Metabolic and the Surgical Stress Response Considerations to Improve Postoperative Recovery

  • Erik M. Helander
  • Michael P. Webb
  • Bethany Menard
  • Amit Prabhakar
  • John Helmstetter
  • Elyse M. Cornett
  • Richard D. Urman
  • Viet H. Nguyen
  • Alan David KayeEmail author
Other Pain (A Kaye and N Vadivelu, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Other Pain


Purpose of Review

Enhanced recovery pathways are a multimodal, multidisciplinary approach to patient care that aims to reduce the surgical stress response and maintain organ function resulting in faster recovery and improved outcomes.

Recent Findings

A PubMed literature search was performed for articles that included the terms of metabolic surgical stress response considerations to improve postoperative recovery. The surgical stress response occurs due to direct and indirect injuries during surgery. Direct surgical injury can result from the dissection, retraction, resection, and/or manipulation of tissues, while indirect injury is secondary to events including hypotension, blood loss, and microvascular changes. Greater degrees of tissue injury will lead to higher levels of inflammatory mediator and cytokine release, which ultimately drives immunologic, metabolic, and hormonal processes in the body resulting in the stress response. These processes lead to altered glucose metabolism, protein catabolism, and hormonal dysregulation among other things, all which can impede recovery and increase morbidity. Fluid therapy has a direct effect on intravascular volume and cardiac output with a resultant effect on oxygen and nutrient delivery, so a balance must be maintained without excessively loading the patient with water and salt. All in all, attenuation of the surgical stress response and maintaining organ and thus whole-body homeostasis through enhanced recovery protocols can speed recovery and reduce complications.


The present investigation summarizes the clinical application of enhanced recovery pathways, and we will highlight the key elements that characterize the metabolic surgical stress response and improved postoperative recovery.


Enhanced recovery pathway Surgical stress response Preoperative optimization 



The manuscript has been read and approved by all the authors, the requirements for authorship have been met, and each author believes that the manuscript represents honest work.

Author Contributions

All authors contributed equally to the manuscript and are involved in institutional protocols and policies for enhanced recovery pathways.

Compliance with Ethical Standards

Conflict of Interest

Erik M. Helander, Michael P. Webb, Bethany Menard, Amit Prabhakar, John Helmstetter, Elyse M. Cornett, and Viet H. Nguyen declare no conflict of interest. Alan Kaye is on the speaker bureau for the Merck and Depomed, Inc. Richard D. Urman received research funding from the Medtronic.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Erik M. Helander
    • 1
  • Michael P. Webb
    • 2
  • Bethany Menard
    • 1
  • Amit Prabhakar
    • 3
  • John Helmstetter
    • 1
  • Elyse M. Cornett
    • 4
  • Richard D. Urman
    • 5
  • Viet H. Nguyen
    • 1
  • Alan David Kaye
    • 1
    Email author
  1. 1.Department of AnesthesiologyLSU School of MedicineNew OrleansUSA
  2. 2.Department of AnesthesiologyNorth Shore HospitalAucklandNew Zealand
  3. 3.Department of Anesthesiology and Critical Care MedicineEmory University HospitalAtlantaUSA
  4. 4.Department of AnesthesiologyLSU Health ShreveportShreveportUSA
  5. 5.Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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