Enhanced Recovery After Surgery Cohort Research Articles

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair.

Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair. A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention. Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective. Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

The impact of an enhanced recovery programme on length of stay and post-discharge resource usage following hip and knee arthroplasty : a service evaluation and cost analysis.

AimsThe aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis.MethodsBetween May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year.ResultsMean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients.ConclusionERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key.Cite this article: Bone Jt Open 2021;2(11):966–973.

Enhanced recovery after surgery (ERAS) for open transforaminal lumbar interbody fusion: a retrospective propensity-matched cohort study

BACKGROUNDThe enhanced recovery after surgery (ERAS) protocol is a multidisciplinary, multimodal approach which has been shown to facilitate recovery of physiological function, and reduce postoperative pain, complication rates, and length of stay without adversely affecting readmission rates. Design and implementation of ERAS protocols in the recent spine surgery literature has primarily focused on patients undergoing minimally invasive lumbar surgery. However, conventional open transforaminal lumbar interbody fusion (TLIF) remains a common procedure and to date there are no studies assessing an ERAS protocol in this patient population. PURPOSEThis study presents a single surgeon experience implementing an ERAS protocol in patients undergoing 1- or 2-level open TLIF. STUDY DESIGN/SETTINGRetrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLEConsecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from 12/2018 – 02/2021 and controls from 12/2011-12/2017 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURESPrimary: length of stay; Secondary: first day to ambulate, first day to bowel movement, first day to void, daily average and maximum pain scores, opioid use, discharge disposition, 30-day readmission rate, and re-operations. METHODSDemographic, perioperative, clinical, radiographic data were collected. Multivariate mixed-linear regression models were developed for length of stay, physiological function, pain scales, and opiate use. RESULTSThere were 114 patients included with 57 in each cohort. After propensity matching, patient characteristics were similar between groups. Operative time decreased significantly after institution of ERAS (170±44 vs. 141±37 minutes, p <.0001) as did length of stay (4.6±1.7 vs. 3.6±1.6 days, p<.0001). First day of ambulation, bowel movement, and bladder voiding improved by 0.8 (p<.0001), 0.7 (p=.008), and 0.8 (p<.0001) days, respectively, in the ERAS cohort. Total daily intravenous morphine milligram equivalent (MME) (8±9 vs. 36±38, p<0.0001) and total 72-hour MME consumption (53±33 vs. 68±48, p<.0001) was significantly lower in the ERAS cohort; however, 72-hour MME consumption was not found to be significantly different in a sensitivity analysis controlling for preoperative MME. Average daily pain scores were similar between groups. CONCLUSIONSConsistent with other studies demonstrating benefit of an ERAS protocol for minimally invasive spine procedures, ERAS was associated with decreased operative time, reduced length of stay, decrease in IV opioid consumption, and improved physiological outcomes for open 1- and 2-level TLIF. ERAS can be a potentially effective strategy for improving patient outcome and efficiency of healthcare resources for common conventional spinal surgeries such as open TLIF.

Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy.

The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.

114. Outcomes of an enhanced recovery after surgery (ERAS) program for patients with metastatic spine tumors

<h3>BACKGROUND CONTEXT</h3> Metastatic spine tumor surgery generally consists of palliative operations performed on frail patients with multiple medical comorbidities. Perioperative complications that may arise can mitigate any potential benefit in this vulnerable patient cohort. Enhanced recovery after surgery (ERAS) programs involve an evidence-based multidisciplinary approach to improve perioperative outcomes. While ERAS programs have been shown to be beneficial in other surgical fields, literature evaluating the feasibility, implementation, and outcomes of an ERAS program dedicated to metastatic spine tumor surgery is limited. <h3>PURPOSE</h3> We present the metastatic spine tumor ERAS pathway and describe the clinical outcomes of the program. <h3>STUDY DESIGN/SETTING</h3> The metastatic spine tumor ERAS program went into effect in April 2019. This protocol focused on multimodality analgesia, including preoperative gabapentinoid, NSAID, and acetaminophen administration in combination with local field blocks with liposomal bupivacaine, to minimize opioid consumption; intraoperative goal-directed fluid management, early advancement of diet, and early ambulation with physical therapy. <h3>PATIENT SAMPLE</h3> A total of 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program were compared to 213 consecutive pre-ERAS patients. <h3>OUTCOME MEASURES</h3> Outcomes measured included: length of hospitalization stay, time to ambulation, urinary catheter duration, time to regular diet, total intraoperative fluid intake, estimated blood loss, intraoperative opioid use, and cumulative postop day 0-5 opioid use. <h3>Methods</h3> Single institution, retrospective review of prospectively collected data. <h3>Results</h3> While the case duration was similar in the ERAS vs pre-ERAS cohort (265 min vs 274 min, p = 0.22), the ERAS cohort had less estimated blood loss (157 mL vs 215 mL, p = 0.003), less postop day 0-5 cumulative opioid use (178 MME vs 396 MME, p < 0.0001), earlier ambulation (34 hours vs 57 hours, p = 0.0001), earlier discontinued urinary catheter (36 hours vs 56 hours, p < 0.001), and had a shorter length of stay (5.4 days vs 7.5 days, p < 0.0001), in comparison to the pre-ERAS cohort. The rates of ER visits, readmissions, and reoperations were not significantly different between the two cohorts. The increased utilization of minimally invasive procedures in the ERAS vs pre-ERAS cohort (46% vs 33%) was not a confounding factor for these outcome improvements. <h3>Conclusions</h3> To date, this is the largest study focusing on outcomes of an ERAS program specifically for patients undergoing metastatic spine tumor surgery. The implementation of an evidence-based multidisciplinary ERAS program has led to a significant reduction in postoperative opioid consumption, improved clinical quality metrics, and shorter hospitalization. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Enhanced Recovery Protocol Enhances Postdischarge Recovery After Laparoscopic Sacrocolpopexy.

The objective of this study is to determine if an ERAS (enhanced recovery after surgery) protocol enhanced the patient-perceived postdischarge recovery after laparoscopic sacrocolpopexy. In this prospective cohort study, patients exposed to an ERAS protocol completed a preoperative survey that included established predictors of postdischarge recovery. Postoperatively, they completed the validated Postdischarge Surgical Recovery 13 (PSR-13) scale at 7, 14, and 42 days. A historical cohort of non-ERAS patients who completed similar surveys were included for comparisons. Characteristics between the 2 cohorts were analyzed using the χ2 test, Student t tests, and Mann-Whitney U tests where appropriate. A mixed-design analysis of variance model was constructed to determine if our ERAS protocol affected recovery as measured by the PSR-13 scale. Eighty-nine ERAS patients were compared with 169 non-ERAS controls. There were no differences in established predictors of recovery between the groups. Length of hospital stay was shorter in the ERAS cohort (33±13.1 hours vs 44.2±25.9 hours; mean difference, 11.2; 95% confidence interval [CI], 6.44-16.0). Postdischarge recovery significantly improved with time (7 days: 52.7; 95% CI, 50.1-55.2; 14 days: 63.4; 95% CI, 60.9-65.8; 42 days: 80.1, 95% CI, 78.1-82.1). The ERAS cohort reported greater postdischarge recovery than the non-ERAS cohort (as measured by the PSR-13 scale) at postoperative days 7, 14, and 42 days (68.4 vs 62.3; mean difference, 6.1; 95% CI, 2.04-10.16). Enhanced recovery after surgery protocols reduce length of hospital stay and enhance patient-perceived postdischarge recovery.

49 Effect of enhanced recovery protocol in urogynecologic surgery

Enhanced Recovery After Surgery (ERAS) protocols are evidence-based, multidisciplinary and outcome-driven measures developed to provide best practice guidelines for surgical care. Limited data exists to support conventional perioperative interventions of caloric restriction, prolonged immobilization, and liberal administration of fluids and opioids. ERAS protocols for urogynecologic populations are being adopted with limited population and procedure-specific outcome data. Our primary aim was to compare opioid use by patients undergoing major pelvic organ prolapse (POP) surgery before and after implementation of an ERAS protocol. Secondary aims included comparing length of stay and 30-day follow-up characteristics. This ambispective cohort study included a retrospective, pre-ERAS cohort of consecutive patients who underwent major POP surgery starting January 2016. A comprehensive ERAS protocol was implemented in October 2019 (Table 1). A prospective, ERAS cohort consisted of consecutive patients undergoing POP surgery starting in January 2020, 3 months after full implementation of the ERAS protocol. ERAS patients were screened for eligibility and enrolled on the day of surgery. Major POP surgery was defined as including an apical procedure. Demographic and clinical data were abstracted. Descriptive statistics were used for demographic variables. Opioid use was converted to morphine milligram equivalents (MME) and compared between cohorts using the t-test. Other outcomes were compared between groups using t-test or Chi-Square as appropriate. Participants (33 pre-ERAS, 32 ERAS) were similar between cohorts and had mean (SD) age 62.4 (9.7) years, body-mass index 28.9 (4.8) kg/m2, and median (IQR) parity 3 (2-4). Similarly, medical co-morbidities and type of apical POP procedure did not differ between groups. Following ERAS implementation, mean total intra- and post-operative MME decreased (59.4 (31.6) vs 36.6 (20.5), P<0.01). Total discharge prescription MME also decreased (392.3 (88.4) vs 94.6 (61.3), P<0.01). Despite decreased opioid use, post-operative pain scores were not different between groups (Table 2). The ERAS cohort had decreased length of stay and were more likely to be discharged on the day of surgery. Mean number of telephone calls within 30 days of surgery increased (1.0 (1.0) to 2.2 (1.9), P<0.01) while clinic visits, emergency room visits and readmissions did not differ. Implementation of an ERAS protocol in women undergoing major POP surgery resulted in decreased opioid use and length of stay without impacting post-operative pain scores.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Reduction of Opioid Use With Enhanced Recovery Program for Total Knee Arthroplasty.

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.

Implementation of an enhanced recovery protocol in gynecologic oncology

Enhanced Recovery after Surgery (ERAS) is an evidence-based approach that aims to reduce narcotic use and maintain anabolic balance to enable full functional recovery. Our primary aim was to determine the effect of ERAS on narcotic usage among patients who underwent exploratory laparotomy by gynecologic oncologists. We characterized its effect on length of stay, intraoperative blood transfusions, bowel function, 30-day readmissions, and postoperative complications. A retrospective cohort study was performed at Abington Hospital-Jefferson Health in gynecologic oncology. Women who underwent an exploratory laparotomy from 2011 to 2016 for both benign and malignant etiologies were included before and after implementation of our ERAS protocol. Patients who underwent a bowel resection were excluded. A total of 724 patients were included: 360 in the non-ERAS and 364 in the ERAS cohort. An overall reduction in narcotic usage, measured as oral morphine milliequivalents (MMEs) was observed in the ERAS relative to the non-ERAS group, during the entire hospital stay (MME 34 versus 68, p < 0.001 and within 72 h postoperatively (MME 34 versus 60, p < 0.005). A shorter length of stay and earlier return of bowel function were also observed in the ERAS group. No differences in 30-day readmissions (p = 0.967) or postoperative complications (p = 0.328) were observed. This study demonstrated the benefits of ERAS in Gynecologic Oncology. A significant reduction of postoperative narcotic use, earlier return of bowel function and a shorter postoperative hospital stay was seen in the ERAS compared to traditional perioperative care.

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

To evaluate the effect of implementing an enhanced recovery after surgery (ERAS) pathway for all cesarean deliveries on postpartum opioid use and pain control We conducted a prospective quality improvement study comparing postoperative opioid use before and after implementation of an ERAS pathway for cesarean delivery (CD). The ERAS pathway included preoperative, intraoperative, and postoperative components, with emphasis on preoperative preparation, hemodynamic optimization, early mobilization and multimodal analgesia. All women undergoing CD, whether scheduled, urgent, or emergent, were included. Demographic, delivery, and inpatient opioid use data were obtained by chart review. Two weeks after discharge, women were surveyed about their delivery experience, analgesic usage, and complications. The primary outcome was inpatient opioid use. The study included 128 women, 56 in the pre-ERAS cohort and 72 in the ERAS cohort. Baseline characteristics, surgical indications, and procedural characteristics for the two groups were similar. The postpartum survey response rate was 94/128 (73%). Opioid use in the first 48 hours postoperatively was significantly lower in the ERAS group compared to the pre-ERAS group (9.4 vs. 21.4 morphine milligram equivalents (MME) 0-24 hours postpartum, p< 0.001; 14.1 vs. 25.4 MME 24-48 hours postpartum, p< 0.001) with no increase in either average or maximum postoperative pain scores. Women in the ERAS group were prescribed fewer opioid pills at discharge compared to the pre-ERAS group (17 vs. 23, p< 0.001) and took fewer opioid pills after discharge (8 vs. 19, p< 0.001). Patient satisfaction and complication rates did not change after ERAS implementation. Implementation of an ERAS pathway for all scheduled and unscheduled cesarean deliveries decreases both inpatient and outpatient postpartum opioid use without increasing pain scores or decreasing patient satisfaction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Opioid prescribing patterns following implementation of Enhanced Recovery After Surgery (ERAS) protocol in pediatric patients undergoing lower tract urologic reconstruction

With increasing awareness of the opioid epidemic, there is a push for providers to minimize opioid prescriptions. Enhanced Recovery After Surgery (ERAS) is a comprehensive multidisciplinary perioperative protocol that includes minimization of opioid analgesia in favor of non-opioid alternatives and regional analgesia. While ERAS protocols have consistently been shown to decrease inpatient opioid utilization, the impact on opioid prescribing practices and use after discharge in pediatric surgical patients is unclear. This study aims to assess the impact of an ERAS protocol on outpatient opioid prescription patterns after pediatric lower urinary tract reconstructive surgery. We hypothesize that implementation of an ERAS protocol leads to fewer outpatient opioid prescriptions as measured by number and total quantity of oral morphine milligram equivalents by body weight per patient. All patients who underwent bladder augmentation, creation of a continent catheterizable channel, bladder neck reconstruction or closure, or revision of prior reconstructive procedures at our tertiary care facility between 2011 and 2017 were reviewed. Patients were divided into pre-ERAS and ERAS cohorts based on whether surgery occurred before or after ERAS implementation. The Colorado Prescription Drug Monitoring Program was used to track filling of postoperative opioid prescriptions for patients covered by the database. A total of 167 urologic reconstructive surgeries were analyzed, including 83 before ERAS and 84 after ERAS implementation. Patients in the ERAS cohort received and filled more outpatient opioid prescriptions at time of discharge (82.6% historical vs 93.9% ERAS, p=0.015; 76.1% vs 57.9%, p=0.012). There were no differences in prescription total morphine milligram equivalents normalized to body mass, total days supplied, or 90-day opioid prescription refill rates. We found an unexpected increase in postoperative outpatient opioid prescriptions following implementation of an ERAS protocol for lower urinary tract reconstructive surgery. Possible reasons include worry about pain crisis at home in the setting of decreased hospital length of stay in the ERAS cohort or generalized upward drift in opioid prescribing patterns over time. ERAS protocols in other subspecialties reveal mixed findings but consistently suggest standardization of outpatient opioid prescribing patterns leads to a decrease in opioid prescriptions. Patients received more, not fewer, outpatient opioid prescriptions following major urologic reconstructive surgery after implementation of an ERAS protocol. Purposeful efforts should be made to standardize opioid prescriptions at discharge based on meaningful clinical criteria.

Impact of Multidisciplinary Audit of Enhanced Recovery After Surgery (ERAS)® Programs at a Single Institution.

As Enhanced Recovery After Surgery (ERAS®) programs expand across numerous subspecialties, growth and sustainability on a system level becomes increasingly important and may benefit from reporting multidisciplinary and financial data. However, the literature on multidisciplinary outcome analysis in ERAS is sparse. This study aims to demonstrate the impact of multidisciplinary ERAS auditing in a hospital system. Additionally, we describe developing a financial metric for use in gaining support for system-wide ERAS adoption and sustainability. Data from HPB, colorectal and urology ERAS programs at a single institution were analyzed from a prospective ERAS Interactive Audit System (EIAS) database from September 2015 to June 2019. Clinical 30-day outcomes for the ERAS cohort (n = 1374) were compared to the EIAS pre-ERAS control (n = 311). Association between improved ERAS compliance and improved outcomes were also assessed for the ERAS cohort. The potential multidisciplinary financial impact was estimated from hospital bed charges. Multidisciplinary auditing demonstrated a significant reduction in postoperative length of stay (LOS) (1.5days, p < 0.001) for ERAS patients in aggregate and improved ERAS compliance was associated with reduced LOS (coefficient - 0.04, p = 0.004). Improved ERAS compliance in aggregate also significantly associated with improved 30-day survival (odds ratio 1.04, p = 0.001). Multidisciplinary analysis also demonstrated a potential financial impact of 44% savings (p < 0.001) by reducing hospital bed charges across all specialties. Multidisciplinary auditing of ERAS programs may improve ERAS program support and expansion. Analysis across subspecialties demonstrated associations between improved ERAS compliance and postoperative LOS as well as 30-day survival, and further suggested a substantial combined financial impact.

One-Year Post Hoc Analysis of Renal Function for Live Kidney Donors That Were Enrolled in an Enhanced Recovery After Surgery Pathway With Ketorolac.

Background and ObjectiveOpioid exposure is a concern after live donation for kidney transplants (LDKT). We previously theorized that an enhanced recovery after surgery (ERAS) pathway for LDKT will reduce perioperative narcotic use. The aim of this post hoc analysis of merged data from two ERAS trials was to review the one-year follow-up to determine if the exposure to ketorolac versus placebo had any significant impact on long-term kidney function after LDKT.MethodsOne-year post hoc analysis of merged data from two ERAS LDKT, prospective, double-blind, randomized clinical trials were combined involving a total of 72 patients undergoing nephrectomy for LDKT. Kidney functions of both the ERAS groups' versus placebo were compared prospectively and blinded at one year using estimated glomerular filtration rate (eGFR) and total protein (TP) in the urine in compliance with United Network for Organ Sharing (UNOS) live donor requirements.ResultsThere was no significant difference in postoperative eGFR at one year between ERAS and placebo groups. TP urine at one-year post-operative was significantly lower in the ERAS cohort by 4.7 mg/dl (95% CI 0.48 ~ 8.82, p = 0.025).ConclusionsThe ERAS groups' exposure to ketorolac did not negatively affect kidney function at one year after LDKT.

MP24-13 COST ANALYSIS OF RADICAL CYSTECTOMY DONE WITH AND WITHOUT IMPLEMENTATION OF AN ERAS PROTOCOL

INTRODUCTION AND OBJECTIVE: Bladder cancer is the second most common malignancy of the genitourinary tract with approximately 80,00 new cases diagnosed in 2018. Roughly one-quarter of patients with urothelial carcinoma of the bladder are initially diagnosed with or eventually progress to muscle-invasive disease. Muscle invasive bladder cancer (MIBC) is a morbid condition often requiring multimodal therapy with significant clinical and economic impact. The Enhanced Recovery After Surgery (ERAS) protocol has be adapted to radical cystectomy (RC) and urinary diversion and has been demonstrated to improve patient outcomes while potentially minimizing cost. In this study, we aim to describe the cost of RC with and without implementation of ERAS protocol. METHODS: All patients who underwent RC at our institution between January 2016 and June 2019 were retrospectively reviewed. Financial identification numbers (FINs) were processed by our financial office and cost was divided into total and variable cost for each patient. Patient demographics, cost of RC and subsequent hospital stay were collected and analyzed. Costs were adjusted to 2019 US dollars using the Producer Priced Index. Analysis was run on variable costs using independent samples t-tests between non-ERAS and ERAS cohorts. RESULTS: Figure 1 displays the patient characteristics and cost analysis. There was no significant difference in total variable cost between the total ERAS cohort ($604) and the male ERAS sub-cohort ($1,989) compared to their non-ERAS counterparts (p=0.75, p=0.24) Across all patients, ERAS patients had less costs associated with blood bank ($142) and all therapy modalities ($123) compared to the non-ERAS cohort costs of blood bank ($366) and therapy ($182), (p<0.05). In the male sub-cohort, ERAS patients had less average cost for anesthesia ($880 vs. $1,087, p=0.002), blood bank ($319 vs. $72, 0.0001), ICU ($77 vs. $540, p=0.025), radiology ($129 vs. $82, p=0.017), respiratory ($181 vs. $74, p=0.048), and therapy ($183 vs. $109, p=0.002) compared to non-ERAS male patients. CONCLUSIONS: Male patients who underwent RC with implementation of ERAS were found to have lower costs than their non-ERAS counterparts in certain care categories. Further studies with larger cohorts are necessary to help understand variances in cost patterns when implementing an ERAS protocol.Source of Funding: None

Enhanced recovery and accelerated discharge after endoscopic transsphenoidal pituitary surgery: safety, patient feedback, and cost implications.

Enhanced recovery after surgery (ERAS) is a constant motivation. There is growing evidence that an endoscopic (rather than microscopic) transsphenoidal approach to pituitary tumours can play a role, facilitating faster recovery and a commensurate reduction in length of stay (LOS). Reducing LOS is beneficial to both patients and healthcare systems. We sought to assess the safety, patient feedback, and resource implications of adopting an enhanced recovery and accelerated discharge policy for elective pituitary surgery. We retrospectively assessed two consecutive cohorts of patients undergoing elective surgery for pituitary adenoma in a single UK centre between July 2016 and November 2019. The pre-ERAS cohort included 52 sequential patients operated prior to protocol change. The ERAS cohort included 55 sequential patients operated after a protocol change. Patient demographic data, tumour characteristics, intra- and post-operative CSF leak, the rate and cause of readmission (within 30days), and the mean and median LOS were recorded. Patient feedback was collected from a subset of patients (n = 23) in the ERAS group. The two cohorts were well-matched with respect to their demographic, pathological, and operative characteristics. The rates of readmission within 30days of discharge were similar between the two groups (8% pre-ERAS cohort, 9% ERAS cohort, p = 0.75). In the pre-ERAS cohort, the mean LOS was 4.5days and median LOS was 3days. This compares with significant reduction in LOS for the ERAS group: mean of 1.7days and median of 1day (p < 0.05). Thirty-nine of 55 patients in the ERAS group were discharged on post-operative day 1. Patient feedback was very positive in the ERAS group (mean patient satisfaction score of 9.7/10 using a Likert scale). An enhanced recovery protocol after elective endoscopic pituitary surgery is safe, reduces length of stay, and is associated with high patient satisfaction.

Abstract P1-20-08: Breast surgery ERAS program: Trends since implementation on post-operative pain and discharge narcotic prescribing at our institution

Abstract Introduction: Recently, enhanced recovery after surgery (ERAS) pathways have been gaining popularity within surgical sub-specialties. Key ERAS concepts include the standardization of perioperative care such as pre-operative counseling, protocolization of analgesia and anesthesia regimens as well as early mobilization, among others. This approach aims to achieve cost savings through decreased length of stay, reduced opioid complications, and overall improved outcomes. In concordance with this trend, many institutions are now implementing ERAS protocols for breast surgery, especially with cases of mastectomy followed by immediate reconstruction. Our institution implemented a Breast Surgery ERAS program in February of 2018, consisting of standardized peri-operative analgesia/anesthesia, most significantly including a pre-operative pectoral block performed by anesthesia. We hypothesize that the use of the pre-operative pectoral block in the ERAS cohort will result in improved post-operative pain scores from the Non-ERAS cohort; additionally, we expect that the percentage of patients requiring opioid prescriptions at discharge for pain control will be decreased in the ERAS cohort. Methods: The EMR was queried for patients who underwent breast surgery with immediate reconstruction. The experimental group consisted of ERAS patients from February 6, 2018 to February 1, 2019 with an n = 107. The control group consisted of non-ERAS patients from April 19, 2016 to January 30, 2018 with an n=117. Chart review was performed for discharge medications, as well as pain scores recorded from time immediately post-operative, to just prior to discharge. Statistical analysis of the data was performed with a comparison of difference in means and Fischer exact test. Results: The ERAS cohort was noted to have a statistically significant decrease in the mean immediate post-operative pain scores (ERAS 2.04, Non-ERAS 4.04; p-value &amp;lt; 0.0001). There was no difference with comparison of the means of last pain scores recorded prior to discharge between the ERAS and Non-ERAS groups (ERAS 3.36, Non-ERAS 3.63, p-value 0.34). There was a statistically significant decrease in the percentage of patients discharged with opioid prescriptions in the ERAS group compared to the Non-ERAS group (ERAS 58.9% v 87.2% Non-ERAS; p-value &amp;lt;0.0001). The ERAS cohort LOS was also statistically significantly less than the Non-ERAS (ERAS 1.28 days, Non-ERAS 1.61 days; p-value = 0.0002). Discussion: Our ERAS protocol utilizes multi-modal pain control methods beginning pre-operatively, including the addition of a pectoral block placed by anesthesia, which we expect contributed highly to the lower mean immediate post-operative pain scores expressed by the ERAS cohort. This is important in the context of our nation’s current opioid epidemic, where decreasing discharge opioid prescriptions is imperative for reducing the risk for development of addictive behaviors, as well as the risk for opioid side effects such as nausea, constipation, and altered mental status. With the implementation of our Breast Surgery ERAS program, we have demonstrated clear progress towards this goal with the hope for continued improvement. Citation Format: Ashley A Woodfin, Emily Ramirez, Alison Coogan, Nehl Mehta, Anuja K Antony, Deana Shenaq, Keith C Hood, Cristina O'Donoghue, Claudia Perez, Rosalinda Alvarado, Andrea Madrigrano. Breast surgery ERAS program: Trends since implementation on post-operative pain and discharge narcotic prescribing at our institution [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-08.

Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction.

Purpose:We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block.Patients and methods:This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block.Results:Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results (P ⩾ .2).Conclusions:Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.

286. Early adoption of enhanced recovery after surgery protocol following adult spinal deformity surgery is not associated with decreased in-hospital opioid use

BACKGROUND CONTEXT The United States is facing an opioid crisis. Opioid use is common and widespread in the adult spinal deformity (ASD) population. Enhanced Recovery After Surgery (ERAS) is a multimodal and multidisciplinary evidence-based, perioperative approach for surgery intended to reduce surgical morbidity and improve recovery. We sought to evaluate the effects of ERAS implementation on postoperative opiate consumption, length of stay (LOS), and postoperative day of ambulation (PDA) following ASD surgery. PURPOSE The purpose of this study is to test if the implementation of ERAS protocol will help reduce in-hospital opioid use, length of stay and postoperative day of ambulation following ASD surgery. STUDY DESIGN/SETTING Single site, multisurgeon, retrospective longitudinal cohort study. PATIENT SAMPLE We sampled a total of 50 patients, 6 months pre- (n=20) and post- (n=30) ERAS implementation. METHODS A single center, multisurgeon, retrospective review identified patients with adult deformity who underwent ASD surgery 6 months pre- (n=20) and post- (n=30) ERAS implementation. The 2 cohorts were statistically similar in age, sex, BMI, diagnosis, ASA grade and levels fused. Total morphine equivalent doses (MED) in-hospital as well as 90-day postoperative prescriptions were calculated. LOS and PDA were also evaluated. Preoperative opiate prescriptions were recorded to determine baseline opioid use. RESULTS We found no difference in hospital postoperative mean total MED between the 2 cohorts (preERAS=263, postERAS=211, p=0.44). The 90-day mean total MED was also not significantly different between the cohorts (preERAS= 572, postERAS=326, p=0.12). 25 (50%) patients were taking opiates prior to surgery. Opiate naive patients required significantly less in-hospital mean total MED compared to nonopiate naive patients (124 vs 629, p=0.02, respectively). However, 90-day mean total MED was not significantly different between the 2 cohorts (naive=197 vs non-opiate naive=311, p=0.18). LOS for ERAS cohort (5.20.±73) was less when compared to preERAS cohort (5.9±0.6, p=0.22), but this was not significant. PDA was significantly decreased after ERAS implementation (1.1 vs 0.43, p=0.006). CONCLUSIONS Early adoption of ERAS did not decrease in-hospital opioid consumption or total 90-day opioid prescription. In-hospital opioid consumption was correlated with preoperative opioid use. Decreasing presurgical opioid use has a significant effect on postoperative patient opioid consumption and should be implemented as part of ERAS protocol. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Reductions in length of stay, narcotics use, and pain following implementation of an enhanced recovery after surgery program for 1- to 3-level lumbar fusion surgery.

OBJECTIVELumbar fusion is typically associated with high degrees of pain and immobility. The implementation of an enhanced recovery after surgery (ERAS) approach has been successful in speeding the recovery after other surgical procedures. In this paper, the authors examined the results of early implementation of ERAS for lumbar fusion.METHODSBeginning in March 2018 at the authors' institution, all patients undergoing posterior, 1- to 3-level lumbar fusion surgery by any of 3 spine surgeons received an intraoperative injection of liposomal bupivacaine, immediate single postoperative infusion of 1-g intravenous acetaminophen, and daily postoperative visits from the authors' multidisciplinary ERAS care team. Non-English- or non-Spanish-speaking patients and those undergoing nonelective or staged procedures were excluded. Reviews of medical records were conducted for the ERAS cohort of 57 patients and a comparison group of 40 patients who underwent the same procedures during the 6 months before implementation.RESULTSGroups did not differ significantly with regard to sex, age, or BMI (all p > 0.05). Length of stay was significantly shorter in the ERAS cohort than in the control cohort (2.9 days vs 3.8 days; p = 0.01). Patients in the ERAS group consumed significantly less oxycodone-acetaminophen than the controls on postoperative day (POD) 0 (408.0 mg vs 1094.7 mg; p = 0.0004), POD 1 (1320.0 mg vs 1708.4 mg; p = 0.04), and POD 3 (1500.1 mg vs 2105.4 mg; p = 0.03). Postoperative pain scores recorded by the physical therapy and occupational therapy teams and nursing staff each day were lower in the ERAS cohort than in controls, with POD 1 achieving significance (4.2 vs 6.0; p = 0.006). The total amount of meperidine (8.8 mg vs 44.7 mg; p = 0.003) consumed was also significantly decreased in the ERAS group, as was ondansetron (2.8 mg vs 6.0 mg; p = 0.02). Distance ambulated on each POD was farther in the ERAS cohort, with ambulation on POD 1 (109.4 ft vs 41.4 ft; p = 0.002) achieving significance.CONCLUSIONSIn this very initial implementation of the first phase of an ERAS program for short-segment lumbar fusion, the authors were able to demonstrate substantial positive effects on the early recovery process. Importantly, these effects were not surgeon-specific and could be generalized across surgeons with disparate technical predilections. The authors plan additional iterations to their ERAS protocols for continued quality improvements.

Surgical site infections after pancreatic surgery in the era of enhanced recovery protocols.

Few data exist on risk factors (RF) for surgical site infections (SSI) among patients treated in an enhanced recovery after surgery (ERAS) pathway. This study aimed to assess RF for SSI after pancreas surgery in a non-ERAS group and an ERAS cohort.An exploratory retrospective analysis of all pancreas surgeries prospectively collected (01/2000–12/2015) was performed. RF for SSI were calculated using uni- and multivariable binary logistic regressions in non-ERAS and ERAS patients.Pancreas surgery was performed in 549 patients. Among them, 144 presented a SSI (26%). In the non-ERAS group (n = 377), SSI incidence was 27% (99/377), and RF for SSI were male gender and preoperative biliary stenting. Since 2012, 172 consecutive patients were managed within an ERAS pathway. Forty-five patients (26%) had SSI. On multivariable analysis no RF for SSI in the ERAS cohort was found. In the ERAS group, patients with a pathway compliance ≤70% had higher occurrence of SSI (30/45 = 67% vs. 7/127 = 6%, p < 0.001) and patients with and without SSI had similar median overall compliances (77%, IQR 71–80 vs. 80%, IQR 73–83, p = 0.097).In the non-ERAS cohort, male gender and preoperative biliary stenting were RF for SSI, whereas in the ERAS group no RF for SSI was found. In an ERAS pathway, having an overall compliance >70% might diminish the SSI rate.