Adherence to enhanced recovery protocol in emergency general surgery: a prospective observational study

Area of Science:

• Surgical Outcomes
• Emergency General Surgery
• Evidence-Based Medicine

Background:

• Enhanced recovery pathways (ERPs) optimize surgical outcomes but face challenges in emergency general surgery (EGS) due to patient instability and time constraints.
• Adapting ERPs to EGS requires evaluating adherence and impact on short-term outcomes in a high-risk population.

Purpose of the Study:

• To evaluate adherence to individual Enhanced Recovery Pathway (ERP) items in emergency general surgery (EGS).
• To assess the impact of ERP adherence on short-term outcomes, including mortality, morbidity, and length of hospital stay in EGS patients.

Main Methods:

• A multicenter observational prospective study involving 13 Italian centers.
• Inclusion of adult patients undergoing surgery for intestinal occlusion or perforation, excluding those re-operated after elective surgery.
• Analysis of 760 patients between March 2023 and March 2024, focusing on intraoperative and postoperative ERP adherence and clinical outcomes.

Main Results:

• High adherence observed for active warming (97%), PONV prevention (92%), and opioid avoidance (87%).
• Low adherence noted for invasive monitoring (35%), anesthesia depth monitoring (34%), locoregional analgesia (31%), and minimally invasive surgery (26%).
• By postoperative day 3, 66% tolerated solid diets, 58% were off IV fluids; 3% mortality, 33% morbidity, 9% major complications, median hospital stay of 7 days.

Conclusions:

• Adherence to ERPs in EGS is feasible and demonstrates potential for improving perioperative outcomes in this high-risk group.
• Strategies to enhance adherence to underutilized ERP components (e.g., goal-directed fluid therapy, minimally invasive surgery) are needed.
• Further optimization of ERP protocols specifically for emergency surgical settings is warranted to maximize benefits.