ASERalert April 2017 | Volume 2, Issue 1 ERAS for Gynecologic Surgery OFFICIAL PUBLICATION OF The Perioperative Quality Initiative (POQI) Consensus Conferences Engage With Primary Care Providers Ambulatory Corner also in this issue

Board of Directors Officers President Tong J (TJ) Gan, MD, MHS, FRCA President-Elect Julie Thacker, MD Vice-President Timothy Miller MB, ChB, FRCA Treasurer Roy Soto, MD Secretary Stefan D. Holubar MD, MS, FACS, FASCRS Directors Keith A. (Tony) Jones, MD Anthony Senagore, MD Maxime Cannesson, MD, PhD Terrence Loftus, MD, MBA, FACS Andrew Shaw MB, FRCA, FFICM, FCCM Desiree Chappel, CRNA Newsletter Committee Thomas Hopkins, MD: Chair Lyla Hance, MPH: Co-Chair Jeffrey Huang, MD Uday Jain, MD, PhD Amy McCutchan, MD Asha Naik, FRCA Christina Solis, MHA Matthias Stopfkuchen-Evans, MD About ASER ASER is a nonprofit organization with an international membership, which is dedicated to thepractice of enhanced recovery in the perioperative patient through education and research. ASER’s mission is to advance the practice of perioperative enhanced recovery, to contribute to its growth and influences, by fostering and encouraging research, education, public policies, programs and scientific progress. Administrative Office American Society for Enhanced Recovery 6737 W Washington St. | Ste. 4210 Milwaukee, WI 53214 414-389-8610 | info@aserhq.org President’s Message By Tong J (TJ) Gan, MD, MHS, FRCA, President A s I am writing this message, Chinese communities have just celebrated the Year of the Rooster. According to the Chinese zodiac, there are 5 types of roosters, based on the 5 elements: wood, fire, metal, water and gold. 2017 is the Fire Rooster Year. What does “Fire Rooster Year” Mean? Some characteristics of the rooster are energetic, determined, perseverant and forward-looking. I believe these characteristics represent the membership of ASER. We are here to promote enhanced recovery after surgery and help hospitals implement enhanced recovery pathways to improve patient care. The US healthcare system is going through a period of uncertainty with the current administration. It is unclear what the future direction holds. Regardless, enhanced recovery principles are here to stay and will benefit patients, physicians and hospitals irrespective of what the models of healthcare turn out to be. I encourage all of you to be active participants in ASER activities. We have a few exciting events over the next several months. The upcoming ASER/EBPOM Congress will be held on April 27-29, 2017 at the Hyatt Regency Washington on Capitol Hill in Washington DC. Dr. Timothy Miller, the scientific program Chair, has put together a superb and scientifically robust program covering multiple surgical disciplines in the context of enhanced recovery and perioperative medicine. We have successfully conducted two leadership forums in Louisville, KY and Miami, FL and have received 2 great feedback. ASER and The Detroit Medical Center Perioperative Institute For Surgical Excellence (PISE) cohosted a symposium on Healthcare Reform and Innovation in Perioperative Musculoskeletal Care in Detroit in December 2016, with more than 200 attendees. Last fall, ASER participated in the “Plan Against Pain” campaign to promote awareness regarding the many options of analgesics for perioperative pain management, using a multimodal approach to reduce opioid related side effects and potential opioid abuse and addiction. You can read the details in this newsletter. The second PeriOperative Quality Initiative (POQI) conference was successfully held in Stony Brook, NY on December 2-3, 2016. A summary on the POQI activities in the past year as well as future meeting is presented in this newsletter. Many of our committees have been extremely active, providing great ideas to expand membership and moving ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org the society forward. I would like to thank the Newsletter Committee for their diligence and hardwork in producing this content rich newsletter. Last but not least, it is a great time to be in Washington DC during the spring season. Look forward to seeing you at the ASER/EBPOM Congress. n Tong J (TJ) Gan, MD, MHS, FRCA President American Society for Enhanced Recovery Professor and Chairman Department of Anesthesiology Stony Brook University tong.gan@stonybrookmedicine.edu ANNUAL CONGRESS OF ENHANCED RECOVERY AND PERIOPERATIVE MEDICINE APRIL 27TH -29TH , 2017 HYATT REGENCY WASHINGTON ON CAPITOL HILL 400 NEW JERSEY AVE NW, WASHINGTON, D.C. 20001 Registration Information on pages 15-19 FASTER RECOVERY, FEWER COMPLICATIONS, IMPROVING OUTCOMES CHOOSE ENHANCED RECOVERY Become an ASER member today! For further information and to apply online visit aserhq.org/membership Follow us on Social Media ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org ASER Member Benefits ª Implementation Consultation and Guidance ª Practice Guidelines & Patient Educational Materials ª Networking with Experts ª Professional Development Opportunities ª Access to Enhanced Recovery Best Practices ª Access to Publications & Ongoing Research ª Discounts to the ASER Annual Congress 3 2017

The American Society of Enhanced Recovery (ASER) is a Multispecialty Nonprofit Organization with a Growing Global Following. ASER encouraging research, education, public policies, and scientific progress. ASER supports patient care, keeping you up to date in information on best practices, ongoing research, and practice guidelines pertaining to enhanced recovery. We also provide implementation guidance and shared experiences so as to help make your hospital’s implementation of enhanced recovery go smoother. The ASER mission is simple. We support the growth of enhanced recovery and perioperative medicine so that our surgical patients can benefit from a faster recovery, fewer complications and a quicker return to pre-operative functional status. Help us in supporting this mission and support ASER. Below are some of the membership benefits offered by ASER. • Network with Experts in Enhanced Recovery and Perioperative Medicine You will have the opportunity to meet and stay connected with experts in the field. • Implementation Guidance, Consultation and Resource Access Get help with your hospital’s enhanced recovery implementation process by participating in the ASER Leadership Forum. At this Leadership Forum, a team of implementation experts will give advice and guidance so as to ensure your hospital’s transition goes as smoothly as possible. ASER provides a variety of implementation resources such as the ASER Enhanced Recovery 4 Implementation Guide and our Enhanced Recovery for Major Abdominal Surgery book. You will also have access to a variety of enhanced recovery patient booklets and pathways examples. • Access to Enhanced Recovery Best Practices and Ongoing Research Gain access to Perioperative Medicine, the official journal of ASER, our newsletter ASER Alert, and presentations on enhanced recovery principles, guidelines and ongoing research. • Professional Development Receive CME credit at our ASER Annual Congress Meeting where experts and health professionals from all over the world share their experiences. Members will receive annual meeting discounts. • Get involved Join the many committees that ASER has to offer. Member Bring a Member Campaign ASER members will get 10% off of their next year’s membership for every one new member recruited. This 10% deduction is additive for each new member recruited for the year. If 10 new members are brought in by a member, the member will get a free ASER membership for that following year. New members recruited must indicate the ASER member’s name that referred them. This can be done under the referral section located on the ASER membership application form. n ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org is committed to improving peri-operative patient outcomes by advancing the practice and application of enhanced recovery pathways after surgery. Our goal is to promote the growth of enhanced recovery through Choices Matter: Changing the Perioperative Experience for Patients to Reduce Opioid Risks T he numbers continue to validate the severity of the opioid epidemic – keeping this issue center stage among patients, physicians and the media. In fact, the CDC reports that 91 people die every day in the United States from an opioid overdose.1 And it’s not just overdose – but addiction contributing to the problem. Recent research found that an alarming 10 percent of patients reported becoming addicted or dependent on opioids following surgery.2 Concerns over addiction and dependence are weighing on patients as 37 percent report that addiction is a top concern when scheduling a surgery. The concern is more prevalent in men, with 41 percent of men and 34 percent of women concerned about becoming addicted to opioids.3 Reducing the risk of opioid use, abuse and dependence is a conversation that should remain at the forefront of this epidemic for both in the consumer and clinical space. There are several ways to mitigate opioid use, including education, offering alternatives and assessing the perioperative medicine model. The perioperative discussion has become even more important in recent years as additional options have become available to minimize postsurgical pain before a surgeon even finishes his or her procedure. Easing patients’ concerns about postsurgical pain cannot be lost in this conversation, however. Patients and physicians are eager and open to trying non-opioid options. According to the Choices Matter survey, 79 percent of patients reported that they would choose a non-opioid option over opioids and 70 percent of surgeons would do the same if they knew it could effectively manage their patient’s pain.4 By collaborating together, patients and physicians can develop pain management plans and implement contracts that allow physicians to prescribe fewer painkillers and reduce opioid risks that can occur in short term usage. We acknowledge that some surgical procedures are needed immediately and some require opioids post-surgery; however having a conversation and discussing options, when available, is important since research finds some patients are delaying surgery due to fear of pain. Patients and physicians deserve a choice – which thematically was a cornerstone of the Choices Matter campaign that the American Society for Enhanced Recovery and Pacira Pharmaceuticals embarked on last year. The unbranded education campaign was developed to empower and activate patients, caregivers and physicians to proactively discuss ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org postsurgical pain management, including non-opioid options before surgery. It is imperative that the medical community continue to work together to change the perioperative and postoperative experience and create viable alternatives to effectively manage pain. To do so, collaboration among patients, physicians and the community at-large will need to continue to work together on the front lines of this epidemic to combat it head on and educate one another on the non-opioid options available to reduce the risks of opioid addiction. If an option is not available, having the conversation about postsurgical pain (how it will be managed before, during and after surgery) is still a great way to start. n References 1. CDC Report. https://www.cdc.gov/ drugoverdose/epidemic/. Accessed on January 27, 2017. 2. Choices Matter Survey. Released on August 1, 2016. Report available upon request. 3. Choices Matter Survey. Released on August 1, 2016. Report available upon request. 4. Choices Matter Survey. Released on August 1, 2016. Report available upon request. 5

The Perioperative Quality Initiative (POQI) Consensus Conferences By Timothy E Miller,MD; Julie K Thacker, MD & Tong J Gan, MD, FHS, FRCA T he Perioperative Quality Initiative (POQI) is a recently formed international, multidisciplinary non-profit organization whose intent is to organize a series of consensus conferences on topics of interest related to perioperative medicine. Each consensus conference will aim to provide an objective, dispassionate distillation of the literature related to the chosen topics, and then to produce a consensus statement that interprets the available data, identifies unanswered questions and most importantly offers recommendations to improve patient care. The POQI consensus conference process consists of three stages: pre-conference planning, conference, and post-conference.1 During the pre-conference phase, the POQI conference directors select topics for which there is an apparent need for a consensus statement from a group of international experts to offer recommendations for patient care. Work groups are then assembled to review each topic. The work group consists of a chair, co-chair, and several delegates who are experts in at least one of the topics that will be discussed. Each work group will thoroughly review the literature, generate a bibliography of relevant Delegates at the 1st POQI Consensus Conference. literature, and identify a list of important questions to be addressed in the final consensus manuscript. The POQI conference itself is an intensive 2-day interactive face-to-face meeting where delegates debate and question the key issues in each topic. Post-conference, each workgroup finalizes a consensus statement on their topic for publication in a peer-reviewed journal. Delegates are expected to contribute to the preparation of each manuscript during the process. The first two POQI Consensus Conferences were supported by the American Society for Enhanced Recovery (ASER) and Evidence-Based Perioperative Medicine (EBPOM). The 1st POQI Consensus Conference took place 6 in Durham, NC on March 4th-5th 2016. The conference focused on “Enhanced Recovery for colorectal surgery”. The four discussion topics chosen were: 1. Perioperative fluid management – how can we best manage fluid within an Enhanced Recovery Pathways (ERP) for colorectal surgery2 2. Perioperative analgesia – how can we best manage pain within an ERP for colorectal surgery? 3. Preventing nosocomial infection – how can we best prevent nosocomial infection within an ERP for colorectal surgery 4. Measurement and quality – how can we measure the of quality of care within an ERP for colorectal surgery These manuscripts have all been accepted for publication, and at the time of print are either published or will be published shortly in Perioperative Medicine https://perioperativemedicinejournal. biomedcentral.com The 2nd POQI Consensus Conference took place at Stony Brook University in Stony Brook, NY on December 2nd-ˇ3rd 2016, and was entitled “Key Concepts within Enhanced Recovery Pathways.” The three chosen topics were: 1. Perioperative nutrition - how can we best manage preoperative and postoperative nutritional status within an ERP? ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org 2. Patient reported outcomes - what Patient Reported Outcomes should be measured within an ERP? 3. Postoperative Gastrointestinal Dysfunction – how can be best prevent and manage postoperative gastrointestinal dysfunction within an ERP The 3rd POQI Consensus Conference will occur in London in July 2017. The subject of the conference will be perioperative blood pressure management. The key figures and manuscript will be made available whenever possible on the POQI website, poqi.us. The POQI process aims to combine a “thorough review of the literature” with “expert appraisal and debate” to offer practical advice that is sometimes missing from consensus statements that purely review the literature. It is based on the longstanding Acute Dialysis Quality Initiative (ADQI) that has been particularly successful in generating consensus definitions and classification systems (including the RIFLE classification for Acute Kidney Injury) Whilst this approach is not without criticism, we believe that this methodology provides the best of both methods, and hopefully the POQI manuscripts that are supported by ASER will provide practical consensus statements and recommendations to guide practice. n Valuable insight to help you guide volume administration. Clarity gives you the control to make more informed decisions. Edwards Lifesciences’ range of hemodynamic monitoring solutions provides key fl ow parameters shown to be more informative in determining fl uid responsiveness than pressure-based parameters.1 Each off ers continuous information which may be used in Perioperative Goal-Directed Therapy (PGDT) to hemodynamically optimize your moderate to high-risk surgery patients. The Edwards Enhanced Surgical Recovery Program can help you implement PGDT today. PGDT can help ensure your patients are consistently maintained in the optimal volume range. Know more. Know now. Edwards.com/ASER17 1. Michard F, Biais M. Rational fl uid management: dissecting facts from fi ction. Br J Anaesth 2012 For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards Lifesciences devices placed on the European market, meet the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/EEC, and bear the CE marking of conformity. Edwards, Edwards Lifesciences, the stylized E logo, ClearSight, Enhanced Surgical Recovery Program, FloTrac and Swan-Ganz are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners. © 2017 Edwards Lifesciences Corporation. All rights reserved. AR11991 Edwards Lifesciences • One Edwards Way, Irvine CA 92614 USA • edwards.com ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org 7 ClearSight noninvasive system CO, SV, SVV, SVR, cBP* FloTrac minimally-invasive system CO, SV, SVV, SVR Swan-Ganz system CCO, RVEDV, RVEF, SvO2 * Continuous Blood Pressure Delegates at the 2nd References 1. 2. Consensus Conference. Miller TE, Mythen MG, Shaw AD, Gan TJ. Evidence-Based Perioperative Medicine comes of age: the Perioperative Quality Initiative (POQI). Periop Med 2016; 5:26 Thiele RH, Raghunathan K, Brudney CS, et al. American society for enhanced recovery (ASER) and perioperative quality initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Periop Med 2016; 5:24

Engage With Primary Care Providers By Chad M. Craig, MD, FACP E nhanced recovery programs surrounding surgery have the potential to assist with more than successful surgical outcomes alone. Enhanced Recovery Programs fall under the umbrella of Perioperative Surgical Homes, and integration of care between such programs and outpatient providers have the opportunity to strongly influence the trajectory of patients’ health beyond the surgical episode.1 An enormous amount of information is often gathered during the preoperative phase of care, including for example new diagnoses of anemia, type 2 diabetes mellitus, kidney disease, or cardiopulmonary disease. Such information is useful to the perioperative team, but often not reliably communicated during short-term transitions of care to rehabilitation facilities, or to outpatient primary care providers. This holds true for information gathered during the operative and post-operative periods as well, for example: a short run of atrial fibrillation intraoperatively that self-resolves and is of unclear clinical significance. At many hospitals there is a significant reliance on traditional discharge summaries from the index hospital stay, without verbal handoff of key information, or a reliable way to know if select information was reviewed and acted upon by a primary provider or specialist. Enhanced recovery programs have identified and bundled key interventions that are known to influence the success of surgical and patient outcomes.2 Functionality, pain, and quality-of-life are three key issues addressed in such programs, and this holds true for a wide range of surgical specialties: oncologic, orthopaedic, cardiovascular, and general surgery. These three issues are likewise of enormous importance to patients and primary care providers in the outpatient setting over the long term. Programs that optimize nutrition, and focus on healthy diets may translate in to long term healthy eating behaviors. Tobacco cessation programs, diabetes education, exercise, home safety, biofeedback and psychological health, and multimodal pain management programs are additional examples that have the potential to significantly impact how patients engage in and manage their longer term health. These are costly interventions and it would be a shame if we were to consider them one-and-done interventions surrounding the surgical episode. Many surgical-focused hospitals have invested enormous financial resources into programs to aide patients in achieving successful outcomes. Outpatient practices may not have the same resources, and could greatly benefit from information gathered by the former. Additionally, it often takes repeated clinical encounters with patients before unhealthy behaviors are altered, as for example with tobacco smoking cessation. From a longitudinal health viewpoint, one might view Enhanced Recovery Programs as similar to community health fairs: excellent opportunities to employ select highimpact health interventions, and change the trajectory of short and long term health. For large integrated health systems, the components and resources dedicated to Enhanced Recovery Programs will often overlap with the goals of other providers within the same system.3 However, within much of the United States patient care remains fragmented between multiple providers. For those 8 select centers that are optimizing patient care around the time of surgery and providing excellent outcomes through Enhanced Recovery Programs, there is a real opportunity for them to feedback that information and patient education strategies (where successful) with outpatient providers. This is especially true for geriatric patients, in whom medical comorbidity rates are high, and new medical issues are often identified in the setting of surgical stressors. A number of phone-based applications are increasingly offering an easy platform for such communication between providers. Proactive, goal-directed behavior that is often highlighted as part of Enhanced Recovery Programs, supports the concept of patients engaging in shared-decision making and playing an overall proactive role in their health.4 Patients should also proactively identify their support team before surgery, an overlooked area of importance highlighted by both patients and investigators alike in one study.5 The ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org transition home is identified frequently by patients as one of the most stressful periods of perioperative care,6 and having adequate resources identified proactively, as well as effective handoff to primary providers may aide in alleviating such anxiety. Engaging primary care providers directly in a consistent and systematic manner, during the preoperative and postoperative phases of care, is one practical strategy that may aide with such communication, and often yield additional pertinent health information not previously disclosed by patients. Additional strategies that ease the communication between Enhanced Recovery Program providers and primary outpatient providers would be welcome to this field. This is an area that would benefit from additional research, and no-doubt would be highly utilized in various health system structures throughout the country. n References 1. Mello MT, Azocar RJ, Lewis MC. Geriatrics and the Perioperative Surgical Home. Anesthesiol Clin. 2015;33(3):439-45. 2. King AB, Alvis BD, McEvoy MD, Enhanced recovery after surgery, perioperative medicine, and the perioperative surgical home: current state and future implications for education and training. Curr Opin Anaesthesiol. 2016;29(6):727-32. 3. Kash BA, Zhang Y, Cline KM et al. The preioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominately positive quality and dost outcomes. Milbank Q. 2014;92(4):796-821. 4. Li Y. Strategy and prospective of enhanced recovery after surgery for esophageal cancer. Chinese Journal of Gastrointestinal Surgery. 2016;19(9):965-70. 5. Galli E, Fagnani C, Laurora I et al. Enhanced Recovery After Surgery (ERAS) multimodal programme as experienced by pancreatic surgery patients: Findings from an Italian qualitative study. Int J Surg. 2015;23:152-9. 6. Archer S, Montague J, Bali A. Exploring the experience of an enhanced recovery programme for gynaecological cancer patients: a qualitative study. Perioper Med. 2014;3(1):2. You can reduce post-surgical complications by 32% 1 in your moderate to high-risk patients. A large body of evidence demonstrates that hemodynamic optimization through Perioperative Goal-Directed Therapy (PGDT), utilizing dynamic parameters which are informative in determining fluid responsiveness, has been shown to reduce post-surgical complications.1–4 30+ 14+ randomized controlled trials and meta-analyses confirmed reduction of risk for AKI, anastomotic leaks, pneumonia, SSI and UTI.1–4 When evidence inspires action, Edwards Enhanced Surgical Recovery program is here to help you implement PGDT. Edwards.com/ASER2017 References: 1. Grocott et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane systematic review. Br J Anaesth 2013 2. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 2009; 103: 637–46 3. Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N. Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care 2011; 15: R154 4. Corcoran T et al. Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis. Anesthesia – Analgesia 2012 Edwards, Edwards Lifesciences, the stylized E logo, and Enhanced Surgical Recovery are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners. © 2017 Edwards Lifesciences Corporation. All rights reserved. AR11710 Edwards Lifesciences • edwards.com One Edwards Way, Irvine CA 92614 USA ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org 9

“WILL MY PATIENT RESPOND TO FLUIDS?” WHEN VOLUME MATTERS, CONFIDENCE COUNTS. Clinicians make vital fluid and drug decisions every day, often with limited and inconclusive information. Challenging the heart with fluid and measuring its response can provide the insight needed to guide therapy in perioperative volume management. Cheetah Medical’s Starling™ SV Hemodynamic System is 100% noninvasive and provides continuous, accurate, and individualized volume management for patients across the continuum of care. Cheetah Medical, Inc. 1320 Centre St., Suite 104, Newton Center, MA 02459 USA Toll free: 866.751.9097 • Tel: 617.964.0613 • cheetah-medical.com The Starling SV is a trademark of Cheetah Medical, Inc. ©2017 Cheetah Medical ERAS for Gynecologic Surgery By Anna Strohl,MD; Jeffrey Huang, MD & Shireen Ahmad, MD Introduction E care.1 Several protocols and guidelines have been designed for the management of patients undergoing colorectal surgeries incorporating the ERAS principles. More recently, growing evidence supports the expansion of ERAS protocols to include women undergoing gynecologic surgery. Clinical Evidence Despite the significant number of randomized controlled trials (RCTs) in the colorectal literature, there is no evidence from randomized control trials (RCTs) to support or refute the use of ERAS in gynecologic surgery.2 Existing data examining clinical pathways aimed at improving postoperative recovery in gynecologic surgery include small cohort studies; however, these data report similar findings to those published in the colorectal literature, suggesting that ERAS protocols can be expanded to gynecologic subspecialty surgery. A recent review of ERAS programs in general gynecologic surgery demonstrated that ERAS-driven protocols reduce length of stay (LOS) without increasing complication or readmission rates.3 Dickson et al. demonstrated that an ERAS pathway in 400 women undergoing abdominal hysterectomy for benign disease decreased median LOS from 3 days to 1 day following implementation (p<0.001) without an increase in complications.4 A separate study compared 136 patients on an ERAS pathway with 211 historical controls using a conventional protocol and found that the median LOS decreased from 3 to 2 days (p=0.007) while also reducing complications rates from 40.2% to 21.3% (p=0.004).5 The benefits ERAS protocols are not limited to woman undergoing hysterectomy for benign disease. Carter et al. reviewed a 22-point ERAS program in 389 women undergoing laparotomy for suspected or confirmed gynecologic malignancy. This study found a median LOS of 3 days with a readmission rate of 4%.6 Kalogera et ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org al. included women with gynecologic malignancy in a retrospective study evaluating the implementation of an ERAS study in laparotomy for complex gynecologic surgery. This study found that median LOS was 4 days less in the ERAS group than in the conventional group (8.7 vs 11.9 days, p<0.001).7 While few data exist on ERAS programs specifically in women with gynecologic cancer, a systematic review of seven cohort studies found that enhanced recovery pathways in gynecologic cancer patients is safe and reduces length of stay, as well as cost.8 Due to the extensive data in support of ERAS programs from the colorectal literature, as well as the growing data from gynecologic surgery, the Society for Gynecologic Oncology (SGO) has endorsed the implementation of ERAS-driven programs in women undergoing gynecologic surgery in an effort to improve postoperative outcomes. , Future studies need to focus on the development of consistent, comprehensive ERAS programs in order to truly evaluate its impact on gynecologic surgery outcomes.9, 10 Recommended Preoperative Management: Patient education establishes expectations and promotes active participation of the patient in his/her own care and is strongly recommended.11 Preoperative cessation of smoking and alcohol consumption for at least 4 weeks and preoperative medical optimization reduces complications and is recommended. Routine preoperative mechanical bowel preparation lacks evidence of benefit in the gynecologic population and is not recommended. Patients without risks for delayed gastric emptying, should refrain from solids for 6 hours and liquids for 2 hours prior to surgery. The evidence supports preoperative carbohydrate loading to prevent postoperative insulin resistance and increased complications.12 In order to facilitate early ambulation and feeding routine administration of long acting sedatives is discouraged. Prophylactic anticoagulation and the use of pneumatic compression 11 nhanced Recovery After Surgery (ERAS) is a standardardized, highly coordinated interdisciplinary perioperative surgical care program that incorporates evidence-based interventions to minimize surgical stress, improve physiological and functional recovery, reduce complications, and facilitate earlier discharge from the hospital and reduced cost of

stockings decrease the incidence of venous thromboembolism and is recommended.13 Intravenous antibiotics and antimicrobial skin preparation is strongly recommended to prevent surgical site infections. Preoperative iron therapy in anemic patients reduces the need for perioperative transfusion, which along with erythropoiesis stimulating agents is associated with increased tumor recurrences. Recommended Intra-operative Management: Opioid sparing anesthetic techniques and lung protective ventilation are recommended. Due to the high incidence of postoperative nausea and vomiting in the gynecologic population multimodal antiemetic prophylaxis is recommended. Minimally invasive surgery improves patient outcomes and is strongly recommended. Nasogastric tubes increase postoperative pulmonary complications and patient discomfort and are strongly discouraged.14 Temperature monitoring and use of active warming devices is mandatory to prevent hypothermia and its consequences on coagulation, infection and cardiac complications. Maintaining normovolemia with goal directed fluid therapy has been demonstrated to reduce morbidity in the colorectal surgery and is strongly recommended. Balanced salt solutions are preferable to normal saline solutions. Advanced hemodynamic monitoring facilitates optimizing of patients volumes status in high risk patients or patients having extensive surgeries.15 Recommended Postoperatve Management: Thromboprophylaxis is recommended for 30 days postoperatively due to a high incidence of venous thrombosis in gynecologic oncology patients.16 Multimodal analgesia with scheduled administration of nonsteroidal anti-inflammatory agents, and acetaminophen is strongly recommended.17 9. A recent review of patients undergoing hysterectomy found that gabapentin has effective in reducing pain and opioid adverse effects. Dexamethasone is recommended for the analgesic and anti-emetic effects.18 The evidence supporting the use of epidural analgesia is weak, and, it may result in impaired mobilization and need for a urinary catheter. Systemic lidocaine analgesia is associated with opioid sparing effects and is gaining popularity, but the optimum dosage has to be determined.19 Conclusions These recommendations are based on current scientific literature and are subject to change(s) as additional institutions adopt the principles of ERAS and the number of high quality randomized controlled studies that incorporate ERAS principles increases. n References 1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183: 630-41. 2. Lu D, Wang X, Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database Syst Rev. 2015; 19:3. 3. Miralpeix E, Nick AM, Meyer LA, Cata J, Lasala J, Mena GE, Gottumukkala V, Iniesta-Donate M, Salvo G, Ramirez PT. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016; 141: 371-78. 4. Dickson E, Argenta PA, Reichert JA. Results of introducing a rapid recovery program for total abdominal hysterectomy. Gynecol Obstet Investig 2012; 73: 21-25. 5. Modesitt SC, Sarosiek BM, Trowbridge ER Redick DL, Shah PM, Thiele RH, Tiouririne M, Hedrick TL. Enhanced recovery implementation in major gynecologic surgeries: effect of care standardization. Obstet Gynecol 2016; 123:457-66. It is strongly recommended that intravenous fluids be discontinued within 24 hours after surgery and oral diet and analgesics commenced. 6. Carter J. Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit. ISRN surg 2012; 368014. 7. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, Trabuco E, Lovely JK, Dhanorker S et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013; 122, 1305. 8. Nelson G, Kalogera E, Dowdy S. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol. 2014 135(3): 586-94. 12 ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC. Guidelines for pre- and intraoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations – Part I. Gynecol Oncol 2016; 140, 313-322. 10. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N, Ljungqvist O, Dowdy SC. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations – Part II. Gynecol Oncol 2016; 140, 323-332. 11. Egbert LD, Battit GE, Welch CE, Bartlett MK: Reduction in postoperative pain bt encouragement and instruction of patients. A study of patient-doctor rapport. NEJM 1964; 270: 825-827. 12. Smith MD, McCall J, Plank L, Herbison GP, Soop M, Nygren J: Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev (8) 2014. 13. Amato A, Pescatori M: Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev (1) 2006. 14. Cheatham MI, Chapman WC, Key SP, sawyers JL: A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221: 469-476. 15. Hamilton MA, Cecconi M, Rhodes A: A systematic review and meta-analysis on the use of pre-emptive hemodynamic intervention to improve postoperative outcomes in moderate and high risk surgical patients. Anesth Analg 2100; 112: 1392-1402 16. Rasmussen MS, Jorgensen LN, WilleJorgensen P: Prolonged thromboprophylaxis with low molecularweight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev (1) 2009. 17. Ong CK, Seymour RA, Lirk P, Merry AF: Combining paracetamol (acetaminophen) with nonsteroidal anti-inflammatory drugs; aqualitative systematic reviewof analgesic afficacy for acute postoperative pain. Anesth Analg 2010; 110: 1170-1179. 18. Alayed N, Alghanaim N, Tan X, Tulandi T: Preemptive use of gabapentin in abdominal hysterectomy: a systematic review and meta-analysis. Obstet Gynecol 2014; 123: 1221-1229. 19. Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, et al; Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev (7), 2015. Ambulatory Corner By Katherine H. Dobie, MD I t is estimated that more than 70% of surgery today is performed in the outpatient setting, with a forecasted 16% growth in outpatient volumes and a 3% decline of inpatient discharges in the next ten years. When considered within the context of the current trend to enhance our value proposition across all of healthcare, this rapidly changing landscape requires that we carefully consider our role in the outpatient perioperative space. As we embrace and navigate the advent of perioperative medicine and enhanced recovery, we must remain committed to applying the principles of this practice in the ambulatory setting. Ambulatory surgery has seen tremendous advances in the last ten years, with an increase in medically complex patients undergoing more difficult procedures safely at free-standing Ambulatory Surgery Centers (ASCs). Interestingly, the success of this evolution has relied squarely on some of the basic tenets of perioperative care, the same concepts that we are now applying inside the walls of the hospital. Ambulatory perioperative care by definition is an enhanced recovery program, with a prescribed, multidisciplinary protocol designed to deliver a fixed patient disposition: to home, pain controlled, great experience, and back to their baseline as soon as possible. ASCs are less expensive, have higher patient experience ratings, less complications, and most patients return to at least some functionality day of surgery. While we as perioperative physicians will need to lead the care that enhances the aforementioned metrics inside the walls of the hospital, it will be essential that we also remain focused on the surgical outpatient, and recognize that our ability to continue to innovate in this space will add immensely to our value proposition. It’s exciting to consider what cases we will be doing at free-standing surgery centers with a plan to discharge to home on the day of surgery in ten years. Ambulatory physicians are the gatekeepers of ASCs, holding the future of perioperative innovation in free standing centers in our hands. n Look for our “Ambulatory Corner” in the next newsletter, where we will expand on the challenges and opportunities facing Ambulatory Physicians in the context of Enhanced Recovery! Tom Hopkins, MD Chair, ASER Newsletter Committee Lyla Hance, MPH Co-Chair, ASER Newsletter Committee ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org 13

2017 ANNUAL CONGRESS OF ENHANCED RECOVERY AND PERIOPERATIVE MEDICINE APRIL 27TH –29TH , 2017 HYATT REGENCY WASHINGTON ON CAPITOL HILL 400 NEW JERSEY AVE NW, WASHINGTON, D.C. 20001 6737 W. Washington St., Suite 4210 • Milwaukee, WI 53214 (P) 414-389-8610 • (F) 414-276-7704 • www.aserhq.org • info@aserhq.org

Meeting Accreditation Information LEARNING OBJECTIVES • Discuss the various elements of an enhanced recovery pathway • Appreciate the current evidence base, as well as gaps in understanding and controversies • Understand new care delivery models and approaches, and how to apply these models in their hospital to improve outcomes ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Amedco and Sexual Medicine Society of North America (SMSNA). Amedco is accredited by the ACCME to provide continuing medical education for physicians. Invited Speakers Anoushka Afonso, MD Memorial Sloan Kettering Cancer Center New York, NY USA Robin Anderson, RN, BSN Duke Health Durham, NC USA Solomon Aronson MD, MBA, FACC, FCCP, FAHA, FASE Duke University School of Medicine Durham, NC USA Syed A. Azim, MD Stony Brook University Medical Center Stony Brook, NY USA Kristen Ban, MD Loyola university Medical Center Maywood, IL USA Elliot Bennett-Guerrero, MD Stony Brook School of Medicine Stony Brook, NY USA Maxime Cannesson, MD, PhD UCLA Irvine, CA USA Desiree Chappell, CRNA, MSNA Norton Audubon Anesthesia Louisville, KY USA Mitchell T. Heflin, MD Duke University School of Medicine Durham, NC USA Deborah Hobson, RN, BSN Johns Hopkins Hospital Baltimore, MD USA Lindsey Koshansky, RN, BSN Locus Health Charlottesville, VA USA Traci Hedrick, MD University of Virginia Charlottesville, VA USA Mark Edwards, MRCP, FRCA, MD(Res) University Hospital Southampton, UK Hampshire, UK Lee Fleisher, MD University of Pennsylvania Philadelphia, PA USA Jeff Gadsden, MD, FRCPC, FANZCA Duke University Medical Center Durham, NC USA Tong J. Gan, MD, MHS, FRCA Stony Brook University Stony Brook, NY USA Mike Grocott, MD, FFCIM, MBBS, FRCP, FRCA, BSc University of Southampton Southampton, UK Ruchir Gupta, MD Stony Brook University Stony Brook, NY USA Margaret Holtz, MD WellStar Kennestone Regional Medical Center Marietta, GA USA Stefan Holubar, MD, MS, FACS, FASCRS Geisel School of Medicine at Darthmouth Lebanon, NH USA David Hoyt, MD, FACS American College of Surgeons Chicago, IL USA Robert Isaak, DO UNC School of Medicine Chapel Hill, NC USA Henrik Kehlet, MD, PhD Rigshospitalet Copenhagen University Copenhagen, DENMARK Michael Kelly, MD Hackensack UMC Hackensack, NJ USA Adam King, MD Vanderbilt Universty Nashville, TN USA Clifford Y. Ko, MD, MS, MSHS, FACS, FACRS UCLA Schools of Medicine and Public Health Los Angeles, CA USA Vicki Morton, DNP, AGNPBC Providence Anesthesiology Associates Charlotte, NC USA James Nicholson, MD Stony Brook Medical Center Stony Brook, NY USA Rupert Pearse, MD, FRCA, FFICM Queen Mary University of London London, UK Bethany Sarosiek, RN, MSN, MPH, CNL UVA Health System Charlottesville, VA USA Terrence Loftus, MD Loftus Health Tempe, AZ USA Christopher Mantyh, MD Duke Health Durham, NC USA Amy McCutchan, MD Indiana University Indianapolis, IN USA Matthew D. McEvoy, MD Vanderbilt University Nashville, TN USA Frederic Michard, MD, PhD Ryan-Kay Lausanne, Switzerland Timothy Miller, MD Duke University Durham, NC USA Michael Scott, MD Virginia Commonwealth University Health System Richmond, VA USA Anthony Senagore, MD, MBA University of Texas Medical Branch at Galveston Galveston, TX USA Daniel Sessler, MD The Cleveland Clinic Cleveland, OH USA Andrew Shaw, MB, FRCA, FCCM, FFICM Vanderbilt University Nashville, TN USA Roy Soto, MD Oakland University William Beaumont School of Medicine Royal Oak, MI USA Julie Thacker, MD Duke University Durham, NC USA Robert Thiele, MD University of Virginia School of Medicine Charlottesville, VA USA Paul Wischmeyer, MD Duke University School of Medicine Durham, NC USA Sabino Zani Jr., MD Duke Health Durham, NC USA CREDIT DESIGNATION STATEMENT (CME) Amedco designates this live activity for a maximum of 17.75 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. APPROVAL STATEMENT (ANAA) An application has been submitted to The American Association of Nurse Anesthetists. Credit approval is pending. APPROVAL STATEMENT (ANCC) Amedco is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This course is co-provided by Amedco and American Society for Enhanced Recovery. Maximum of 17.75 contact hours. Schedule of Events THURSDAY, APRIL 27TH 2017 1515 – 1545 SESSION 1: ENHANCED RECOVERY – INTRODUCTION SESSION Moderator: Timothy Miller, MD 0800 – 0810 Introduction Timothy Miller, MD 0810 – 0825 0825 – 0840 0840 – 0900 0900 – 0930 0930 – 1000 ERAS and ASER in 2016 Tong J. Gan, MD, MHS, FRCA Perioperative Medicine – A Global Perspective Mike Grocott, MD, FFCIM, MBBS, FRCP, FRCA, BSc ERAS – Results, Successes and Challenges Julie Thacker, MD 1625 – 1645 System Wide Implementation Clifford Y. Ko, MD, MS, MSHS, FACS, FACRS Break with Sponsors and Exhibitors SESSION 2: ASER AND POQI CONSENSUS STATEMENTS – PATIENTS FOCUSED AND SCIENCE BASED Moderators: Andrew Shaw, MB, FRCA, FCCM, FFICM; Anthony Senagore, MD, MBA 1000 – 1020 1020 – 1040 1040 – 1100 Perioperative Fluid Management within ERPs Robert Thiele, MD Perioperative Analgesia within ERPs Matthew D. McEvoy, MD Prevention of Postoperative Infection within ERPs Stefan Holubar MD, MS, FACS, FASCRS 1100 – 1120 1120 – 1200 1200 – 1330 Patient Reported Outcomes Elliot Bennett–Guerrero, MD Panel Discussion LUNCH & Edwards Lifesciences Symposia: Preventable Hypotension – Know More. Act Early. SESSION 3: OPTIMIZATION PROGRAMS Moderators: Solomon Aronson, MD, MBA, FACC, FCCP, FAHA, FASE; Matthew McEvoy, MD 1330 – 1350 1350 – 1410 Perioperative Nutrition Paul Wischmeyer, MD POSH – Perioperative Optimization of Senior Health Mitchell T. Heflin, MD 1410 – 1430 1430 – 1450 Fit – 4 – Surgery School Mark Edwards, MRCP, FRCA, MD(Res) Prehabilitation and Exercise Programs Mike Grocott, BSc, MBBS, MD, FRCA, FRCP, FFICM 0630 – 0800 0645 – 0745 FRIDAY, APRIL 28TH Breakfast Symposia SESSION 5: ERAS RESCUE: CONTINGENCY PLANS TO KEEP PATIENTS ON TRACK Moderators: Julie Thacker, MD; Roy Soto, MD 0800 – 0820 Postoperative Ileus Traci Hedrick, MD 0820 – 0840 0840 – 0900 0900 – 0930 Should We Be Obsessed with Readmissions? Christopher Mantyh, MD Discharge Criteria Krisen Ban, MD Panel Discussion SESSION 5B: ANESTHESIA WORKSHOP 0930 – 1000 2017 1645 – 1705 1605 – 1625 Break with Sponsors and Exhibitors SESSION 4: INNOVATIONS TO IMPROVE QUALITY Moderators: Maxime Cannesson, MD, PhD; Stefan Holubar, MD, MS, FACS, FASCRS 1545 – 1605 Wearable Technologies and Digital Innovations for ERPs Frederic Michard, MD, PhD Measurement to Maintain and Improve Quality of ERPs Mike Grocott, BSc, MBBS, MD, FRCA, FRCP, FFICM EHRs and ERAS: The Challenges of Data Collection and Automation Julie Thacker, MD There’s an App for That: Connecting with Patients Where They Are 1705 – 1715 1715 – 1730 1730 – 1900 Bethany Sarosiek, RN, MSN, MPH, CNL Panel Discussion Annual Business Meeting Opening Reception and Poster Presentations 1450 – 1515 Panel Discussion Break with Sponsors and Exhibitors SESSION 6: THE FUTURE Moderators: Tong J. Gan, MD, MHS, FRCA; Timothy Miller, MD 1000 – 1005 1005 – 1040 Poster Winner Announcement Plenary Lecture – Enhanced Recovery in 2020 Henrik Kehlet, MD, PhD

Schedule of Events continued 1040 – 1110 1110 – 1140 Volume to Value Transition in the USA Lee Fleisher, MD Five Phases of Care for Best Surgical Outcomes 1140 – 1200 1200 – 1330 David Hoyt, MD, FACS Panel Discussion LUNCH & Mallinckrodt Pharmaceuticals Symposia: Multimodal Analgesia in the Era of Enhanced Recovery and the Perioperative Surgical Home 1635–1715 SESSION 7A: EBPOM 1 – BIG DATA AND BIG TRIALS Moderators: Andrew Shaw, MB, FRCA, FCCM, FFICM; Lee Fleisher, MD 1330 – 1355 Large Trials in Perioperative Medicine in the UK: What’s New and What’s in the Pipeline Rupert Pearse, MD, FRCA, FFICM 1355 – 1420 Perioperative Myocardial Injury – Can it be Prevented? Recent Evidence from Large Trials Daniel Sessler, MD 1420 – 1455 Challenges of Big Data – The NSQIP Experience Julie Thacker, MD 1455 – 1515 1515 – 1545 Panel Discussion Break wtih Sponsors and Exhibitors 1000–1030 BREAK SESSION 7B: MAKING IT ALL HAPPEN Moderator: Bethany Sarosiek, RN, MSN, MPH, CNL 1330–1350 Implementation Basics: It’s More Than Just an Order Set Robin Anderson RN, BSN 1350–1410 The Change Adoption Triad – A Straightforward Approach for the Enhanced Recovery Multi–Discipinary Team Desiree Chappell, CRNA, MSNA 1410–1430 Innovative & Engaging Approaches for Educating Patients Lindsey Koshansky, RN, BSN 1430–1515 1515–1545 Q&A/Panel discussion Break with Sponsors and Exhibitors SESSION 8A: EMERGENCY SURGERY Moderator: Mike Grocott, MD, FFCIM, MBBS, FRCP, FRCA, BSc 1545–1610 1610–1635 1635–1715 Fractured Neck of Femur Jeff Gadsden, MD, FRCPC, FANZCA Emergency Laparotomy Rupert Pearse, MD, FRCA, FFICM Surgery May Not be the Right Option – The Elephant in the Room Panel Discussion Jeff Gadsden, MD, FRCPC, FANZCA; Terrence Loftus, MD; Rupert Pearse, MD, FRCA, FFICM; Julie Thacker, MD 1030–1230 FACULTY: HPB – Moderator: Michael Scott, MB, ChB, FRCP, FFICM Panelists: Robert S. Isaak, DO; Adam King, MD; Sabino Zani Jr., MD Orthopedic – Moderator: Jeff Gadsden, MD, FRCPC, FANZCA Panelists: James Nicholson, MD; Syed A. Azim, MD; Margaret Holtz, MD Implementation – Moderator: Julie Thacker, MD Panelists: Robin Anderson, RN, BSN; Terrence Loftus, MD; Amy McCutchan, MD Colorectal/Cystectomy – Moderator: Stephan Holubar, MD, MS, FACS, FASCRS Panelists: Anoushka Afonso, MD; Desiree Chappell, CRNA, MSNA; Ruchir Gupta, MD 1230 – 1330 LUNCH SATURDAY AFTERNOON WORKSHOPS 1330–1630 1330–1630 HPB BREAK Orthopedic BREAK Real–life challenges with implementation BREAK Colorectal/ cystectomy 0630 – 0800 SESSION 8B: THEN WHAT? – HOW DO WE KEEP MOVING FORWARD? Moderator: Robin Anderson RN, BSN 1545–1610 1610–1635 Nursing Led Research and Enhanced Recovery Vicki Morton, DNP, AGNP–BC Panel Discussion: Sustainability and Growth – Managing the Spread Robin Anderson RN, BSN; Deborah Hobson, RN, BSN; Bethany Sarosiek, RN, MSN, MPH, CNL; Vicki Morton, DNP, AGNP–BC SATURDAY, APRIL 29TH Breakfast Symposia 2017 SESSION 9: PROCEDURE SPECIFIC CASE DISCUSSIONS Time 0800–1000 Breakout Room 1 HPB Breakout Room 2 Orthopedic Breakout Room 3 Real–life challenges with implementation Breakout Room 4 Colorectal/ cystectomy Tracking Process Measure Compliance – Does it Help with Sustainability? Deborah Hobson, RN, BSN Ultrasound - Guided Infiltration Workshop Workshop - Topic TBD Meeting Registration Form ONLINE REGISTRATION www.aserhq.org Online registration accepted until Friday, April 14, 2017 MAIL OR FAX REGISTRATION FORM This is how your name will appear on your name badge. *Required fields. *FIRST NAME: *LAST NAME: PROFESSION: *COMPANY/INSTITUTIONAL AFFILIATION: *ADDRESS: *STATE/PROVINCE: *PHONE: *EMAIL ADDRESS: Special Needs:  Hearing Impaired  Sight Impaired  Other:  Dietary (Please Specify) REGISTRATION FEES Course materials, 1 cocktail events, 3 lunches & 3 continental breakfasts Early Bird by 2/17/17  ASER Physician Member Registration ...................................... $600.00  ASER Physician Non-Member Registration*............................. $725.00  ASER Non-Physician Member Registration ................................ $50.00  ASER Non-Physician Non-Member Registration ...................... $150.00  Residents/Fellows/Medical Students Registration ................... $50.00  ASER Industry Member .......................................................... $600.00  ASER Industry Non-Member*................................................. $725.00 *Non-member fee includes 1 year of membership. SUB TOTAL: PAYMENT MUST ACCOMPANY REGISTRATION TOTAL DUE: 3/31/17 $700.00 $825.00 $75.00 $175.00 $50.00 $700.00 $825.00 *HIGHEST DEGREE(S): Paper Registrations By Fax or Mail (SEE CONTACT INFORMATION BELOW) If you are unable to register online please fax or mail your paper registration form. Onsite Registrations Online registration accepted until April 14, 2017. After April 14th limited onsite registration is available. *ZIP: FAX: *COUNTRY: Registration Cancellation All cancellations must be in writing and sent via U.S. mail, email or fax. Fee for cancellations postmarked or date stamped before April 14, 2017 will be completely refunded with an administrative fee of $25. NO REFUNDS WILL BE MADE AFTER APRIL 14, 2017. After 4/14/17 $800.00 $925.00 $100.00 $200.00 $50.00 $800.00 $925.00 Questions? Contact Us: American Society for Enhanced Recovery 6737 W. Washington St. Suite 4210 Milwaukee, WI 53214 info@aserhq.org office: 414-389-8610 fax: 414-276-7704 PLEASE NOTE: Registration is not complete until you receive a confirmation email for your registration. If you do not receive this email within 5-7 days of registration, please contact us at 414-3898610. METHOD OF PAYMENT The following methods of payment are acceptable for the registration fee: 1. Check: Made payable to ASER. There is a $25 returned check fee.  Check Included 2. Credit Card Payments:  Visa  MasterCard  Discover  AMEX NAME ON CARD: CARD #: SECURITY CODE: SIGNATURE: It is recommended to bring your confirmation of registration with you to the conference. EXP. DATE: /

ASERalert Copyright© ASER 2017 unless otherwise indicated. All rights reserved. No part of this publication may be reproduced without permission from the editor. American Society for Enhanced Recovery 6737 W Washington St. | Ste. 4210 | Milwaukee, WI 53214 414-389-8610 | info@aserhq.org

ASERalert November 2016 | Volume 1, Issue 1 ERAS for Hip and Knee (THA and TKA) Arthroplasty – A Need to Look Beyond LOS OFFICIAL PUBLICATION OF ERAS for Total Joint Arthroplasty: Past, Present and Future Enhanced Recovery for Orthopedic Surgery ERAS for Spine Surgery: A New Frontier also in this issue

ANNUAL CONGRESS OF ENHANCED RECOVERY AND PERIOPERATIVE MEDICINE APRIL 27TH -29TH , 2017 HYATT REGENCY WASHINGTON ON CAPITOL HILL 400 NEW JERSEY AVE NW, WASHINGTON, D.C. 20001 For more information please visit www.aserhq.org 2 ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org 2017 President’s Message By Tong J (TJ) Gan, MD, MHS, FRCA, President Board of Directors I t is my great pleasure to announce the inaugural issue of the ASER Newsletter. Founded in 2014, ASER is a multi-specialty nonprofit organization with an international membership and is dedicated to the practice of enhanced recovery in the perioperative patient through education and research. We are experiencing a period of tremendous expansion and growth, as is evidenced by the great interest to implement the enhanced recovery pathway in hospitals around the country. The ASER Mission is to advance the practice of perioperative enhanced recovery and to contribute to its growth and influences, by fostering and encouraging research, education, public policies, programs and scientific progress. We have achieved much over the past 2 years, including: • Annual ASER/EBPOM Congress • ASER website • ASER manual of Enhanced Recovery for Major Abdominopelvic Surgery • Enhanced Recovery Implementation Guide • Regional Leadership forums • Perioperative Medicine as the official society journal This newsletter aims to share information, best practices, sample protocols and members’ experiences in implementing enhanced recovery pathways. It serves as a forum for communication of the many activities of the society. I would like to thank Dr. Thomas Hopkins, Lyla Hance and their committee for editing the newsletter and those who generously donated their time to contribute to this edition. We want this newsletter to be valuable for you, so please share your feedback and suggestions to help us improve. Please forward it to friends and colleagues who you think will benefit from this newsletter. n Enjoy reading. Tong J (TJ) Gan, MD, MHS, FRCA President American Society for Enhanced Recovery Professor and Chairman Department of Anesthesiology Stony Brook University tong.gan@stonybrookmedicine.edu Officers President Tong J (TJ) Gan, MD, MHS, FRCA President-Elect Julie Thacker, MD Vice-President Timothy Miller MB, ChB, FRCA Treasurer Roy Soto, MD Secretary Stefan D. Holubar MD, MS, FACS, FASCRS Directors Keith A. (Tony) Jones, MD Anthony Senagore, MD Maxime Cannesson, MD, PhD Terrence Loftus, MD, MBA, FACS Andrew Shaw MB, FRCA, FFICM, FCCM Desiree Chappel, CRNA Newsletter Committee Thomas Hopkins, MD: Chair Lyla Hance, MPH: Co-Chair Jeffrey Huang, MD Uday Jain, MD, PhD Amy McCutchan, MD Asha Naik, FRCA Christina Solis, MHA Matthias Stopfkuchen-Evans, MD About ASER ASER is a nonprofit organization with an international membership, which is dedicated to thepractice of enhanced recovery in the perioperative patient through education and research. ASER’s mission is to advance the practice of perioperative enhanced recovery, to contribute to its growth and influences, by fostering and encouraging research, education, public policies, programs and scientific progress. Administrative Office American Society for Enhanced Recovery 6737 W Washington St. | Ste. 4210 Milwaukee, WI 53214 414-389-8610 | info@aserhq.org ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org 3

ERAS for Hip & Knee (THA & TKA) Arthroplasty – A Need To Look Beyond LOS By Henrik Kehlet, Prof. MD, PhD E RAS programs in total joint arthroplasty have been introduced worldwide in many centers with documented success and reduced length of stay (LOS) and morbidity. However, despite the achieved success, several challenges lie ahead. First of all “what is the optimal LOS?”, since there is a lack of documentation on the economic and safety aspects of same-day discharge vs next day in a general THA and TKA population vs the proportion of selected suitable patients. Although overall morbidity is reduced by ERAS, further studies on the relative importance of conventional risk factors needs to be clarified, since recent data question the relevance from standard risk assessment within traditional care. Still, a major problem is the need to improve pain management after discharge in relation to patient activity and optimal rehabilitation. In this context, further 4 The optimal technique of rehabilitation needs evaluation... studies are required to preoperatively predict high-pain responders in subpopulations such as pain catastrophizers, preoperative opioid users and other pain “sensitized” patients. Also, more data are required on the otherwise documented risk of postoperative delirium especially with opioid-based pain management, but where a fully implemented opioidsparing ERAS program may almost eliminate this problem. Although it is well-established that preoperative anemia should be diagnosed and treated, more focus on postdischarge anemia should be made, since it may impair rehabilitation and increase risk of organ dysfunction, but so far with sparse available data. Further data are required on thromboembolic complications and need for prophylaxis, since early mobilization with ERAS may reduce the risk. Importantly, readmissions and discharge destination must be clarified due to a huge discrepancy between individual institutions and countries and where readmission to “own institution” is insufficient because some patients may be readmitted to other institutions. Also, discharge destination, which has major economic implications, needs further evaluation, since discharge to a “nursing care facility” or “rehabilitation” institution is variable, and in some ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org feature countries standard practice is discharge to home instead. The optimal technique of rehabilitation needs evaluation, since present data even with immediate strength training have been disappointing and where all data have documented a reduction of muscle function for several weeks postoperatively. Although patient-reported outcomes are fashionable and important, further studies to compare these with objectively measured function and activity are required, since initial data are disappointing and showing a gap between the positive patient-reported outcomes vs the rather disappointing objective recovery data. Finally, a very large number of publications on ERAS cohorts often has an insufficient interpretation compared with global literature, and a lack of balanced discussion on international experiences and consequences in different health care systems. In summary, despite an obvious success of ERAS in THA and THA to reduce LOS and morbidity, several challenges lie ahead to improve postdischarge recovery. n References Aasvang EK, Luna IE, Kehlet H. Challenges in postdischarge function and recovery: the case of fasttrack hip and knee arthroplasty. Br J Anaesth 2015; 115:861-866.Cyriac J, Garson L, Schwarzkopf R, Ahn K, Rinehart J, Vakharia S, Cannesson M, Kain Z. Total joint replacement perioperative surgical home program: 2-year follow-up. Anesth Analg 2016; 123:51-62. Artz N, Elvers KT, Lowe CM, Sackley C, Jepson P, Beswick AD. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. BMC Musculoskelet Disord 2015; 16:15. Cyriac J, Garson L, Schwarzkopf R, Ahn K, Rinehart J, Vakharia S, Cannesson M, Kain Z. Total joint replacement perioperative surgical home program: 2-year follow-up. Anesth Analg 2016; 123:5162. Fragiadakis GK, Gaudilliere B, Ganio EA, Aghaeepour N, Tingle M, Nolan GP, Angst MS. Patient-specific immune states before surgery are strong correlates of surgical recovery. Anesthesiology 2015; 123:12411255. Hossain FS, Konan S, Patel S, Rodriguez-Merchan EC, Haddad FS. The assessment of outcome after total knee arthroplasty: are we there yet? Bone Joint J 2015; 97-B:3-9. Jans O, Kehlet H. Postoperative orthostatic intolerance: a common perioperative problem with few available solutions. Can J Anaesth 2016 (Epub). Jorgensen CC, Petersen MA, Kehlet H. Preoperative prediction of potentially preventable morbidity after fast-track hip and knee arthroplasty: a detailed descriptive cohort study. BMJ Open 2016; 6:e009813. Kehlet H, Jorgensen CC. Rapid Recovery After Hip and Knee Arthroplasty--A Transatlantic Gap? J Arthroplasty 2015; 30:2380. Kehlet H, Jorgensen CC. Advancing surgical outcomes research and quality improvement within an enhanced recovery program framework. Ann Surg 2016; 264:237-238. Kjellberg J, Kehlet H. A nationwide analysis of socioeconomic outcomes after hip and knee replacement. Dan Med J 2016; 63:A5257.Pitter FT, Jorgensen CC, Lindberg-Larsen M, Kehlet H. Postoperative morbidity and discharge destinations after fast-track hip and knee arthroplasty in patients older than 85 years. Anesth Analg 2016; 122:18071815. Pitter FT, Jorgensen CC, Lindberg-Larsen M, Kehlet H. Postoperative morbidity and discharge destinations after fast-track hip and knee arthroplasty in patients older than 85 years. Anesth Analg 2016; 122:18071815. Thienpont E, Lavand’homme P, Kehlet H. The constraints on day-case total knee arthroplasty: the fastest fast track. Bone Joint J 2015; 97-B:40-44. FASTER RECOVERY, FEWER COMPLICATIONS, PROMOTING CHANGE Comitted to Improving Patient Care ASER Member Benefits Become an ASER member today! For further information and to apply one line visit aserhq.org/membership ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org • Implementation Consultation and Guidance • Practice Guidelines and Ongoing Research • Hospital and Patient Educational Materials • Networking • Professional Development and Education • Research Grant Opportunities • Membership Discount to Attend Annual Congress 5

ERAS for Total Joint Arthroplasty: Past, Present and Future By Ellen M. Soffin, MD, PhD; Alana E. Sigmund, MD, FHM & Chad M. Craig, MD, FACP I n the companion article in this edition, we speculate whether Enhanced Recovery After Surgery (ERAS) protocols can be usefully applied to patients undergoing spine surgery. If ERAS for spine represents an emerging concept in orthopedic surgery, ERAS for total joint arthroplasty (TJA) represents the proof of concept. In contrast to spine surgery, elective hip and knee arthroplasty are high-volume, highly standardized surgical procedures typically performed in medically optimized patients. These conditions facilitate the implementation of clinical pathways or fast-track programs which lead directly to reductions in length of stay and improved outcomes. For more than 30 years, there has been compelling evidence to support the use of packages of care to improve recovery after TJA. At Hospital for Special Surgery, Sharrock et al. transformed the care of our TJA patients by incorporating standardized perioperative interventions: universal receipt of epidural anesthesia, invasive goal-directed hemodynamic monitoring, epidural analgesia, pulse oximetry, and post-operative supplemental oxygen, with ICU-level of care for high-risk patients.1 These changes effected a reduction in mortality after total knee arthroplasty from 0.44% to 0.07% over a 10-year period. Importantly, there were no major changes in surgical technique over this interval, suggesting the bundle of interventions led to improved outcomes. More modern fast track protocols reliably demonstrate cost savings and reductions in lengthof-stay – often with discharge to home and without increased complications or readmission.2-6 . The Hospital for Special Surgery clinical pathways for total hip or knee arthroplasty feature pre-operative patient education and discharge planning, pre-emptive analgesia, post-operative nausea and vomiting prophylaxis, regional analgesia techniques, and early mobilization. Patients following these pathways achieve reduced length of stay, superior pain control, and shortened time to functional recovery.7-9 Finally, in a recent study of patients undergoing primary total hip arthroplasty, comparing patients in an enhanced recovery program to patients in the hospital’s standardcare program, the enhanced recovery group showed a decreased length of stay of 1.5 days with no increase in post-operative complications.10 program, patients underwent pre6 operative assessment by a physical therapist, and were educated about the planned day of discharge, wound care and physical therapy, They also received necessary equipment prior to admission, received spinal anesthesia, and also participated in early mobilization. A similar, although smaller, study in total knee arthroplasty showed similar results.11 In this While package of care studies in TJA show benefit for patients, they also have revealed that the two major approaches to standardized care in TJA, ERAS and clinical pathways, have basic differences in form and content. In contrast to ERAS in other surgical subspecialties, the majority of published pathways for TJA comprise intraoperative anesthesia, post-operative analgesia, and early mobilization as the basis of the care trajectory. Standardized ERAS components, including pre-operative education and nutritional optimization, goal directed fluid therapy (GDFT) and audit are often conspicuous by their absence in TJA. A recent review of ERAS for TJA suggests that despite the established success of clinical pathways, there remain major opportunities to apply ERAS principles to patients undergoing elective joint replacement.12 Although ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org ...high dose steroids reduced the amount of patient-reported pain within the first 1-2 days after both hip and knee arthroplasty. there is a large body of evidence to guide decision making in constructing pathways of care, there are equally large gaps in knowledge which suggest avenues for future work. Many ERAS interventions are resource-intensive, so understanding which patients benefit from which components is of primary importance. The literature suggests that education programs could be most effective for anxious or socially isolated patients,13 although it remains to be seen if standardizing the content and method of delivery would have a positive effect for all patients. Likewise, the optimal analgesic regimen has yet to be determined, despite an abundance of choice: epidural, peripheral nerve block or catheter, local infiltration analgesia, and oral/intravenous multimodal agents all show analgesic efficacy and are opioidsparing after TJA. Ultimately, these decisions might have to be made according to institutional practice and capability. The risk-to-benefit balance of preoperative carbohydrate loading has yet to be established in TJA and the role of goal-directed fluid therapy is unclear – and may turn out to be of lesser importance compared to colorectal surgery. The concept of auditing compliance and outcomes, and using institution-specific data to refine pathway components, is currently lacking in TJA clinical pathway care. Additionally, some have argued for a shift of clinical and research efforts from current construction of TJA ERAS pathways, to more broad peri-operative strategies to improve post-discharge function, rehabilitation potential, and global recovery, areas that may prove equally as important to patient outcomes.14 Recent arthroplasty research has focused on improving global recovery through avoiding common postASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org Mallinckrodt, the “M” brand mark and the Mallinckrodt Pharmaceuticals logo are trademarks of a Mallinckrodt company. © 2015 Mallinckrodt. June 2015 operative complications such as anemia and pain. In two separate studies, consecutive patients were enrolled in a multidisciplinary hemoglobin management program that involved pre-operative anemia work-up and management. Both studies were able to show reduced post-operative transfusion rates when compared with a historical cohort.15,16 In order to minimize post-operative pain and nausea, two randomized, placebo-controlled trials were conducted to assess the role of high-dose steroids administered during hip and knee arthroplasty. Although each study enrolled fewer than 100 patients, high dose steroids reduced the amount of patient-reported pain within the first 1-2 days after both hip and knee arthroplasty.17,18 Because of the safety and efficacy of clinical pathways in TJA, we are increasingly offering surgery to patients who probably would have been denied surgery in the past. It has become routine to perform joint replacement for the elderly, morbidly obese, high ASA Physical Status, and/or chronic opioid dependent patient. Demand for same-day or same-admission bilateral TJA is also increasing. These changing patterns require increasingly creative strategies to understand and implement best practice. It may be the right time to standardize language in order to facilitate research and practice. “Clinical pathway”, “ERAS”, “Perioperative Surgical Home” and “Fast Track” are used interchangeably in SEEING COMPLEXITY IN A NEW LIGHT. For nearly 150 years, Mallinckrodt has made complex scientific problems manageable, developing valuable diagnostic tools and treatments for patients who need them. We view challenges as opportunities. See how at Mallinckrodt.com 7

the literature, and many terms lack a definition. In addition to standard language, we advocate that a principal goal should be a standardized ERAS pathway for TJA based on the best available evidence, and including audit. We submit that this process is most effective when it occurs at the Society level with adoption of consensus guidelines, as has been the case for ERAS in other surgical subspecialties. n References 1. Sharrock NE, Cazan MG, Hargett MJ, Williams-Russo P, Wilson PD Jr: Changes in mortality after total hip and knee arthroplasty over a ten-year period. Anesth Analg 1995; 80(2):242-8. 2. Duncan CM, Hall Long K, Warner DO, Hebl JR: The economic implications of a multimodal analgesic regimen combined with minimally invasive orthopedic surgery: a comparative cost study. Reg Anesth Pain Med 2009; 34(4):301-7. 3. Duncan CM, Moeschler SM, Horlocker TT, Hanssen AD, Hebl JR: A self-paired comparison of perioperative outcomes before and after implementation of a clinical pathway in patients undergoing total knee arthroplasty. Reg Anesth Pain Med 2013; 38(6):533-8. 4. Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW: A comprehensive anesthesia protocol that emphasized peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 2005; 87 Suppl 2:63-71. 5. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT: A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anaesth Pain Med 2008; 33(6):510-517. 6. Sutton JC, Antoniou J, Epure LM, Huk OL, Zukor DJ, Bergeron S: Hospital Discharge within 2 Days Following Total Hip or Knee Arthroplasty Does Not Increase MajorComplication and Readmission Rates. J Bone and Joint Surg Am 2016;98;1419-28. 7. Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN: A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J 2011; 7(1):9-15. Learn more about Pacira & ASER’s Partnership Campaign to Combat the Opiod Epidemic, on page 15 8. Gulotta LV, Padgett DE, Sculco TP, Urban M, Lyman S, Nestor BJ: Fast track THR: One hospital’s experience with a 2-day length of stay protocol for total hip replacement. HSS J 2011; 7(3):223-8. 9. Duggal S, Flics S, Cornell CN: Intra-articular analgesia and discharge to home enhance recovery following total knee replacement. HSS J 2015; 11(1):56-64. 10. Maempel J, Clement N, Ballantyne J, Dunstsan E: Enhanced Recovery Programmes After Total Hip Arthroplasty can Result in Reduced Length of Hospital Stay Without Compromising Functional Outcome Bone Joint J 2016; 98-B:475-482. 11. Maempel J, Walmsley P: Enhanced Recovery Programmes Can Reduce Length of Stay After Total Knee Replacement Without Sacrificing Functional Outcome at One Year. Ann R Coll Surg Engl 2015; 97:563-567. 12. Soffin EM, YaDeau JT: Enhanced recovery after surgery for primary hip and knee arthroplasty: A review of the evidence. BJA 2016; in press. 13. McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A: Preoperative education for hip or knee replacement. Cochrane Database Syst Rev 2014; 13(5). 14. Aasvang E, Luna I, Kehlet H: Challenges in postdicharge function and recovery: the case of fast-track hip and knee arthroplasty. Br J Anaesth.2015; 115(6): 861-6. 15. Holt J, Miller B, Callaghan J, Clark C, Willenborg M, Noiseux N: Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach. J Arthroplasty 2016; 31: 378-382. 16. Kopandis P, Hardidge A, McNicol L, Tay S, McCall P, Weinberg L: Perioperative Blood Management Programme Reduces the Use of Allogenic Blood Transfusion in Patients Undergoing Total Hip and Knee Arthroplasty. J Orthop Surg Res 2016; 11:28. 17. Lunn T, Kirstensen B, Andersen L, Husted H, Otte KS, Gaarn-Larsen L, Kehlet H: Effect of high-dose preoperative methylprednisolone on pain recovery after total knee arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth 2011; 106(2):230238. 18. Lunn T, Andersen L, Kirstensen B, Husted H, Otte KS, Gaarn-Larsen L, Bandholm T, Ladelund S, Kehlet H: Effect of high-dose preoperative methylprednisone on recovery after total hip arthroplasty: a randomized, placebo-controlled trial. Br J Anaesth 2012; 110(1):66-73. Used in more than 2 MILLION PATIENTS since 2012 Pacira Pharmaceuticals, Inc. is pleased to support the American Society for Enhanced Recovery Reference: Data on fi le. Parsippany, NJ: Pacira Pharmaceuticals, Inc.; May 2016. For full Prescribing Information, please visit www.EXPAREL.com or call 1-855-RX-EXPAREL (793-9727). ©2016 Pacira Pharmaceuticals, Inc., Parsippany, NJ 07054 PP-EX-US-2048 10/16 8 ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org YOU can reduce post-surgical complications by 32% 1 in your moderate to high-risk patients. A large body of evidence demonstrates that hemodynamic optimization through Perioperative Goal-Directed Therapy (PGDT), utilizing dynamic parameters which are informative in determining fluid responsiveness, has been shown to reduce post-surgical complications.1-4 randomized controlled trials and meta-analyses confirmed reduction of risk for AKI, anastomotic leaks, pneumonia, SSI and UTI.1-4 When evidence inspires action, Edwards Lifesciences Enhanced Surgical Recovery Program can help you implement PGDT. Your vision for reducing post-surgical complications can be realized in a single procedure, or as part of a larger quality improvement initiative. Edwards.com/ESR1 References: 1. Grocott et al. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane systematic review. Br J Anaesth 2013 2. Giglio MT, Marucci M, Testini M, Brienza N. Goal-directed haemodynamic therapy and gastrointestinal complications in major surgery: a meta-analysisof randomized controlled trials. Br J Anaesth 2009; 103: 637–46 3. Dalfino L, Giglio MT, Puntillo F, Marucci M, Brienza N. Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Crit Care 2011; 15: R154 4. Corcoran T et al. Perioperative Fluid Management Strategies in Major Surgery: A Stratified Meta-Analysis. Anesthesia – Analgesia 2012 Edwards, Edwards Lifesciences, the stylized E logo and Enhanced Surgical Recovery Program are trademarks of Edwards Lifesciences Corporation or its affiliates. All other trademarks are the property of their respective owners. © 2014 Edwards Lifesciences Corporation. All rights reserved. AR11710 Edwards Lifesciences | edwards.com One Edwards Way | Irvine, California 92614 USA Switzerland | Japan | China | Brazil | Australia | India

Valuable insight to help you guide volume administration. Clarity gives you the control to make more informed decisions. ClearSight Noninvasive System CO, SV, SVV, SVR, cBP* FloTrac Minimally-Invasive System CO, SV, SVV, SVR Swan-Ganz System CCO, RVEDV, RVEF, SvO2 Edwards Lifesciences’ range of hemodynamic monitoring solutions provides key flow parameters shown to be more informative in determining fluid responsiveness than pressure-based parameters.1 Each offers continuous information which may be used in Perioperative Goal-Directed Therapy (PGDT) to hemodynamically optimize your moderate to high-risk surgery patients. The Edwards Enhanced Surgical Recovery Program can help you implement PGDT today. PGDT can help ensure your patients are consistently maintained in the optimal volume range. Know more. Know now. To see how you can individualize therapy under more conditions, visit Edwards.com/ESRsolutions 1. Michard F, Biais M. Rational fluid management: dissecting facts from fiction. Br J Anaesth 2012 * Continuous Blood Pressure For professional use. CAUTION: Federal (United States) law restricts this device to sale by or on the order of a physician. See instructions for use for full prescribing information, including indications, contraindications, warnings, precautions and adverse events. Edwards Lifesciences devices placed on the European market, meet the essential requirements referred to in Article 3 of the Medical Device Directive 93/42/EEC, and bear the CE marking of conformity. Edwards, Edwards Lifesciences, the stylized E logo, ClearSight, Enhanced Surgical Recovery Program, FloTrac and Swan-Ganz are trademarks of Edwards Lifesciences Corporation. All other trademarks are the property of their respective owners. © 2014 Edwards Lifesciences Corporation. All rights reserved. AR11787 Edwards Lifesciences | edwards.com One Edwards Way | Irvine, California 92614 USA Switzerland | Japan | China | Brazil | Australia | India Enhanced Recovery for Orthopedic Surgery By Arman Dagal MD, FRCA; Chad M. Craig, MD, FACP & Ruchir Gupta, MD T otal hip and knee replacements amount to nearly 1,000,000 surgical procedures annually in the United States and are expected to triple in volume by 2030. It is estimated that 7 million people are currently leaving with total hip or knee replacement in the United States alone. In addition to the joint replacement, spine surgery is amongst the costliest procedures in U.S. Between 1998 to 2008 the number of spinal fusion procedures increased by 137%. The spine care (direct and indirect) cost around $100 billion annually in the U.S. alone. 1 remain variable across institutions.2 Bundled Care and Health Care Delivery. The Center for Medicare and Medicaid Innovation (CMMI) was created by the Affordable Care Act to tests innovative payment and service delivery models that have the potential to reduce Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) expenditures while preserving or enhancing the quality of care for the beneficiaries. The Bundled Payments for Care Improvement (BPCI) initiative is the product of the CMMI. Under this initiative hospital and physician services combined into a single payment, using episode based rather than the fee for service payment method. Bundled payments provide an incentive for the hospitals and its medical staff to improve coordination of care to improve value and eliminate unnecessary cost. Hospitals and its providers share the associated risk and financial penalties if they cannot control the cost and quality of care. In this new definition of the surgical episode also includes the post-acute care expenses up to 90 days from the surgery. Along with the mission of value-based care, this year, Joint Commission launched a new Advanced Certification program for Total Hip and Total Knee Replacement. The Advanced Total Hip and Total Knee Replacement certification program is designed to assist healthcare organizations to provide high-quality healthcare with an emphasis on patient safety. The certification program will focus on the transitions of care for patients undergoing a total joint replacement. The uniqueness of this certification begins with reviewing the procedures associated with the orthopedic consultation, pre-operative, intraoperative and post-surgical orthopedic surgeon follow up care. The Joint Commission identified standardized performance measures for this program. Currently, the joint commission is collaborating with the pilot sites to develop standards for the electronic performance measure set 1-4 in relations to Pre-admitting, Operating Rooms, PACU, and Orthopedic Units areas. https://www. jointcommission.org/total_hip__total_ knee_replacement_/ 1. Usage of Neuraxial Anesthesia 2. Postoperative Mobilization on Day of Surgery 3. Discharged to Home 4. Preoperative Functional/Health Status Assessment ERAS orthopedic care bundles. Enhanced recovery after surgery ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org (ERAS) concept emerged following the work of Henrik Kehlet, M.D., Ph.D 1992 on colorectal surgeries. ERAS is a model of coordinated care delivery of evidence-based care bundles, aimed at achieving perioperative optimization and reducing the adverse effects of the surgical stress response. A number of studies have examined the ERAS pathway care bundles for primary hip and knee replacement surgeries, with a recent review highlighting that such pathways can be applied to a wide variety of patients. Aasvang et al.3 concluded in their study that ERAS can in fact be applied routinely to all hip and knee replacement patients in order to 11 Despite the apparent success of these surgeries, quality and cost

achieve 1–3 days hospital length of stay, a reduced incidence of cardiac and venous thromboembolism complications and reduced postoperative delirium and cognitive dysfunction. The authors further showed that the mean length of stay can be decreased from 76.6 hours to 56.1 hours after implementation of the evidence-based orthopedic ERAS pathway (P < 0.001). This improvement was possible without a concomitant increase in readmission rates. Another study compared 1500 primary hip and knee replacement patients on an ERAS pathway with 3000 patients using a traditional protocol. The authors found that the median LOS decreased from 6 to 3 days, saving 5418 bed days.4 The 90-day mortality rate was also significantly reduced, as well as transfusion requirements. Other studies have found ERAS pathways feasible and safe for more complex groups of patients such as the elderly,5 with a decrease in LOS for patients aged ≥85 years, and no negative effects on morbidity and mortality rates. Additionally, the beneficial effects of ERAS are not limited to the routine primary hip and knee replacements. More complex and surgically variable procedures such as revision joint replacement, shoulder replacement, and in non-elective procedures such as fractured neck of femur patients have found outcomes to similar to those for primary total knee replacement with respect to LOS and morbidity,6 where median LOS was 2 days, no morbidity within 3 months, low readmission rates, and high levels of patient satisfaction. Major spine surgery is another specialty area that the application of ERAS principles has potential to improve patient outcomes.7 When ERAS principles are incorporated into existing or new clinical pathways, they improve the value of care delivery. Risk-adjusted 12 Conclusion Evidence exists to support the increased use of ERAS pathways. High-volume orthopedic surgeries such as total joint arthroplasty as well as spine surgery are ideal for such clinical pathways. Such high-volume procedures also allow for individual centers to track data and feedback data to help optimize the future use of pathways. Adaptation of ERAS patient outcomes, patient safety, and optimizing the use of resources are used for performance and quality indicators.8 2009 meta-analysis suggested that clinical pathways and care organization have significantly impacted the quality of care in joint replacement surgery with reduced postoperative complications, shorter length of stay and potentially lower cost of care.9 Recent, large sample analysis on perioperative fluid administration variability in the hip and knee replacement surgeries concluded that both low and high fluid volumes associate with worse outcomes.10 Suggested orthopedic ERAS care bundles Preoperative Patient education and expectation setting Preoperative nutritional assessment and optimization Carbohydrate loading Minimal preoperative fasting Anemia detection and optimization Preemptive pain management Intraoperative Minimally invasive surgery Multimodal analgesia Goal directed fluid management Nausea vomiting prophylaxis Active warming Blood loss prevention Postoperative Early return to oral diet Physiotherapy and early mobilization Early discharge principles as part of integrated care pathways appear feasible and may effectively improve patient outcomes, satisfaction and reduce cost. ERAS concepts perfectly lines up with the accountable care organizational needs to create a platform for the transformational care initiatives. We encourage institutions to identify multidisciplinary service champions to develop ERAS pathway care. A number of professional organizations including the ERAS Society (erassociety.org), and American Society of Enhance Recovery (aserhq. org) provide guidelines and resources to help with development of such pathways at the institutional level. n References 1. Davis MA, Onega T, Weeks WB, Lurie JD. Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions. Spine 2012;37:1693–701. 2. Maradit Kremers H, Larson DR, Crowson CS, Kremers WK, Washington RE, Steiner CA, Jiranek WA, Berry DJ. Prevalence of Total Hip and Knee Replacement in the United States. The Journal of Bone & Joint Surgery 2015;97:1386–97. 3. Aasvang EK, Luna IE, Kehlet H. Challenges in postdischarge function and recovery: the case of fast-track hip and knee arthroplasty. Hardman JG, ed. Br J Anaesth 2015:aev257–6. 4. A. Malviya, K. Martin, I. Harper, et al. Enhanced recovery program for hip and knee replacement reduces death rate. A study of 4500 consecutive primary hip and knee replacement Acta Orthop, 82 (2011), pp. 577–581 5. C.C. Jorgensen, H. Kehlet, on behalf of the Lundbeck Foundation Centre for Fast-track hip and knee replacement collaborative Group Role of patient characteristics for fast-track hip and knee arthroplasty Br J Anaesth, 110 (2013), pp. 972–980 6. H. Husted, S. Kristian Otte, B.B. Kristensen, et al. Fast-track revision knee arthroplasy Acta Orthop, 82 (2011), pp. 438–440 7. Wainwright TW, Immins T, Middleton RG. Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Practice & Research Clinical Anaesthesiology 2016;30:91– 102. 8. Association EP. Clinical/care pathways. Slovenia Board Meeting, 2005. 9. Barbieri A, Vanhaecht K, Van Herck P, Sermeus W, Faggiano F, Marchisio S, Panella M. Effects of clinical pathways in the joint replacement: a metaanalysis. BMC Medicine 2009 7:1 2009;7:32. 10. Thacker JKM, Mountford WK, Ernst FR, Krukas MR, Mythen MMG. Perioperative Fluid Utilization Variability and Association With Outcomes. Annals of Surgery 2016;263:502–10. ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org ERAS for Spine Surgery: A New Frontier By Ellen M. Soffin, MD, PhD; Alana E. Sigmund, MD, FHM & Chad M. Craig, MD, FACP I t is evident that Enhanced Recovery After Surgery (ERAS) has become an established and effective mechanism for perioperative care across surgical subspecialties. In our companion piece in the Newsletter, we propose total joint arthroplasty (TJA) as the quintessential orthopedic procedure to benefit from ERAS principles: There is already convincing evidence that clinical pathways effect cost savings and clinical benefits for TJA patients, including decreased length of stay and complications. In contrast, there is a paucity of data in the published literature and reports at the institutional level for the role of ERAS pathways in spine surgery. There is much in common between the spine surgery and colorectal surgery patient (where most ERAS evidence exists to date), including predicted systemic inflammatory response (SIR), length of stay, requirement for parenteral analgesics and complications (particularly ileus). Given the evidence and enthusiasm for ERAS, it is unexpected that spine surgery should remain so understudied with respect to ERAS protocols. This inattention occurs despite compelling biochemical, clinical and economic arguments to support ERAS for spine surgery. First, major spine surgery is associated with predicable increases in stress hormones and inflammatory cytokines1 which may be associated with a host of postoperative complications, including thromboembolism, atrial fibrillation and delirium.2,3 Preoperative steroids Specific interventions have been demonstrated to reduce biomarkers of surgical stress and improve outcomes after spine surgery. For example, intraoperative administration of the alpha-2 adrenergic agonist, dexmedetomidine, lowers interleukin-10 and cortisol and improves quality of recovery after multilevel lumbar fusion.4 lower interlukin-6 and C-reactive protein after cervical laminoplasty without increasing the risk of wound infection or compromised healing.5 Minimally invasive surgical techniques are associated with lower levels of cytokines compared to conventional techniques up to 8 days post lumbar fusion.6 The overall safety and efficacy benefits of minimally invasive approaches have yet to be fully established in lumbar spine surgery,7 but represent an intriguing possibility for future research as a component of ERAS for spine pathways. The minimally invasive approach may indeed be the ERAS-for-spine analogy to the laparoscopic approach in ERAS-for-colorectal surgery, in terms of benefits on outcomes and biomolecular markers of surgical stress.8 The second argument in favor of ERAS for spine surgery is an economic one. The demand for spine surgery and the cost of surgery are both increasing exponentially in the United States and abroad.9 Indeed, a recent economic report estimated the total annual cost for back pain in the United States (including diagnosis, treatment and rehabilitation) at over $50 billion US dollars annually, and costs are projected to increase 4.8% annually in the near term.10 According to the report, the demand for spine surgery is being driven by an aging population, an increase in the number of fusions being performed, and technical ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org advances making complex surgery more commonplace. Given these pressures, any reduction in length of stay, no matter how modest, is likely to produce significant economic gains, as has been demonstrated repeatedly for ERAS in other surgical disciplines. As an illustrative example of potential economic gains, we can consider lumbar fusion: The hospital costs associated with lumbar fusion without instrumentation was recently reported in a cohort study to be approximately $14,700.00 US dollars.11 The average length of stay was 3.5 days in a sample of 77 patients. A reduction in length of stay of just 0.5 days per patient would 13

achieve overall hospital costs savings of approximately $161,700.00 in this cohort alone. The third argument should ideally be made on the basis of evidence to indicate improved outcomes, reduced complications and rising patient satisfaction associated with ERAS for spine. However, this evidence is currently scarce and there are no published accounts of comprehensive ERAS pathways for any spine surgery subtypes at this time. However, there is an extensive literature regarding components of care that classically comprise ERAS pathways, together with encouraging results on a range of clinically important outcomes. A full review is outside the scope of this commentary, but several observations can be highlighted: multimodal analgesic regimens incorporating acetaminophen, non-steroidal antiinflammatories, anti-convulsants, and local anesthetics are opioid sparing, and associated with improved patient satisfaction, reduced length of stay, and better pain control than intravenous opioid-based therapy after spine surgery;12 a blood conservation strategy including the anti-fibrinolytic, tranexamic acid, reduces autologous blood transfusion without increasing the risk of thromboembolic events after major reconstructive spine surgery;13 identifying patients at risk of nutritional deficiency and optimizing nutritional status was associated with a faster return to nutritional baseline (or anabolic state) after major reconstruction surgery (>10 spinal levels);14 and intravenous fluid restriction is associated with less post-operative ileus after lumbar fusion irrespective of surgical approach.15 If follows that these examples could be used as the basis for ERAS for spine pathways. However, a closer examination of the state of the evidence base raises more questions than it answers and exposes significant gaps in research and knowledge: What is the role of pre-operative education and shared-decision making in the spine population? How can we standardize pathways for such heterogeneous patients, indications and surgical interventions? What is the role of epidural analgesia after spine surgery? Is early mobilization appropriate after major reconstructive procedures? These are just a very few of the questions that need to be answered urgently if ERAS for spine is to become relevant and useful. In order to most efficiently provide solutions, we advocate creating an ERAS for spine pathway that can be adopted according to institutional capability. At Hospital for Special Surgery, we have recently implemented an ERAS pathway for lumbar spine fusion. The pathway is based on current best evidence, but where evidence is lacking, we have implemented measures that have demonstrated efficacy in other ERAS protocols. We are currently enrolling patients in a prospective study to investigate the effect(s) of the pathway on patient centered outcomes. Additionally, we call for research and well-designed studies that focus on procedure-specific interventions, improving logistics, and fostering a culture of enhanced recovery across disciplines. n References 1. Watt DG, Horgan PG, McMillan DC: Routine clinical markers of the magnitude of the systemic inflammatory response after elective operation: a systematic review. Surgery 2015; 362-80. 2. Hu YF, Chen YJ, Lin YJ, Chen SA: Inflammation and the pathogenesis of atrial fibrillation. Nature Rev Cardiol 2015; 12(4):230-43. 3. Van Munster BC, Korevaar JC, Zwinderman AH, Levi M, Wiersinga WJ, De Rooij SE: Time-course of cytokines during delirium in elderly patients with hip fractures. J Am Geriatr Soc 2008; 56(9):1704-9. 4. Bekker A, Haile M, Kline R, Didehvar S, Babu R, Martiniuk F, Urban M: The effect of intraoperative infusion of dexmedetomidine on quality of recovery after major spinal surgery. J Neurosurg Anesthesiol 2013; 25(1):16-24. 5. Demura S, Takahashi K, Murakami H, Fujimaki Y, Kato S, Tsuchiya H: The influence of steroid administration on systemic response in laminoplasty for cervical myelopathy. Arch Orthop Trauma Surg 2013; 133(8):1041-5. 6. Kim KT, Lee SH, Suk, SK, Bae SC: The quantitative analysis of tissue injury markers after mini-open lumbar fusion. Spine; 31(6):712-6. 7. Payer M: “Minimally invasive” lumbar spine surgery: a critical review. Acta Neurochir (Wein) 2011; 153(7):1455-9. 8. Zhuang CL, Huang DD, Chen FF, Zhou CL, Zheng BS, Chen BC, Shen X, Yu Z: Laparoscopic versus open colorectal surgery within enhanced recovery after surgery programs: a systematic review and meta-analysis of randomized controlled trials. Surg Endosc 2015; 29(8):2091100. 9. Wainwright TW, Immins T, Middleton RG: Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery. Best Pract Res Clin Anaesthesiol 2016; 30(1):91-102. 10. Ken Research. The US Spinal Surgery Market Outlook to 2017: Ageing population and technological advances to intensify the competition. 2013; Available at www.marketresearch.com/product/ sample-7535890.pdf 11. Molina CA, Zadnik PL, Gokaslan ZL, Witham TF, Bydon A, Wolinsky JP, Sciubba DM: A cohort analysis of lumbar laminectomy—current trends in surgeon and hospital fees distribution. Spine J 2013; 13(11):1434-7. 12. Devin CJ, McGirt MJ: Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci 2015; 22:930-38. 13. Soroceanu A, Oren JH, Smith JS, Hostin R, Shaffrey CI, Mundis GM, Ames CP, Burton DC, Bess S, Gupta MC, Deviren V, Schwab FJ, Lafage V, Errico TJ: Effect of antifibrinolytic therapy on complications, thromboembolic events, blood product utilization, and fusion in adult spinal deformity surgery. Spine 2016; 41(14):E897-86. 14. Lapp MA, Bridwell KH, Lenke LG, Baldus C, Blanke K, Iffrig TM: Prospective randomization of parenteral hyperalimentation for long fusions with spinal deformity: its effect on complications and recovery from postoperative malnutrition. Spine 2001;26(7):809-17. 15. Fineberg SJ, Nandyala SV, Kurd MF, MarquezLara A, Noureldin M, Sankaranarayanan S, Patel AA, Oglesby M, Singh K: Incidence and risk factors for postoperative ileus following anterior, posterior and circumferential lumbar fusion. Spine J 2014; 1680-5. 14 ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org Choices Matter: ASER Partners with Pacira Pharmaceuticals to Launch National Campaign to Combat Opioid Epidemic Over the past year, America’s struggle with the growing opioid epidemic has swept national headlines. New reports estimate 78 people die every day in the U.S. from overuse of opioids.1 Adding to this problem is a surreptitious factor: surgery has become an unintentional gateway to this tragic epidemic. In fact, research shows that one-in-10 patients prescribed an opioid following surgery report becoming addicted to or dependent on the drug. It’s clear that we need to improve the dialogue between patients and surgeons related to postsurgical pain management – many patients are still unaware that they have choices, including nonopioid options. That’s why ASER partnered with Pacira Pharmaceuticals to launch Choices Matter, a national, unbranded campaign designed to educate, empower and activate patients, caregivers and physicians to proactively discuss postsurgical pain management, including non-opioid options before surgery. The campaign provides an opportunity to drive consideration for non-opioid alternatives, which can potentially minimize or virtually eliminate the need for prolonged use of opioids after surgery. The Choices Matter campaign launched August 1 in New York City, featuring a top orthopedic surgeon and professional athlete and television personality Gabby Reece. Gabby recently had her own knee replacement surgery without the help of prescription opioids, which made Choices Matter an especially relevant and timely campaign for her. The campaign website – PlanAgainstPain. com – features helpful tools for patients about to undergo their own surgeries, including a customized doctor discussion guide that allows patients to facilitate conversations about non-opioid options with their surgeons. To-date, Choices Matter has generated nearly 240 media placements and more than 476.5 million media impressions. Highlights include a New York Times Letter to the Editor from ASER President, Dr. T.J. Gan, which leveraged key statistics from a national survey of patients and surgeons conducted by Pacira. Additional coverage was featured in USA Today, Good Day New York, U.S. News & World Report, CNBC-TV, Self. com, CBS New York and Parade.com. PlanAgainstPain.com has generated more than 45,000 page views and 180 discussion guide downloads to date. While our efforts have sparked a national dialogue about alternatives to opioids, there is much more work to be done to combat this growing epidemic. For more information visit PlanAgainstPain.com. n References 1. https://www.cdc.gov/drugoverdose/epidemic/ Gabby’s Story By Gabrielle Reece, Professional Volleyball Player, Sports Announcer, Fashion Model & Actress Professional Athlete and Television Personality Gabby Reece Talks About Recovery After Surgery T he intense pain in my knee was starting to affect my life, especially when I exercised or played volleyball. When it got to a place where I knew I couldn’t make it better through training, nutrition or therapy, I decided it was time to get my knee replaced. It has been a little over six months since I had my surgery, and recovery has been a long road for me. Prior to the procedure, I had made a personal decision not to take opioids. Although I was given a low-dose painkiller in the hospital, I knew I didn’t want to take a prescription home with me. I’m very respectful of the fact that opioids are addictive and, although I consider myself a strong person physically and mentally, I’m aware that addiction shows no discrimination when it comes to age, gender, ethnicity, lifestyle, etc. – it can happen to anyone. In fact, a recent survey found that one-in-10 patients prescribed an opioid following surgery report becoming addicted to or dependent on the drug. I’ve been proactive in trying to avoid that because it’s important to me to stay holistic as possible in my recovery through sleep, stress management, ASER ALERT • VOLUME 1, ISSUE 1 • aserhq.org exercise and nutrition. What I didn’t know is that there are many options available for managing pain after surgery, including non-opioids. Choices Matter is important to me because I believe we should all be advocates for our own health. This program is about giving patients the resources they need to make the most educated choice for them. That’s why I’m encouraging people to have a conversation with their doctor about alternatives to managing pain after surgery, including nonopioid options. Visit PlanAgainstPain.com to learn more and download a discussion guide that can help you or a loved one have this important conversation. n 15

ASERalert Copyright© ASER 2016 unless otherwise indicated. All rights reserved. No part of this publication may be reproduced without permission from the editor. American Society for Enhanced Recovery 6737 W Washington St. | Ste. 4210 | Milwaukee, WI 53214 414-389-8610 | info@aserhq.org