide intraoperative fluid management has been used quite frequently. The use of this device for fluid optimi-zation has been studied in several randomized controlled trials or meta-analyses, all of which showed a significant reduction in length of stay of up to 4 days.110,111 Reductions in length of stay have been seen in gastrointestinal surgery, trauma surgery,


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Surgery_Schwartz. trials or meta-analyses, all of which showed a significant reduction in length of stay of up to 4 days.110,111 Reductions in length of stay have been seen in gastrointestinal surgery, trauma surgery, urologic surgery, and also the orthopedic population.112-116 Alter-native devices such as arterial waveform analyzers and pulse oximeter waveform analyzers have been studied and may be promising with the added advantage of lower cost over esopha-geal Doppler.Postoperatively, once the patient is adequately tolerat-ing at least a liquid diet and maintaining adequate hydration, 3Brunicardi_Ch50_p2113-p2136.indd 211801/03/19 9:39 AM 2119OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50supplemental intravenous fluids should be minimized or ter-minated. The use of Dopplers or other volume status wave form analyzers have not been studied in the nonventilated postoperative patient and therefore cannot be used to reli-ably assess volume status. Clinical judgment


Surgery_Schwartz

Surgery_Schwartz. Dopplers or other volume status wave form analyzers have not been studied in the nonventilated postoperative patient and therefore cannot be used to reli-ably assess volume status. Clinical judgment based on patient factors, surgery type, and the clinical findings should be considered in the decision to continue intravenous flu-ids. However, once the patient is able to maintain adequate hydration, supplemental fluids should be used judiciously to limit fluid overload, tissue and lower extremity edema, and the constraints that the intravenous medication pole has upon patient-initiated ambulation.It is not enough to have normovolemia, but one must also consider the type of fluid that should be used for resuscitation. From a recent Cochrane review, there is no evidence that col-loids are superior to crystalloid for resuscitation in patients.117 Therefore, crystalloid fluids should generally be the primary intravenous fluid during the perioperative course. In cardiac sur-gery, the


Surgery_Schwartz

Surgery_Schwartz. are superior to crystalloid for resuscitation in patients.117 Therefore, crystalloid fluids should generally be the primary intravenous fluid during the perioperative course. In cardiac sur-gery, the utilization of 0.9% normal saline solution was associ-ated with hyperchloremia and poor postoperative outcomes, including higher length of stay and increased mortality.118 Fur-ther, a more balanced crystalloid, such as Plasma-Lyte, was associated with improved outcomes in 22,851 surgical patients.119 In this study, there was a 2.05 odds ratio predictor of mortality with normal saline. Other complications such as acute kidney injury, gastrointestinal complications, major hemor-rhage, and major infection were also increased in the group of patients that were hyperchloremic after normal saline adminis-tration. Based on such evidence, it would seem prudent to pro-ceed with a more balanced solution, such as PlasmaLyte, to reduce complications. Perioperative Pain ManagementAccording to the


Surgery_Schwartz

Surgery_Schwartz. adminis-tration. Based on such evidence, it would seem prudent to pro-ceed with a more balanced solution, such as PlasmaLyte, to reduce complications. Perioperative Pain ManagementAccording to the International Association for the Study of Pain (IASP) Taxonomy, the definition of pain is described as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”120 There are two important implications of this: pain is completely subjective in that it is whatever the patient says it is, and patients cannot experience pain while unconscious.121 This has some effects on how the anesthesiologist treats sympathetic stimulation in the operating room. Heretofore, elevations in heart rate and blood pressure were treated with opioid medica-tions, as these sympathetic markers were considered surrogates for patients experiencing pain while under general anesthesia. However, other medications can be used to treat the


Surgery_Schwartz

Surgery_Schwartz. with opioid medica-tions, as these sympathetic markers were considered surrogates for patients experiencing pain while under general anesthesia. However, other medications can be used to treat the sympa-thetic response to surgery such as β-blockers and deepening the anesthesia without administering opioid medications while the patient is unable to experience the pain.The mainstay of alleviating pain has historically relied almost exclusively on opioids, especially with the usage of patient controlled analgesia devices (PCAs). However, limiting opioids in the perioperative setting is of substantial benefit. Opi-oids, in fact, reduce pain immediately after administration. However, they also worsen pain scores after they wear off, increase postoperative opioid requirements, increase nausea and vomiting, cause respiratory depression, reduce gastrointestinal motility, worsen urinary retention, induce endocrine dysfunc-tion, and suppress the immune system.87 There have been a number of