Implementation of an Enhanced Recovery After Surgery Pathway for Pediatric Surgical Oncology using Quality Improvement Methodology.

315: An enhanced recovery after surgery pathway for cesarean delivery decreases postoperative opioid use

Commentary: Everybody hurts, sometimes: ERAS against opioids

Enhanced recovery after surgery (ERAS) protocols have been extensively proven in lower gastrointestinal surgery to decrease postoperative physiologic stress and length of stay (LOS). ERAS in bariatric surgery (ERABS) varies immensely from each program with inconsistent results with a predominant goal of reducing LOS. Our focus in implementing enhanced recovery after bariatric surgery (ERABS) protocols is aimed at reducing postoperative pain and opioid use. This is a retrospective review of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (VSG) at a single high-volume center from June 2016 to October 2017. Patients on previous standard protocol were categorized into "Pre-Liposomal Bupivacaine (LB) group." After routine use of Exparel™, patients were grouped into "LB group." After ERABS protocol was initiated, patients were categorized into "ERABS/LB group." Postoperative opioids were converted to morphine equivalents units (MEU); pain scores, LOS, and 30-day outcomes were analyzed using combination of t test and Mann-Whitney U. A total of 1340 patients were included in the study: 304 patients in pre-LB group; 754 patients in LB group, and 282 patients in ERABS/LB group. Total hospital opioid use was 58.6 MEU in pre-LB, 40.8 MEU in LB, and 23.8 MEU in ERABS/LB (p = 0.01). ERABS/LB group found a 59.5% decline in MEU requirements compared to pre-LB (p < 0.001) and 44.9% of patients did not require any additional narcotics on the floor compared to 0% in pre-LB group (p < 0.001). ERABS/LB LOS was an average of 1.48days compared to 1.54days in pre-LB group (p = 0.03) with an overall decrease of 3.74% in readmission rates (p = 0.03). Implementation of ERABS significantly reduced postoperative opioid use, LOS, and readmissions. With ERABS, a more profound effect was observed than simply adding Exparel™ to preexisting protocols. Almost half of these patients did not require narcotics while recovering on the surgical floor. More studies are required to assess the true effect of ERABS without use of Exparel™.

To conduct a prospective, randomized controlled trial (RCT) of an enhanced recovery after surgery (ERAS) protocol in an elective spine surgery population. Surgical outcomes such as length of stay (LOS), discharge disposition, and opioid utilization greatly contribute to patient satisfaction and societal healthcare costs. ERAS protocols are multimodal, patient-centered care pathways shown to reduce postoperative opioid use, reduced LOS, and improved ambulation; however, prospective ERAS data is limited in spine surgery. This single-center, IRB-approved, prospective RCT enrolled adult patients undergoing elective spine surgery between March 2019 and October 2020. Primary outcomes were peri-operative and 1-month postoperative opioid use. Patients were randomized to ERAS (n=142) or standard of care (SOC; n=142) based on power analyses to detect a difference in postoperative opioid use. Opioid use during hospitalization and the first postoperative month was not significantly different between groups (ERAS 112.2 vs. SOC 117.6 MME, P=0.76; ERAS 38.7% vs. SOC 39.4%, P=1.00 respectively). However, patients randomized to ERAS were less likely to use opioids at 6 months postoperatively (ERAS 11.4% vs. SOC 20.6%, P=0.046) and more likely to be discharged to home after surgery (ERAS 91.5% vs. SOC 81.0%, P=0.015). Here, we present a novel ERAS prospective RCT in the elective spine surgery population. While we do not detect a difference in the primary outcome of short-term opioid use, we observe significantly reduced opioid use at 6-month follow-up as well as an increased likelihood of home disposition after surgery in the ERAS group.

Use of fascial plane blocks is increasing yet their impact on hospital length of stay (LOS) and opioid use within the context of an enhanced recovery after surgery (ERAS) pathway has been inconclusive. We address this gap by examining the impact of fascial plane blocks on postoperative LOS and opioid use for colorectal surgical procedures in a hospital setting with a robust ERAS program. This is a retrospective cohort study using electronic health record data from a large, integrated health care delivery system with an established ERAS program in Northern California. Patients include adults who underwent non-emergent laparoscopic (n=5496) or non-laparoscopic (n=708) colectomy surgery from January 1, 2015 to May 20, 2021. The main exposure was type of anesthesia: general with long-acting fascial plane block, general with short-acting fascial plane block, or general only. Outcomes included postoperative LOS and average daily morphine milligram equivalents (MME) up to three days post-surgery. Most patients were older than age 50 (86% laparoscopic; 83% non-laparoscopic), female (52% laparoscopic; 58% non-laparoscopic), and non-Hispanic White (64% laparoscopic; 62% non-laparoscopic). In LOS adjusted models for laparoscopic and non-laparoscopic surgery, there was no significant difference for LOS with general with long-acting fascial plane block or with general with short-acting fascial plane block, compared to general only. In MME adjusted models for laparoscopic surgery, general with short-acting fascial plane block was associated with higher MME compared with general only (RE: 1.14,[95% CI: 1.03-1.25], p-value=0.01). However, in non-laparoscopic surgery, general with long-acting fascial plane block was associated with lower MME (RE: 0.63, [95% CI: 0.42-0.93], p-value=0.02), compared with general only. Fascial plane blocks did not impact postoperative LOS in either surgical group but long acting resulted in lower overall postoperative opioid use for non-laparoscopic surgery.

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS.Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software.Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD −7.47 h, 95% CI: −8.36 to −6.59 h, p < 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p < 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: −1.23, 95% CI: −1.32 to −1.15, p < 0.00001), opioid use (SMD: −0.46, 95% CI: −0.58 to −0.34, p < 0.00001), and hospital cost (SMD:−0.54, 95% CI: −0.63 to −0.45, p < 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62).Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

INTRODUCTION: One in 300 opioid-naïve women develop opioid addiction following cesarean delivery (CD). Enhanced recovery after surgery (ERAS) pathways provide a multidisciplinary, evidence-based approach to postoperative care and have been shown to decrease postoperative opioid consumption. We implemented an ERAS CD pathway and evaluated the impact on postoperative opioid use and pain scores. METHODS: We conducted an IRB approved, retrospective cohort study comparing postoperative opioid use and pain scores among women on the ERAS CD pathway in the first year of implementation (4/2017-3/2018, n=531) compared to historical controls (3/2016-2/2017, n=661). Women with pregestational diabetes on insulin preconception, preeclampsia with severe features, and/or complex pain needs were excluded. Analysis was stratified for women undergoing planned (no labor, n=530) and unplanned (labor, n=662) CD. Postoperative opioid use and pain scores were compared using chi-squared and t-tests. RESULTS: During implementation, 531 (83%) of 640 eligible women were included in the ERAS CD pathway. Compared to baseline, the ERAS CD pathway resulted in an overall decrease of 13.7% (p=0.001) in postoperative opioid use with a 23.2% reduction in patients with unplanned CD (p&lt;0.001). There was no difference in postoperative opioid use in patients with planned CD (p=0.456). ERAS patients with planned CD had a 9.5% reduction in pain scores on postoperative day 0 (p&lt;0.05). There were no other significant differences in pain scores. CONCLUSION: The ERAS CD pathway was associated with decreased postoperative opioid use overall. Interestingly, the decrease in opioid use was driven by the unplanned CD subset. Further research should explore these differences.

Adequate pain control after total knee arthroplasty (TKA) is critically important to achieve early mobilization, shorten the length of hospital stay, and reduce postoperative complications. At Veterans Affairs North Texas Health Care System (VANTHCS) in Dallas, we implemented a multidisciplinary enhanced recovery after surgery (ERAS) protocol to deal with increasing length of stay and postoperative pain. We hypothesize that this protocol will reduce the overall opioid burden and decrease inpatient hospital length of stay in our TKA population. A retrospective review of all TKAs performed by a single surgeon at VANTHCS from 2013 to 2018 was conducted. A postoperative ERAS protocol was implemented in 2016. We compared perioperative opioid use and LOS between cohorts before and after protocol implementation. Inpatient length of stay between cohorts was reduced from 66.8 hours for the standard of care (SOC) period to 22.3 hours in the ERAS cohort. Inpatient opioid use measured by total oral morphine equivalent doses averaged 169.5 mg and 66.7 mg for SOC and ERAS cohorts, respectively (P = .0001). Intraoperative use of opioids decreased from 57.4 mg in the SOC cohort to 10.5 mg in the ERAS cohort (P = .0001). Postanesthesia care unit (PACU) opioid use decreased from 13.6 mg (SOC) to 1.3 mg (ERAS) (P = .0002). There was no significant difference in complications between cohorts (P = .09). Initiating a multidisciplinary ERAS protocol for TKA at VANTHCS significantly reduced inpatient length of stay and perioperative opioid use with no deleterious effects on complication rates. The ERAS protocol has major medical and financial implications for our unique VA population and the VA health care system.

Genital-based gender affirmation surgery is a physically demanding procedure requiring extensive postoperative pain management. However, perioperative opioid use for these procedures is relatively understudied. This study analyzes whether intravenous patient-controlled analgesia (PCA) enhances pain control after penile inversion vaginoplasty (PIV) in the setting of enhanced recovery after surgery (ERAS) protocols, and whether non-PCA (NCA)-based regimens could reduce postoperative opioid use. All patients undergoing PIV with ERAS protocols by a single provider from December 2018 to November 2020 were retrospectively reviewed. Patient demographics, comorbid conditions, pain scores, length of stay (LOS), and opioid usage during their hospitalization were collected. Postoperative opioid use and pain scores were compared between PCA and NCA patient cohorts. A total of 61 patients were included. 30 patients received intravenous PCA postoperatively, and 31 patients used NCA-based narcotic pain control. All patients underwent ERAS protocol perioperatively. Average patient age was 34.5 years (SD 11.9) in the PCA cohort and 37.6 years (SD 11.9) in the NCA cohort (p = 0.242). Average total postoperative opioid use during hospital stay was reduced by 53.7% in the NCA cohort, with an average use of 501.6 morphine milligram equivalents (MME) (SD 410.3) among PCA patients and an average use of 232.0 MME (SD 216.5) among NCA patients (p = 0.003). Daily average pain scores for postoperative days 1 to 6 did not differ between the PCA and NCA patient groups (p > 0.05). Average hospital LOS was shorter among NCA patients, 6.2 days (SD 1.0) versus 7.3 days (SD 1.4), respectively, (p < 0.001). In combination with an ERAS non-narcotic pain control protocol, it may be possible to reduce opioid use by more than 50% and shorten length of postoperative hospital stay among patients by implementing NCA pain management protocols. Minimizing postoperative opioid consumption after PIV will benefit patients and their sustained well-being.

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1152 Enhanced recovery after surgery pathway for cesarean delivery decreases postpartum opioid use

This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery. This retrospective cohort study was performed in a tertiary care hospital. A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck HospitalofUniversity of Southern California (USC), California, USA, from 2016 to 2020 were included in this study. The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared towarda satisfactory, safe, and expeditious discharge. The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block. The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. New York-Presbyterian Hospital. Patients with cleft palate undergoing primary palatoplasty. Meta-analysis of reported patient outcomes in ERAS and control cohorts. Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.