Enhanced Recovery Pathway Research Articles

Effect of short-term prehabilitation of older patients with colorectal cancer: A propensity score-matched analysis.

The aim of this study was to assess the impact of short-term, hospital-based, supervised multimodal prehabilitation on elderly patients with colorectal cancer. A single-center, retrospective study was conducted from October 2020 to December 2021, which included a total of 587 CRC patients who were scheduled to undergo radical resection. A propensity score-matching analysis was performed to reduce selection bias. All patients were treated within a standardized enhanced recovery pathway, and patients in the prehabilitation group received an additional supervised, short-term multimodal preoperative prehabilitation intervention. Short-term outcomes were compared between the two groups. Among the participants, 62 patients were excluded; 95 participants were included in the prehabilitation group and 430 in the non-prehabilitation group. After PSM analysis, 95 pairs of well-matched patients were included in the comparative study. Participants in the prehabilitation group had better preoperative functional capacity (402.78 m vs. 390.09 m, P<0.001), preoperative anxiety status (9% vs. 28%, P<0.001), time to first ambulation[25.0(8.0) hours vs. 28.0(12.4) hours, P=0.008], time to first flatus [39.0(22.0) hours vs. 47.7(34.0) hours, P=0.006], duration of the postoperative length of hospital stay [8.0(3.0) days vs. 10.0(5.0) days, P=0.007), and quality of life in terms of psychological dimensions at 1 month postoperatively [53.0(8.0) vs. 49.0(5.0), P<0.001]. The short-term, hospital-based, supervised multimodal prehabilitation is feasible with a high degree of compliance in older CRC patients, which improves their short-term clinical outcomes.

Addition of Deep Parasternal Plane Block to Enhanced Recovery Protocol for Pediatric Cardiac Surgery.

This study aims to evaluate if the addition of deep parasternal plane blocks to a pre-existing enhanced recovery pathway for pediatric cardiac surgery improves outcomes. A retrospective review through an EMR query from June 2019 to June 2021 was performed for patients less than 18 years of age who underwent cardiac surgery via median sternotomy and were extubated immediately following surgery in a single academic tertiary care hospital. Patients receiving deep parasternal blocks as part of an enhanced recovery protocol were compared to similar patients from the year prior to block implementation. The primary outcome was intraoperative and postoperative opioid consumption. Secondary outcomes were pain scores, intensive care unit (ICU) length of stay and time to first oral intake. There was a statistically significant reduction in intraoperative opioid administration and pain scores in the first 24 hours post-operatively. There was also a statistically significant reduction in ICU length of stay. There was no statistically significant difference in post-operative opioid consumption and time to first oral intake. Bilateral deep parasternal blocks may reduce opioid consumption, provide effective postoperative pain control, and result in decreased length of intensive care unit stay across both simple and complex pediatric cardiac procedures when added to a pre-existing enhanced recovery protocol.

DAY-CASE TOTAL HIP ARTHROPLASTY PATHWAY USING THE POSTERIOR APPROACH

As Total Hip Replacement (THR) rates increase healthcare providers have sought to reduce costs, while at the same time improving patient safety and satisfaction. Up to 50% of patients may be appropriate for Day Case THR, and in appropriately selected patients’ studies show no increase in complication rate while affording a significant cost saving and maintaining a high rate of patient satisfaction.Despite the potential benefits, levels of adoption of Day Case THR vary. A common cause for this is the perception that doing so would require the adoption of new surgical techniques, implants, or theatre equipment. We report on a Day-Case THR pathway in centres with an established and well-functioning Enhanced Recovery pathway, utilising the posterior approach and standard implants and positioning.We prospectively collected the data on consecutive THRs performed by a single surgeon between June 2018 and July 2021. A standardised anaesthetic regimen using short acting spinal was used. Surgical data included approach, implants, operative time, and estimated blood loss. Outcome data included time of discharge from hospital, post operative complications, readmissions, and unscheduled health service attendance.Data was gathered on 120 consecutive DCTHRs in 114 patients. 93% of patients were successfully discharged on the day of surgery. Four patients required re-admission: one infection treated with DAIR, one dislocation, one wound ooze admitted for a day of monitoring, one gastric ulcer. One patient had a short ED attendance for hypertension.Our incidence of infection, dislocation and wound problems were similar to those seen in inpatient THR. Out data show that the widely used posterior approach using standard positioning and implants can be used effectively in a Day Case THR pathway, with no increase in failure of same-day discharge or re-admission to hospital.

Fast-track protocols for patients undergoing spine surgery: a systematic review

Background contextFast-track is an evidence-based multidisciplinary strategy for pre-, intra-, and postoperative management of patients during major surgery. To date, fast-track has not been recognized or accepted in all surgical areas, particularly in orthopedic spine surgery where it still represents a relatively new paradigm.PurposeThe aim of this review was provided an evidenced-based assessment of specific interventions, measurement, and associated outcomes linked to enhanced recovery pathways in spine surgery field.MethodsWe conducted a systematic review in three databases from February 2012 to August 2022 to assess the pre-, intra-, and postoperative key elements and the clinical evidence of fast-track protocols as well as specific interventions and associated outcomes, in patients undergoing to spine surgery.ResultsWe included 57 full-text articles of which most were retrospective. Most common fast-track elements included patient’s education, multimodal analgesia, thrombo- and antibiotic prophylaxis, tranexamic acid use, urinary catheter and drainage removal within 24 hours after surgery, and early mobilization and nutrition. All studies demonstrated that these interventions were able to reduce patients’ length of stay (LOS) and opioid use. Comparative studies between fast-track and non-fast-track protocols also showed improved pain scores without increasing complication or readmission rates, thus improving patient’s satisfaction and functional recovery.ConclusionsAccording to the review results, fast-track seems to be a successful tool to reduce LOS, accelerate return of function, minimize postoperative pain, and save costs in spine surgery. However, current studies are mainly on degenerative spine diseases and largely restricted to retrospective studies with non-randomized data, thus multicenter randomized trials comparing fast-track outcomes and implementation are mandatory to confirm its benefit in spine surgery.

Investigating Glycemic Control in Patients Undergoing Lower Extremity Bypass Within an Enhanced Recovery Pathway at a Single Institution

Enhanced recovery pathways (ERPs) have been used with success in several surgical subspecialties including colorectal surgery and cardiovascular surgery. Vascular surgery ERPs for lower extremity bypass have also been associated with improved patient outcomes regarding length of stay after index operation. The primary goal of ERPs is to reduce perioperative physiological stress. This is achieved in a multimodal fashion by limiting preoperative fasting, optimizing perioperative pain control, early initiation of postoperative nutrition, and early involvement of physical rehabilitation.

Enhanced Recovery Pathway Application for Perioperative Outcomes among Women Undergoing Gynecological Oncology Operations

Enhanced Recovery Pathway Application for Perioperative Outcomes among Women Undergoing Gynecological Oncology Operations

Evolution of postoperative care: marked reduction of opioid consumption when ERAC pathway added to wound soaker therapy for cesarean delivery

Objective Achieving functional recovery after cesarean delivery is critical to a parturient’s ability to care for herself and her newborn. Adequate pain control is vital, and without it, many other aspects of the recovery process may be delayed. Reducing opioid consumption without compromising analgesia is of paramount importance, and enhanced recovery pathways have generated considerable interest given their ability to facilitate this. Our group’s process for reducing opioid consumption for cesarean delivery patients evolved over time. We first demonstrated that providing additional incisional pain control with continuous bupivacaine infusions through wound catheters, with the concurrent use of neuraxial morphine, reduced postoperative opioid use. Iterations of an enhanced recovery after cesarean (ERAC) delivery pathway were then implemented after the Society for Obstetric Anesthesia and Perinatology’s consensus statement for ERAC was issued to eliminate variability in both hospital course and in the treatment of postoperative pain. In this retrospective cohort analysis, we sought to identify whether adding ERAC protocols to our existing combination of neuraxial morphine and wound soaker catheters further reduced opioid consumption after cesarean delivery. Methods A retrospective cohort analysis of cesarean deliveries from 2015 through 2020 was performed. Deliveries were divided by analgesic pathway into four time-periods – time-point 1 [January 2015-April 2016, previous standard of care (control, N = 61)]: neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 2 [May 2016–May 2019, introduction of wound soaker (wound-soaker, N = 40)]: continuous wound catheter infusions of local anesthetic, neuraxial morphine in addition to as needed opioid and non-opioid analgesics; time-point 3 [May 2019–December 2019, wound soaker + early ERAC pathway (early ERAC, N = 78)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine, in addition to scheduled non-opioid analgesics (acetaminophen and ibuprofen) every 6 h, alternating in relation to one another so that one is given every 3 h; time-point 4 [January 2020–July 2020, wound soaker + late ERAC pathway (late ERAC, N = 57)]: continuous wound catheter infusion of local anesthetic, neuraxial morphine in addition to non-opioid analgesics scheduled together every 6 h (to facilitate periods of uninterrupted rest). Cumulative and average daily opioid use for postoperative days (POD) 1–4 were analyzed using ANOVA and a mixed effect model, respectively. Results Average daily opioid consumption and total cumulative opioid consumption POD 1–4 (morphine milligram equivalents) for both early and late ERAC groups (23.9 ± 31.1 and 29.4 ± 35.1) were significantly reduced compared to control and wound soaker groups (185.1 ± 93.7 and 134.8 ± 77.1) (p < .001). Conclusion The addition of ERAC protocols to our standardized multimodal analgesic regimen (local anesthetic wound infusion catheters and neuraxial morphine) for cesarean delivery significantly reduced postoperative opioid consumption.

Transversus Thoracic Muscle Plane Block for Attenuating the Haemodynamic Response to Median Sternotomy: A Case Series.

With the emergence of opioid-sparing and enhanced recovery pathways, cardiac anaesthesiologists are highly motivated to formulate regional analgesia-centric multimodal regimes, particularly prompted by the inclusion of safer fascial plane blocks to the analgesic repertoire. Ahead of the encouraging literature on perioperative pain relief with the thoracic fascial plane blocks, the fraternity continues to search for promising options for ensuring sternal analgesia. While the novel transversus thoracic muscle plane block emerges as the recent kid on the block for effective sternal analgesia (in the most anatomical sense of the matter), the sporadic case reports and feasibility studies primarily focus on an overall perioperative analgesic role of the block. The index case series describes a noteworthy experience with a pre-induction transversus thoracic muscle plane block administration for attenuating the intraoperative (particularly, median sternotomy) haemodynamic response in adult cardiac surgical patients, with a potential to translate into reduced perioperative fentanyl requirement, augmented recovery, and fast-tracking.

Does rapid mobilisation as part of an enhanced recovery pathway improve length of stay, return to function and patient experience post primary total hip replacement? A randomised controlled trial feasibility study

PurposeDay-zero ambulation may enable patients to recover and leave hospital quicker following total hip replacement (THR). The present randomised control feasibility study investigated the efficacy of day-zero ambulation as a physiotherapeutic intervention.MethodsThirty-six non-blinded adults aged 44–85 (Mean 67.1; SD 9.6 years) undergoing primary, uncomplicated THR were block randomized to either a control group (n = 18) with standard post-operative physiotherapy or an intervention group (n = 18) incorporating walking on the same day as the operation. Outcomes were length of hospital stay (LOS), time to reach functional milestones and achieve all physiotherapy discharge criteria, post-operative pain scores, complications and patient experience.ResultsParticipants treated with day-zero ambulation had reduced median hospital LOS of 1 day (p = .096), and median reduced times to reaching functional milestones of 39.7 h quicker to transfer to a chair (p < .001), 24.5 h quicker to walk 10 m (p = .009) and 26.4 h quicker to independently ascend and descend stairs (p = .01). Participants in the intervention group were deemed physiotherapy ready to leave hospital significantly earlier than control group (1.04 days, p = .015).ConclusionsDay-zero ambulation appears safe and may have clinically relevant effects in speeding patient functional recovery and facilitating earlier discharge from hospital.Implications for RehabilitationDay-zero ambulation following total hip replacement (THR) appears safe.Preliminary data suggest that day-zero mobilisation following THR could be efficacious and support the need for a fully powered randomised controlled trial.There may be a clinically relevant effect in speeding patient functional recovery and facilitating an earlier discharge from hospital.

A retrospective analysis of early discharge following minimally invasive colectomy in an enhanced recovery pathway.

There is increasing evidence to support discharge prior to gastrointestinal recovery following colorectalsurgery. Furthermore, many patients are discharged early despite being excluded from an ambulatory colectomy pathway. The objective of this study was to determine the outcomes of patients discharged early following laparoscopic colectomy in an enhanced recovery pathway (ERP). Aretrospective review of all adult patients undergoingelectivelaparoscopic colectomy at a single university-affiliated colorectal referral center(08/2017-06/2021)was performed.Patients were included if they had undergone elective laparoscopic colectomyor ileostomyclosure andexcluded if they had been enrolled in an ambulatory colectomy pathway. Patients were then divided into three groups: LOS=1 day, LOS 2-3 days, and LOS 4+ days. The main outcomeswere30-day emergencyroom (ER)visitsand readmissions. Reasons for inpatient stay per post-operative day (POD) werealso recorded. A total of497 patients were included[LOS1 n=63 (13%), LOS2-3 n=284 (57%), and LOS4+ n=150 (30%)]. There were no differences in patient characteristics, diagnosis, or procedure between the groups. Patients were discharged with gastrointestinal recovery (GI-3) in 54% LOS1 vs. 98% LOS2-3 vs. 100% LOS4+ (p<0.001). Shorter procedure duration, transversus abdominus plane block, and lower opioid requirements were associated with shorter LOS (p<0.001). The absence of flatus was the most common reason to keep patients hospitalized:61%onPOD1, 21%onPOD2,and8%onPOD3(p<0.001).There were no differences in30-dayemergencyvisits,orreadmissionbetween the groups.In the LOS1 group, there were no differences in outcomes between patients with full return of bowel function at discharge compared to those without. Discharge onPOD1was not associated withincreased emergency department use, complications, or readmissions.Importantly, full return of bowel function at discharge did not affect outcomes. There may be potential to expand eligibility criteria for ambulatory colectomy protocol.

Introduction of an enhanced recovery program for young adults undergoing posterior spinal fusion surgery for idiopathic scoliosis: a single-centre pilot study evaluating short term outcomes

Background: The large surgical incision and extensive tissue trauma in posterior spinal fusion for adolescent idiopathic scoliosis causes severe acute postoperative pain. Furthermore, posterior spinal fusion is associated with a risk of persistent postsurgical pain. Six months after posterior spinal fusion, the incidence of persistent postsurgical pain is as high as 22% of the patients. Optimizing pain management therefore remains crucial, but challenging. Objective: The study objective is to design and implement an enhanced recovery pathway for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion integrating all aspects of biopsychosocial care. Its outcomes are assessed, including its effect on postoperative pain and early mobilization. Design and settings: A prospective cohort study was performed at the Antwerp University Hospital. Methods: In December 2019, a prospective cohort study was set up in which an enhanced recovery pathway substitutes more than the patient controlled intravenous analgesia containing morphine postoperatively. This pathway consists of m/eHealth based psychological screening questionnaires, patient education, early mobilization, and a multimodal analgesia protocol consisting of preemptive gabapentin, an intraoperatively given single dose of methadone (0.2 mg kg-1), non-steroidal anti-inflammatory drugs, and acetaminophen. Results: We treated 25 adolescents (10 males and 15 females) with the developed enhanced recovery pathway with a mean age of 16.5 years (range 12-22). The mean number of spinal levels fused was 10 (range 6-13). Mean numerical rating scale scores were 4.17 at postoperative day 1, 4.46 at postoperative day 2, and 3.74 at postoperative day 3 in enhanced recovery pathway treated patients. Mean bladder catheterization duration was 3.04 days and enhanced recovery pathway patients stayed in the hospital for an average of 7.4 days. Conclusions: Using an enhanced recovery pathway for patients undergoing posterior spinal fusion could not only reduce the acute and chronic opioid consumption and its side effects, but could also result in less postoperative pain, shorter hospital stay and higher patient satisfaction. Further reevaluation and improvement focused on these variables will likely further improve the effectiveness of enhanced recovery pathways. Trial registration: ClinicalTrials.gov NCT04038229.

Lower extremity amputation protocol: a pilot enhanced recovery pathway for vascular amputees.

Vascular patients, an inherently older, frail population, account for >80% of major lower extremity amputations (transtibial or transfemoral) in the United States. Retrospective data have shown that early physical therapy and discharge to an acute rehabilitation facility decreases the postoperative length of stay (LOS) and expedites ambulation. In the present study, we sought to determine whether patients treated with the lower extremity amputation protocol (LEAP) will have improved outcomes. We performed a nonrandomized prospective study of vascular patients undergoingan amputation from January 2019 to February 2020. Patients who were nonambulatory or had undergone a previous contralateral major amputation were excluded. LEAP is a multidisciplinary team approach to the perioperative care of amputees using an outlined protocol. The prospective patients were compared with historic controls treated before the initiation of LEAP (January 2016 to December 2018). The primary outcomes included the postoperative LOS, time to receipt of a prosthesis, and time to ambulation. Of the 141 included patients, 130 were in the retrospective group and 11 in the LEAP group. The demographics and comorbidities were similar. All 11 LEAP patients had undergone a below-the-knee amputation, with 1 requiring revision to an above-the-knee amputation. Of the 130 retrospective patients, 122 (94%) had undergone a below-the-knee amputation, with 1 requiring revision to an above-the-knee amputation. The LEAP patients were more likely to be discharged to acute rehabilitation (100% vs 27%; P<.001), receive a prosthesis (100% vs 45%; P< .001), and ambulate with the prosthesis (100% vs 43%; P< .001). The LEAP patients had received physical therapy 2days sooner than had the retrospective controls (P= .006) with a shorter postoperative LOS (3days vs 6days; P< .001). Of the patients who had received their prosthesis, the LEAP patients had received their prosthesis, on average, 2months sooner than had the retrospective cohort (81± 39days vs 137± 97days, respectively; P= .002) and had ambulated with their prosthesis sooner (86± 53days vs 146± 104days, respectively; P=.002). No differences were found in the incidence of surgical site complications or unplanned readmissions between the two groups. The results from the present pilot study have demonstrated that the use of LEAP can significantly decrease postoperative LOS and expedite the time to independent ambulation with a prosthesis for vascular patients undergoing a major lower extremity amputation. These findings suggest a powerful ability to bridge the healthcare gap for this high-risk, underserved, and ethnically diverse population using a disease-specific standardized protocol.

Enhanced recovery after surgery (ERAS) in Latin America: The story so far.

Despite modern perioperative care, postoperative complications continue to play a significant role in patient's recovery. Implementation of enhanced recovery pathways has consistently demonstrated better outcomes, reduced complications, and improved length of stay across the globe. However, the literature is scarce with regard to the peaks and valleys encountered during the implementation of these programs in Latin America. The purpose of this review is to shed light on the development and establishment of enhanced recovery pathways in the region. Moreover, it discusses current challenges and future perspectives on perioperative optimization.

Early Postoperative Low Compliance to Enhanced Recovery Pathway in Rectal Cancer Patients.

Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.

Opioid Use After Colorectal Resection: Identifying Preoperative Risk Factors for Postoperative Use

IntroductionAppropriate prescribing practices are imperative to ensure adequate pain control, without excess opioid dispensing across colorectal patients. MethodsNational Surgical Quality Improvement Program, Kentucky All Scheduled Prescription Electronic Reporting, and patient charts were queried to complete a retrospective study of elective colorectal resections, performed by a fellowship-trained colorectal surgeon, from January 2013 to December 2020. Opioid use at 14 d and 30 d posthospital discharge converted into morphine milligram equivalents (MMEs) were analyzed and compared across preadmission and inpatient factors. ResultsOne thousand four hundred twenty seven colorectal surgeries including 56.1% (N = 800) partial colectomy, 24.1% (N = 344) low anterior resection, 8.3% (N = 119) abdominoperineal resection, 8.4% (N = 121) sub/total colectomy, and 3.0% (N = 43) total proctocolectomy. Abdominoperineal resection and sub/total colectomy patients had higher 30-day postdischarge MMEs (P < 0.001, P = 0.041). An operative approach did not affect postdischarge MMEs (P = 0.440). Trans abdominal plane blocks do not predict postdischarge MMEs (0.616). Epidural usage provides a 15% increase in postdischarge MMEs (P = 0.020). Age (P < 0.001), smoking (P < 0.001), chronic obstructive pulmonary disease (P = 0.006, < 0.001), dyspnea (P = 0.001, < 0.001), albumin < 3.5 (P = 0.085, 0.010), disseminated cancer (P = 0.018, 0.001), and preadmission MMEs (P < 0.001) predict elevated 14-day and 30-day postdischarge MMEs. ConclusionsWe conclude that perioperative analgesic procedures, as enhanced recovery pathway suggests, are neither predictive nor protective of postoperative discharge MMEs in colorectal surgery. Provider should account for preoperative risk factors when prescribing discharge opioid medications. Furthermore, providers should identify appropriate adjunct procedures to improve discharge opioid prescription stewardship.

N-Acetylcysteine and Postoperative Atrial Fibrillation: Reply.

We thank Dr. Kinoshita and Dr. Kawashima,1 and Dr. Wen, Dr. Huang, and Dr. Li2 for their comments and their interest in our work. In the comments from Kinoshita and Kawashima,1 they speculate that exposing our patients to a high fraction of inspired oxygen during one-lung ventilation negated the potential antioxidant effects of N-acetylcysteine during the 48 h after surgery. In our study, N-acetylcysteine was started only 1 to 2 h after the patient arrived at the postanesthesia care unit, where they had been receiving oxygen, by nasal cannula in most cases and occasionally by face mask, with varying degrees of inspired oxygen (typically in the range of 30 to 40%). In our practice, oxygen administration is usually titrated off as long as the patient is able to maintain an oxygen saturation measured by pulse oximetry greater than 94% on room air. Most lung-resection patients at our center are ambulating the day after surgery; among the patients in our study,3 some were discharged from the hospital upon completion of 48 h of N-acetylcysteine or placebo infusions. Although Dr. Kinoshita’s and Dr. Kawashima’s work in experimental animals is very interesting, it cannot be assumed that these findings apply to humans, nor is it warranted to speculate on which of the mechanisms that they identify apply to postoperative patients.Dr. Wen, Dr. Huang, and Dr. Li suggest the performance of a subgroup analysis by surgical modailty.2 However, because of the small number of patients within the groups and the lack of power to do so, we did not perform a secondary subgroup analysis of the incidence of atrial fibrillation by type of surgery, whether open or minimally invasive. We have previously shown that the extent of lung resection affects the incidence of atrial fibrillation, and it is for this reason that we included patients who underwent anatomical lung or esophageal resection.4 However, on the basis of our work—and the recommendations from the American Association for Thoracic Surgery task force on this topic—we disagree that the side of surgery affects the incidence of atrial fibrillation.5,6 We also disagree with the authors’ assertion that our finding of a lack of effect for N-acetylcysteine on inflammatory or oxidative stress markers is attributable to a lack of power. First, the number of patients in each of the randomized groups in our study was not small, and both groups were well balanced in terms of demographic and surgical characteristics. Second, all patients participated in an institutional enhanced recovery pathway and received similar intraoperative and postoperative opioid analgesics. Finally, the inflammatory and oxidative marker data were well distributed and did not require log transformation before statistical analysis. Considering that our use of N-acetylcysteine or placebo was intravenous over the course of 48 h and was started in the postanesthesia care unit long after intraoperative drugs, such as dexmedetomidine, were used, we do not believe that these pharmacologic agents influenced our findings.Support was provided solely from institutional and/or departmental sources.Dr. Jones serves as a consultant for AstraZeneca (Cambridge, United Kingdom) and on a Clinical Trial Steering Committee for Merck (Kenilworth, New Jersey). The other authors declare no competing interests.

GPP06 Presentation Time: 8:50 AM: Enhanced Recovery Pathway (ERP) in Patients Undergoing Brachytherapy for Gynecologic Cancer (GYN-BT)

<h3>Purpose</h3> ERPs have been adopted by many surgical specialties and have demonstrated improved outcomes, including shorter hospital stay, decreased healthcare costs, improved time to functional recovery and patient satisfaction.¹ There is no current literature evaluating ERP for patients undergoing brachytherapy as part of their radiation treatment. We plan to implement an ERP to standardize and optimize the peri-operative phase and to determine the impact on patient outcomes. <h3>Methods</h3> A single institution, prospective study evaluating the outcomes of patients undergoing GYN-BT before (33 patients) and after (33 patients) the implementation of an ERP. The ERP will include multidisciplinary interventions that span the pre-, intra-, and post-operative phases; including pre-habilitation, early referral to social work and psychiatric services, patient/caregiver education, pre-operative carbohydrate-loading, goal directed fluids, and opioid-sparing analgesia. Questionnaires (MDASI-PeriOp-GYN, EORTC QLQ-C30, and EORTC QLQ-CX24) to assess patient reported outcomes (PROs) at baseline, post-brachytherapy, and 60-day follow-up are collected. MDASI-PeriOp-GYN consists of 28 questions, scored from 0 to 10, with a score ≥7, considered severe. <h3>Results</h3> Twenty patients have enrolled and completed baseline PROs, of these 7 have completed post-brachytherapy surveys. Baseline mean total score was 3.07 (range, 1.3-7.9) and post-BT was 2.78 (range, 0.1-5.5). Mean number of severe events at baseline was 7 vs. 5.7 after brachytherapy. Independent symptom scores for the baseline population were worse for distress (3.7 vs 3), sadness (3.9 vs 2.4), ability to work (4.9 vs 4.4), relations with others (2.7 vs 2.1), pain (2.6 vs 2.0), constipation (3.1 vs 2.0) and bloating (3.1 vs 1.9); while post-BT scores were worse for dysuria (1.4 vs 0), diarrhea (4.6 vs 4.1), vomiting (1.4 vs 1.1), dizziness (2.1 vs 1.4), fatigue (6.1 vs 5.6), and hot flashes (2.9 vs 1.7) (Figure 1). <h3>Conclusion</h3> Female patients with gynecologic malignancies represent a population with high-symptom burden and social stress throughout treatment. Baseline data show that patient experience may be improved through early focus on social support and pain control and optimization of symptom management after brachytherapy; including nausea/vomiting, diarrhea, dehydration, and urinary toxicity. Our proposed ERP plans to address both of these initiatives.

Development of a predictive model for unplanned Intensive Care Unit admission after pancreatic resection within an enhanced recovery pathway

Development of a predictive model for unplanned Intensive Care Unit admission after pancreatic resection within an enhanced recovery pathway

Benefits of Implementing an Enhanced Recovery After Surgery Protocol in Ambulatory Surgery.

Enhanced recovery after surgery (ERAS) protocols in orthopaedic surgery have garnered significant focus due to their ability to control pain adequately in the immediate postoperative window, allowing for earlier mobilization, shorter hospital stays, and fewer complications. Virginia Commonwealth University created a multimodal pain management approach in which patients receive a preoperative femoral nerve block followed by periarticular intraoperative local injection anesthesia consisting of bupivacaine, ketamine, and ketorolac. We hypothesized that implementation of the ERAS protocol will decrease postoperative pain scores, decrease recovery time in the postanesthesia care unit (PACU), and decrease opioid use in anterior cruciate ligament (ACL) reconstruction. Cohort study; Level of evidence, 3. Two patient cohorts were involved: before ERAS implementation (pre-ERAS) and after (post-ERAS). Patients with ACL reconstruction only and patients with ACL reconstruction with meniscal repair were analyzed separately. Post-ERAS patients received an intraoperative periarticular injection of bupivacaine, ketamine, and ketorolac and a postoperative multimodal pain regimen. Outcomes included time spent in the PACU, short-term and long-term opioid consumption, and pain score at discharge from the PACU. Compared with pre-ERAS patients, post-ERAS patients had decreased pain (2.1 vs 0.84 out of 10, respectively), spent less time in the PACU (79.4 vs 62.8 minutes, respectively), and had less opioid consumption in the immediate postoperative period (4.55 vs 2.26 total morphine milligram equivalents [MMEs], respectively) (P < .001 for all). After ERAS implementation, long-term MME use decreased from 410 to 321 between 0 and 2 weeks postoperatively, 92.6 to 1.69 between 2 and 6 weeks, and 494.5 to 323 between 0 and 6 weeks (P < .001 for all). All domains showed significant improvements for both the ACL and the ACL plus meniscal repair cohorts, with the exception of pain at discharge in the ACL plus meniscal repair group. The study findings suggest that an enhanced recovery pathways protocol that includes a standardized intraoperative periarticular bupivacaine, ketamine, and ketorolac injection improves pain scores in the immediate postoperative window, decreases opioid consumption, and reduces recovery time in the PACU for patients undergoing ACL reconstruction.

Baseline Characteristics of Patients Undergoing Brachytherapy for Gynecologic Cancer (GYN-BT) and the Role for an Enhanced Recovery Pathway (ERP)

<h3>Purpose/Objective(s)</h3> ERPs have been adopted by many surgical specialties and have demonstrated improved outcomes, including shorter hospital stay, decreased healthcare costs, improved time to functional recovery and patient satisfaction.¹ There is no current data evaluating ERP for patients undergoing brachytherapy. We plan to implement an ERP for patients with gynecologic malignancies, who will receive brachytherapy, with the goal to standardize and optimize the peri-operative phase and evaluate the impact on patient experience. <h3>Materials/Methods</h3> A single institution, prospective study evaluating the outcomes of patients undergoing GYN-BT before (33 patients) and after (33 patients) the implementation of an ERP. The ERP will include multidisciplinary interventions that span the pre-, intra-, and post-operative phases; including pre-habilitation, early referral to social work and psychiatric services, patient/caregiver education, pre-operative carbohydrate-loading, goal directed fluids, and opioid-sparing analgesia. Questionnaires to assess patient reported outcomes (PROs) at baseline, post-brachytherapy, and 60-day follow-up are collected. The EORTC QLQ-C30 consists of 30 items scored on a 4-point Likert scale and linearly transformed to a score, ranging from 0-100. Higher scores for functional scales and global health represent a favorable outcome, whereas a higher score for a symptom is unfavorable. A difference >10 was considered significant. <h3>Results</h3> Sixteen patients have been enrolled on study and completed baseline PRO questionnaires. Mean EORTC-QLQ-C30 global health score was 41.7, comparing unfavorably to the reference population of females with any cancer diagnosis²(59.3). Social functioning was worse (58.3) compared to the reference population (72.1), but there was no significant difference in physical, role, emotional or cognitive functioning. Additionally, this patient population had a significantly higher symptom burden, specifically fatigue (48.6 vs 37.7), nausea/vomiting (21.9vs 10.8), appetite loss (35.4 vs 23.8), and diarrhea (20.8 vs 9.3). Notably, mean score for financial difficulties was 45.8, more than double the reference value of 17.5. A significant proportion of patients described depression (56.3%), worry (68.8%) and interference with family life (62.5%). <h3>Conclusion</h3> Baseline data show that female patients with gynecologic malignancies represent a population with high-symptom burden and social stress. This data highlights the significant need for improved social support and multi-disciplinary care. We propose an ERP, with pre-habilitation and medical optimization, in combination with early referral to social work and psychiatric resources to standardize and improve care for this high-risk patient population.