Cerebral Autoregulation-Targeted Mean Arterial Pressure

Abstract

In Reply We have carefully read the comments of Rozental et al regarding our published article. 1 The authors suggest that the implementation of Enhanced Recovery After Surgery (ERAS) protocols not only decreases morbidity rate and hospital stay 2 but, when used worldwide, it should reduce disparities in health care. We could not agree more. In this context, the relevant question has moved from documenting the effectiveness of the Enhanced Recovery Pathways (ERP) to detect which items are significantly associated with both better outcomes and adherence to the protocol. Our study showed that the adherence to ERAS protocols in colorectal surgery is low, and there are many centers that wrongly believe they are doing well with the compliance. 1 Regarding disparities in health care, Europe could be in some way different to the United States, but a study conducted in Scandinavia 3 has found that although their centers have a greater adherence to the protocol than the Spanish ones, there is a great disparity within compliance between hospitals. 3 In 2014, the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) introduced 13 process elements through an Enhanced Recovery in NSQIP pilot project designed to support ERP implementation for colectomy. Data from this registry, including 8139 patients undergoing elective colectomy at 113 hospitals, were recently published. As expected, a greater adherence to the ERP was associated with earlier recovery, decreased complications, and shorter length of stay. 4 Interestingly, and unlike European registers, 1,3 racial/ethnic and dependency data were collected as well as other demographic variables. Ethnic minorities, obese patients, dependent patients, and patients with higher American Society of Anaesthesiologists scores had a lower adherence to the ERAS protocol evaluated. 3 Thorn et al 5 defined the active and passive ERAS elements. They considered as passive elements the elements that do not require the participation of the patient, such as epidural thoracic anesthesia or the avoidance of the nasogastric tube, and the active elements as the ones that need the cooperation of the patients to be carried out; for example, early mobilization. In addition, they found that poor active compliance was associated with increased morbidity and longer length of stay, suggesting that dependent, elderly, and frail patients need more resources to achieve compliance with the active part of the ERP that is also associated with outcomes. 1,3 In any case, the success of a good implementation could be much simpler if we bear in mind that the existence of more than 20 perioperative items in the protocols makes it difficult to carry them out, especially when some of these steps lack the proper scientific evidence. 6 Moreover, in our opinion, it is not enough to ease the ERAS protocols; they must be adapted to local, regional, or cultural particularities of the patients. This should lead to greater compliance and ultimately fewer inequalities.