Restoration of function: the holy grail of peri‐operative care

1Consultant, Department of Anaesthesia and Peri-operativeMedicine,West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, UK 2 Professor, Anaesthesia andCritical CareMedicine, SouthamptonNational Institute for Health Research (NIHR) Biomedical ResearchCentre, University Hospitals SouthamptonNHS Foundation Trust / University of Southampton, Southampton, UK 3 Professor, Gastrointestinal Surgery, NottinghamDigestive Diseases Centre andNational Institute for Health Research (NIHR) NottinghamBiomedical ResearchCentre, NottinghamUniversity Hospitals NHS Trust andUniversity of Nottingham,Queen’sMedical Centre, Nottingham, UK 4Clinical Director, DavidGreenfieldHuman Physiology Unit,MRCVersus Arthritis Centre forMusculoskeletal Ageing, School of Life Sciences, University of Nottingham,Queen’sMedical Centre, Nottingham, UK ............................................................................................................................................................................................................................................................................................................ Correspondence to: N. Levy Email: nicholas.levy@wsh.nhs.uk

In this collaborative supplement published by Anaesthesia and the British Journal of Surgery, there are reviews of enhanced recovery after surgery in both the elective [1] and the emergency patient [2] by Kehlet, a surgeon from Denmark. These are complimented by reviews on the quality of recovery by Myles [3], and on patient-centred outcomes by Ladaha and Wijeysundera [4], anaesthetists from Australia and Canada, respectively.
As the originator of the concept of enhanced recovery after surgery (ERAS)/fast track surgery, Kehlet describes the challenges of introducing ERAS programmes [1]. These challenges persist despite the well-documented success of ERAS programmes in improving surgical outcomes as defined by reduced length of stay, re-admission rates, medical complications and healthcare costs. He also articulates the pathophysiological challenges of surgery, and the recurring theme is promoting return of normal function. In fact, Kehlet first identified the importance of promoting restoration of function in 1994, when he was devising the concept of multimodal analgesia, and he discussed the triple aim of postoperative pain relief in providing subjective comfort, attenuation of the stress response and to "enhance restoration of function by allowing the patient to breathe, cough and move more easily" [5]. This remarkable insight from 25 years ago is only now beginning to be fully appreciated. Crucially, despite an absence of evidence of efficacy [6] or safety [7], many centres continue to administer postoperative opioid analgesia in response to unidimensional pain intensity scores [4,8], rather than function. This is despite a paucity of evidence to support the discredited "Pain as the Fifth Vital Sign" campaign [8]. In fact, in 1994, Kehlet proposed the concept that pain should be managed to promote function [5]. Only recently has the necessity to titrate additional opioid analgesia to promote restoration of function been more widely recognised [8][9][10][11][12]. Titration of additional opioid to improve function should consider the balance between the beneficial effects of analgesia in relieving pain and promoting restoration of function, and the wellrecognised adverse effects of excessive opioids including sedation; opioid-induced ventilatory impairment, dependence and delayed return of gastro-intestinal function after surgery to be achieved more safely [8][9][10][11][12][13].
This concept has now been endorsed by several organisations including the Joint Commission, the health services regulatory body of the United States [9] and the Australian and New Zealand College of Anaesthetists [10].
The Functional Activity Score is a simple but effective measurement tool that is beginning to gain traction to promote this goal [8,[10][11][12].

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In the past 25 years, patient baseline characteristics have evolved, as have patient expectations. Thus, the proportion of elderly patients with multiple comorbidities and polypharmacy presenting for both elective and emergency surgery has increased and will continue to do so [4]. This presents particular challenges and Kehlet discusses the evolving field of optimisation of function (preoptimisation) before surgery [1]. While prehabilitation encompasses the concept of pre-optimisation of the patient's physical and psychological state [14], comorbidity management describes the optimisation of care for preexisting medical conditions (e.g. diabetes and anaemia). It is now being increasingly appreciated that one of the major current challenges facing both anaesthetists and surgeons is the identification of the group of patients that will not achieve restoration of function/return of independence and do not have either the physiological or psychological reserve to benefit from pre-optimisation or surgery [4,15].
Thus, all patients now require a thorough pre-operative assessment [4], which is often and increasingly being supplemented by cardiopulmonary exercise stress testing [13]. As well as the physical conditions including frailty that may preclude or delay return of function [4], there is growing awareness that pre-existing psychological states, including, for example, chronic pain states, patients on preexisting opioids and pain catastrophisers may also preclude restoration of function [1]. Moreover, there is a realisation that many patients may prioritise restoration of function including preservation of independence over longevity, and for them, an acceptable outcome entails improvement in health, rather than simply avoidance of death or an overt complication [4]. Shared decision-making allows these dilemmas to be articulated [16] and involves a detailed and individualised discussion with the patient concerning the likelihood of potential harms, including non-return to base line function and independence, while discussing the benefits of surgery and any alternatives to the proposed surgical procedure. Critical to enabling these processes is the reconfiguration of pre-operative pathways to allow sufficient time for assessment and discussion; pathway redesign is becoming an important theme in peri-operative care [17].
In the narrative on optimising recovery after emergency laparotomy, Foss and Kehlet discuss the challenges facing the peri-operative team to improve the outcome of the patient requiring emergency laparotomy, and lament the lack of robust scientific data to guide practice [2]. However, As well as discussing the tools that are available to record the quality of recovery, and noting that some are now being used to facilitate shared decision-making, Myles [3] emphasises that one of the most important functions of analysing recovery data is to promote continuous quality if early DREAMing is shown to be beneficial, intra-operative techniques can be adjusted to promote restoration of major organ function further [20]. This may include increased reliance on regional anaesthesia techniques as a part of procedure-specific postoperative pain management (PROSPECT) [21,22]. However, although DREAMing is a binary measure summarising return of intestinal, cardiorespiratory and muscular function, it does not record return of cognitive function. It is increasingly being recognised that peri-operative neurocognitive disorders (PNCD) are a major cause of morbidity [23], and unlike the QoR scores, DREAMing does not incorporate it. Thus, despite its simplicity, it cannot replace currently validated scoring systems.
In addition, none of the scoring systems reviewed by either Myles [3] or Ladha and Wijeysundera [4] are designed to examine explicitly the incidence or causes of the major iatrogenic peri-operative complication of the 21st century, namely prescribed opioid dependence [24]. The incidence of persistent postoperative opioid use ranges from 0.6% to 26% for opioid-na€ ıve patients and from 35% to 77% for patients with previous opioid exposure [25]. Therefore, there is now an urgent need for quality of recovery scoring systems to be updated or augmented to examine the incidence and causes of persistent postoperative opioid use. The benefits of surgery must not be allowed to be negated by the subsequent harm and reduction in function caused by persistent opioid use.
In conclusion, over the past quarter of a century there has been a gradual recognition that promotion of restoration of function is vital to a full recovery and is an important outcome that matters both to patients and health services. The challenges for the next 25 years will include improvements in collaborative working between surgeons, anaesthetists and other health professionals to promote restoration of function further. This must be coupled with the continuous evolution of scoring systems so that surgical patients at risk of not achieving restoration of normal homeostatic, physical and psychological function, including independence, can be identified earlier. This evolution of practice will enable the individualisation of care to facilitate restoration of function and full recovery through shared decision making, prehabilitation, peri-operative comorbidity management and rehabilitation to achieve the best outcomes for our patients. This is the goal of perioperative care.