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: /
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