Use of Modified Enhanced Recovery after Surgery Protocol to Improve Pain and Decrease Narcotic Use in Gynecologic Oncology Patients

Abstract

Study Objective We investigate how implementation of multimodal scheduled analgesia affects pain scores and narcotic use. Design Retrospective chart review of patients who underwent minimally invasive gynecologic surgery from September 2017 until June 2018. Setting Community medical center, patients on gynecologic oncology service. Patients or Participants Total of 120 charts initially reviewed. Patients excluded if underwent laparotomy or complete charts unavailable for review. Total of 72 charts reviewed after exclusion. Interventions Modified ERAS (enhanced recovery after surgery) protocol was defined as patients who received pre-operative pain medication including acetaminophen and celecoxib, and post-operatively received scheduled acetaminophen and ketorolac and as needed narcotics. 32 patients analyzed in pre-ERAS group and 40 patients analyzed in modified ERAS group. Measurements and Main Results For the primary outcome of narcotic use, pre-ERAS patients utilized significantly more narcotics on both post-operative day 0 and 1 (p= 0.003, p=0.001 respectively using Chi Square analysis). For the secondary outcome of decreased pain, median pain score on post-operative day 0 was not different in pre-ERAS vs. modified ERAS groups with median pain score of 5 (mean 5.8 +/- 2 vs. 5.2 +/- 2.1 using Wilcox Rank Sum). Median pain score on post-operative day 1 was decreased in modified ERAS patients, with median pain score of 7 for pre-ERAS patients and 4 for modified ERAS patients (mean 6.5 +/- 1.9 vs. 3.8 +/- 2.4 using Wilcox Rank Sum). Total narcotic use was increased for pre-ERAS patients compared to modified ERAS patients, with median number of 2.5 pills for pre-ERAS patients and 0 pills used for modified ERAS (mean 4.8 +/- 5.4 vs. 1.5 +/- 2.8 using Wilcox Rank Sum). Conclusion Our analysis demonstrates that patients receiving pre-surgical and scheduled post-operative pain medication utilized less narcotics in than those that did not. Our research shows that scheduled pain medication can improve patient care by decreasing pain and decreasing narcotic use.