16: Peri-operative analgesia and anti-emetic use after implementation of enhanced recovery after surgery (ERAS) in an urogynecology population

Abstract

ERAS protocols include pre-medication with analgesics and anti-emetics along with avoidance of intra-operative inhalation anesthesia and narcotic analgesics to reduce post-op pain and nausea. There is limited data exploring the impact of these ERAS elements in patients undergoing prolapse procedures. Our objective was to evaluate if ERAS implementation in an Urogynecology population decreased peri-operative narcotic analgesia and anti-emetic use. A retrospective analysis of anesthetic and analgesic administration, pain scores and post-surgical recovery time was performed of women undergoing major surgery before (January-June 2016) and after (February-July 2017) ERAS implementation. ERAS protocol included pre-medication with acetaminophen, celecoxib, morphine and perphenazine, and intra-operative avoidance of inhalation anesthetics and narcotics. Groups were compared using χ2, Wilcoxon rank sum, and t-tests. VAS pain scores were assessed using generalized linear models. Mean age and BMI of 258 women (137 pre-ERAS and 121 ERAS) were 65.5 ± 11.3 and 28.2 ± 5.0 with the most common pre-operative diagnosis being prolapse (93.8%). Apical suspension procedures: 58 (25.1%) transvaginal, 112 (48.8%) laparoscopic/robotic and 61 (26.4%) obliterative; 57.4% had a hysterectomy. Demographic and surgical procedures were similar in both groups. Compared to pre-ERAS, the ERAS group was more likely to receive pre-medication with acetaminophen (96.7 vs. 24.1%), perphenazine (92.6% vs. 16.8%), morphine sulfate ER (93.4 vs. 0%), and celecoxib (82.6 vs. 0%; all p < 0.001). Of ERAS patients, 76.5% received 4 of 4 pre-meds and 17.4% received 3 of 4 pre-meds compared to 0 pre-ERAS (p < 0.001). Compared to pre-ERAS, the ERAS group was more likely to received general anesthesia (93.4 vs. 83.2%, p = 0.037); but less likely to receive sevoflurane gas (18.2 vs. 73.0%). ERAS group received higher doses of propofol (1,942.7 vs. 302.3 mg), lidocaine IV (195.9 vs. 71.1 mg), and ketamine (27 vs. 1.3 mg, all p < 0.001). They received less intra-operative analgesics: fentanyl (5.8 vs. 88.3%), hydromorphone (0.8 vs. 17.5%, all p < 0.001), and intra-operative morphine equivalents (0 mg [IQR 0] vs. 70 mg [IQR 5.3], p < 0.001). Intra-operative anti-emetic doses were similar between groups. Post-surgical analgesic administration favored non-narcotics in the ERAS group: fentanyl (3.3 vs. 54.7%), acetaminophen (73.6 vs. 14.6%), and ketorolac (65.3 vs. 15.3%; each p < 0.001), morphine equivalents (4 mg [IQR 16.0] vs. 12.5 mg [IQR 31.3], p = 0.007). Pain scores compared across each 15-minute time interval while in post-surgical recovery were less in the ERAS group (β -0.34, p < 0.001). Recovery time was similar between groups (2.6 ± 0.8 vs. 2.6 ± 0.9 hours, p = 0.955). Overall ERAS patients received less morphine equivalents (27 mg [IQR 23.5] vs. 89.5 mg [IQR 67], p < 0.001) and 1 additional dose of an anti-emetic (4 [IQR 1] vs. 3 [IQR 2], p < 0.001). Length of admission was decreased by 13.8 hours in ERAS patients (12.1 ± 11.2 vs. 25.9 ± 13.5 hours, p < 0.001). Implementation of an ERAS protocol of pre-operative multimodal analgesics and restricted use of intra-operative narcotics and inhalation anesthetics results in superior pain management and decreased overall length of admission.