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Improving perioperative outcomes and the giants of evidence-based medicine

Advances in technology are making it possible to perform complex operations on high-risk patients who, in previous decades, would not have been surgical candidates. Yet, on a frailer patient population, the ability to withstand perioperative complications is decreased. In fact, it has been shown that the occurrence of a 30-day complication is a greater risk factor than preoperative patient illness in determining survival after major surgery [1]. The articles in this section on anesthesia and medical disease focus on topics related to the prevention of perioperative complications through improved preoperativepreparationand perioperativepatient management. The review by Hall et al. (pp. 349–355) on the perioperative management of aspirin illustrates how a once widely held belief (e.g., the bleeding risk associated with aspirin use required its discontinuation 1 week prior to surgery) may be called into question by a reanalysis of evidence [2]. The management of antiplatelet agents is one of several topics discussed in the American Heart Association/American College of Cardiology’s new ‘Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery’, reviewed by Thompson et al. (pp. 342–348). The other reviews in this section (Nygren et al. (pp. 364–369) on perioperative oral carbohydrates, Shander et al. (pp. 356–363) on blood conservation strategies, and Ertmer et al. (pp. 370–377) on the role of starches in intraoperative fluid therapy) deal with topics related to Enhanced Recovery After Surgery (ERAS) guidelines. In 2010, the ERAS Society was founded in Sweden out of a surgical research group interested in establishing best practices and standardization of care for the purpose of improving patient outcomes. That group in turn was extending on the work of Dr Henrik Kehlet [3], who, in the 1990s, put forth the idea using multimodal surgical and anesthetic techniques to reduce the surgical stress response, improve pain control and patient morbidity, and reduce patient length of stays. The American Society for Enhanced Recovery, pioneered