Post-operative Nausea and Analgesia Following Total Mastectomy is Improved After Implementation of an Enhanced Recovery Protocol.

Abstract

Enhanced Recovery Protocols (ERPs) provide a multimodal approach to perioperative care, with the aims of improving patient outcomes while decreasing perioperative antiemetic and narcotic requirements. With high rates of post-operative nausea or vomiting (PONV) following total mastectomy (TM), we hypothesized that our institutional designed ERP would reduce PONV while improving pain control and decrease opioid use. An ERP was implemented at a single institution for patients undergoing TM with or without implant-based reconstruction. Patients from the first two months of implementation (ERP group, N = 72) were compared with a retrospective usual-care cohort from a three-month period before implementation (UC group, N = 83). Outcomes included PONV incidence, measured with antiemetic use; patient-reported pain scores; perioperative opioid consumption, measured by oral morphine equivalents (OME); and length of stay (LOS). The characteristics of the two groups were similar. PONV incidence and perioperative opioid consumption were lower in the ERP than the UC group (21% vs. 40%, p 0.011 and mean 44.1 OME vs. 104.3 OME, p < 0.001), respectively. These differences in opioid consumption were observed in the operating room and post-anesthesia care unit (PACU); opioid consumption on the floor was similar between the two groups. Patient-reported pain scores were lower in the ERP than the UC group (mean highest pain score 6.4 vs. 7.4, p 0.003). PACU and hospital LOS were similar between the two groups. ERP implementation was successful in decreasing PONV following TM with and without reconstruction, while simultaneously decreasing overall opioid consumption without compromising patient comfort.