Implementation Of Enhanced Recovery After Surgery Protocol Research Articles

Post-Caesarean Rehabilitation: Evaluation Of Practices

Background: Early Rehabilitation, "Fast-Track Surgery," or Enhanced Recovery After Surgery (ERAS) protocols have shown significant benefits in various surgical procedures, including caesarean sections. These protocols aim to expedite recovery, reduce hospital stays, and minimize complications through a multidisciplinary approach. Despite their proven effectiveness, the implementation of such protocols in post-caesarean recovery remains uneven and warrants further investigation. Objective: This study aims to evaluate the current practices of early post-caesarean rehabilitation, focusing on pain management, early nutritional intake, mobilization, and mother-child bonding to identify gaps and opportunities for improvement. Methods: A prospective observational multicenter study was conducted between January and April 2021 at the Maternity and Neonatology Center of Tunis and the Principal Military Hospital of Tunis. The study involved 170 parturients undergoing caesarean section under spinal anesthesia, excluding those with contraindications. Data were collected using a standardized form, covering demographic details, medical history, surgical and anesthesia details, and post-operative recovery metrics, including pain assessment (VAS scores), timing of first oral intake, mobilization, and mother-child bonding. Statistical analysis was performed using SPSS version 25. Results: The average age of parturients was 30 ± 5 years. A majority (73%) of caesarean sections were planned, with surgery durations mostly within one to two hours. Post-operative pain management revealed that 73% of parturients reported a VAS ≤ 2 at the 3rd hour, but 77% experienced a VAS ≥ 4 by the 6th hour. Early oral intake was initiated by 66% of parturients before the 6th hour for liquids and before the 12th hour for light meals. The urinary catheter was removed before the 12th postoperative hour in 56% of cases. Early mobilization was achieved by 67% of parturients before the 12th hour, and 82% were breastfeeding naturally, with 79.7% satisfaction with care. Conclusion: The study highlights the partial implementation of ERAS protocols in post-caesarean recovery, pinpointing areas for improvement, particularly in pain management, early oral intake, and mobilization. A standardized approach to early post-caesarean rehabilitation could significantly enhance maternal and neonatal outcomes, reduce complications, and improve patient satisfaction.

Enhanced recovery after elective spinal surgery: an Australian pilot study.

The principles of enhanced recovery after surgery (ERAS) aim to reduce the physiological stress of surgery which in turn improve clinical and health economic outcomes. There is ample evidence in literature supporting ERAS methodologies in other surgical specialties, but its adoption in spinal surgery, especially in Australia remains in infancy. The aim of this project is to describe the early experience with an evidence-based ERAS pathway for simple spine surgery, a first of its kind in Australia. An ERAS protocol was designed using an evidenced-based review of the literature. The authors then conducted a prospective cohort analysis looking at outcome of patients undergoing elective spinal (lumbar and cervical) decompression surgery under ERAS principles by a single surgeon on the Westmead Hospital Campus between March 2021 to May 2023. Primary outcomes were patient length of stay (LOS), patient reported pain and disability scores and complications (including readmissions within 30 days and re-operation within 6 months). Secondary outcomes included predictors of failure for same-day discharge. A total of 52 patients underwent spinal decompression surgeries under the ERAS protocol. Overall 43 out of 52 patients (83.7%) were successfully discharged on the same day as their surgery. Patient reported outcomes were improved at 6 weeks and 6 months confirming durability of intervention. The rates of complications were similar to literature reported rates for simple lumbar or cervical decompression procedures and there were no readmissions within 30 days or re-operations within 6 months of surgery. Being of non-English speaking background [odds ratio (OR) =6.08, P=0.04] and from home alone (OR =10.25, P=0.03) were predictors of failure of same day discharge in this small cohort. Implementation of ERAS protocols for simple spinal decompression surgeries is feasible and produces durable improved patient outcomes while reducing LOS in hospitals. Patient social factors can be predictive of lack of compliance.

A meta-analysis of the implementation of enhanced recovery after surgery pathways in anterior cervical spine surgery for degenerative cervical spine diseases.

To systematically evaluate the perioperative effects of enhanced recovery after surgery (ERAS) protocol on anterior cervical spine surgery by means of meta-analysis. According to the PRISMA guidelines, the article's search on the China National Knowledge Infrastructure (CNKI), Wanfang data resource system, VIP, PubMed database and Cochrane library was conducted to identify clinical studies investigating the effects of ERAS protocols on anterior cervical spine surgery. A quantitative meta-analysis was performed for the clinical outcomes extracted from the studies that met inclusion criteria. Of the 21 studies identified from the article search, 10 studies met inclusion criteria. The meta-analysis showed shorter length of stay (LOS) (MD = -2.16, 95% CI (-2.57, -1.75), P < 0.00001) and higher patient satisfaction for the ERAS protocols (OR = 3.13, 95% CI (1.97, 4.98), P < 0.00001). Furthermore, ERAS programs led to significant decreases in cost (MD = -0.81, 95% CI (-1.08, -0.53), P < 0.00001) and complication rates (OR = 0.15, 95% CI (0.08, 0.27), P < 0.00001), but no difference in 90-day readmission (OR = 0.63, 95% CI (0.30, 1.35), P = 0.24). The data of this study suggest that the implementation of ERAS protocol decreases LOS, cost and complications rates and improve satisfaction for the patients undergoing anterior cervical spine surgery. To support the practice use of ERAS in anterior cervical spine surgery further, controlled trials will be indispensable.

Comparison of Enhanced Recovery After Surgery (ERAS) protocol versus Conventional Approach for Laparoscopic Cholecystectomy: An Interventional Study

Introduction: Laparoscopic cholecystectomy is considered the gold standard for benign gallbladder disease due to its minimal invasiveness, reduced bleeding, and rapid recovery. Enhanced Recovery After Surgery (ERAS) protocols, recognised for lowering surgical stress and complications, are increasingly adopted for their postoperative benefits. Aim: To assess and compare postoperative outcomes in laparoscopic cholecystectomy patients undergoing ERAS versus conventional approaches. Materials and Methods: This prospective interventional study was conducted at the Surgery Department of Mahatama Gandhi Medical College and Research Institute, Puducherry, India from January 2021 to June 2022. All patients above 18 years of age undergoing laparoscopic cholecystectomy with American Soceity of Anaesthesiologists (ASA) I and II were included. A total of 90 subjects, 45 subjects in the Group A (ERAS protocol) and 45 subjects in the Group B (Conventional approach), were included based on computer-generated random numbers with concealment of allocation. Key parameters, including length of hospital stay, morbidity, postoperative pain, and protocol compliance, were evaluated between both groups. Continuous variables were presented as means with standard deviations and analysed using unpaired t-tests. Categorical variables were expressed as percentages and compared using chisquare tests. Results: The mean age of the study population in ERAS and conventional was 41.3±7.9 years and 41.6±9.6 years, respectively. Similarly, 17 male participants were from the ERAS group and 15 were from the conventional group, whereas among female participants 28 were from the ERAS group and 30 were from the conventional group. The ERAS group demonstrated significant advantages: shorter hospital stays (91.2% vs. 73.4%, p=0.0274), lower Grade 1 morbidity (p=0.0213), and reduced postoperative pain (p=0.0001). Conclusion: The ERAS group exhibited notable benefits, including a shorter hospital stay, reduced morbidity, and lower postoperative pain. These findings suggest the potential for enhanced recovery outcomes with ERAS protocol implementation in laparoscopic cholecystectomy patients.

The iterative implementation of a comprehensive enhanced recovery after surgery protocol in all spinal surgery in Korea: a comparative analysis of clinical outcomes and medical costs between primary spinal tumors and degenerative spinal diseases.

Most studies on the enhanced recovery after surgery (ERAS) protocol in spine surgery have focused on patients with degenerative spinal diseases (DSDs), resulting in a lack of evidence for a comprehensive ERAS protocol applicable to patients with primary spine tumors (PSTs) and other spinal diseases. The authors had developed and gradually adopted components of the comprehensive ERAS protocol for all spine surgical procedures from 2003 to 2011, and then the current ERAS protocol was fully implemented in 2012. This study aimed to evaluate the impact and the applicability of the comprehensive ERAS protocol across all spine surgical procedures and to compare outcomes between the PST and DSD groups. Adult spine surgical procedures were conducted from 2003 to 2021 at the Seoul National University Hospital Spine Center and data were retrospectively reviewed. The author divided the study periods into the developing ERAS (2003-2011) and post-current ERAS (2012-2021) periods, and outcomes were compared between the two periods. Surgical procedures for metastatic cancer, infection, and trauma were excluded. Interrupted time series analysis (ITSA) was used to assess the impact of the ERAS protocol on medical costs and clinical outcomes, including length of stay (LOS) and rates of 30-day readmission, reoperation, and surgical site infection (SSI). Subgroup analyses were conducted on the PST and DSD groups in terms of LOS and medical costs. The study included 7143 surgical procedures, comprising 1494 for PSTs, 5340 for DSDs, and 309 for other spinal diseases. After ERAS protocol implementation, spine surgical procedures showed significant reductions in LOS and medical costs by 22% (p = 0.008) and 22% (p < 0.001), respectively. The DSD group demonstrated a 16% (p < 0.001) reduction in LOS, whereas the PST group achieved a 28% (p < 0.001) reduction, noting a more pronounced LOS reduction in PST surgical procedures (p = 0.003). Medical costs decreased by 23% (p < 0.001) in the DSD group and 12% (p = 0.054) in the PST group, with a larger cost reduction for DSD surgical procedures (p = 0.021). No statistically significant differences were found in the rates of 30-day readmission, reoperation, and SSI between the developing and post-current ERAS implementation periods (p = 0.65, p = 0.59, and p = 0.52, respectively). Comprehensive ERAS protocol implementation significantly reduced LOS and medical costs in all spine surgical procedures, while maintaining comparable 30-day readmission, reoperation, and SSI rates. These findings suggest that the ERAS protocol is equally applicable to all spine surgical procedures, with a more pronounced effect on reducing LOS in the PST group and on reducing medical costs in the DSD group.

The Impact of Enhanced Recovery After Surgery Protocol Implementation on Postoperative Pain Management in the Era of Opioid Crisis: The Post- Chemotherapy Open RPLND Experience.

Enhanced Recovery After Surgery (ERAS) protocols have been proven to optimize postoperative outcomes; however, misuse of opioid analgesics can still hinder postoperative recovery due to related side effects and potential complications. To determine if the implementation of ERAS protocol in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) patients could help with reducing postoperative pain and opioid use. A case-control study of consecutive testicular cancer patients with indications for PCRLPND, who were offered Conventional Post-operative Management (CPM) or ERAS protocol. Outcomes of interest included Visual Analogue Scale (VAS)-assessed pain level at postoperative days 3, 7, and 30, and Morphine-Equivalent Doses (MEDs)/postoperative day. Intraoperative parameters and postoperative complications were recorded. Parametric and non-parametric tests were used for statistical analysis. In total, 100 opioid-naïve PC-RPLND patients were studied. CPM and ERAS groups (36 and 64 patients, respectively) had similar demographic and baseline clinical characteristics). ERAS group patients had significantly lower blood loss (p = 0.005), blood transfusion rate (p < 0.001), and duration of the procedure (p < 0.001). Post-operative complications were comparable between groups. Nausea and bowel disorders were numerically but not statistically more frequent in the CPM group. ERAS patients had shorter mean hospital stay (5.3 ± 1.4 vs. 7.4 ± 1.6 days, p < 0.001), lower daily MEDs (4.73 ± 2.63 vs. 7.04 ± 2.29, p < 0.001), and lower VAS scores on post-operative day 7 (3.89 ± 1.07 vs. 4.67 ± 1.17, p = 0.001). Post-operative pain was similar between groups on post-operative days 3 and 30. Systematic implementation of ERAS protocol after PC-RPLND improves pain management, optimizes patient recovery, and prevents over-prescription of opioid analgesics.

Early versus delayed mobilization after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of efficacy and safety.

A central tenet of Enhanced Recovery After Surgery (ERAS) is evidence-based medicine. Survivors of aneurysmal subarachnoid hemorrhage (aSAH) constitute a fragile patient population prone to prolonged hospitalization within neurointensive care units (NICUs), prolonged immobilization, and a range of nosocomial adverse events. Potentially, well-monitored early mobilization (EM) could constitute a beneficial element of ERAS protocols in this population. Therefore, the objective was to summarize the available evidence on EM strategies in patients with aSAH. The authors retrieved prospective and retrospective studies that reported efficacy or safety data on EM (defined as EM in the NICU starting ≤ 7 days after ictus) versus delayed mobilization (DM) (any strategy that comparatively delayed mobilization) after aSAH and were published after January 1, 2000, in PubMed/MEDLINE, Embase, and the Cochrane Library. Random-effects meta-analysis was performed. Ten studies analyzing 1292 patients were included for quantitative synthesis, including 1 randomized, 1 prospective nonrandomized, and 8 retrospective studies. Modified Rankin Scale scores at discharge were not different between the EM and DM groups (mean difference [MD] [95% CI] -0.86 [-2.93 to 1.20] points, p = 0.41). Hospital length of stay in days was markedly reduced in the EM group (MD [95% CI] -6.56 [-10.64 to -2.47] days, p = 0.002). Although there was a statistically significant reduction in radiological vasospasms (OR [95% CI] 0.65 [0.44-0.97], p = 0.03), the reduction in clinically relevant vasospasms was nonsignificant (OR [95% CI] 0.63 [0.31-1.26], p = 0.19). The odds of shunting were significantly lower in the EM group (OR [95% CI] 0.61 [0.39-0.95], p = 0.03). The rates of mortality, pneumonia, and thrombosis were similar among groups (p > 0.05). Due to a lack of high-quality studies, vastly varying protocols, and resulting statistical clinical and statistical heterogeneity, the level of evidence for recommendations regarding EM in patients with aSAH remains low. The currently available data indicated that mobilization within the first 5 days after aneurysm repair was feasible and safe without significant excessive adverse events, that neurological outcome with EM was almost certainly not worse than with prolonged immobilization, and that there was likely at least some reduction in length of hospital stay. Radiological and clinical vasospasms were not more frequent-with signals even trending toward a decrease-in patients who mobilized early. Higher-quality studies and implementation of full ERAS protocols are necessary to evaluate efficacy and safety with a higher level of evidence and to guide practical implementation through increased standardization. Clinical trial registration no.: CRD42023432828 (www.crd.york.ac.uk/prospero).

The Enhanced Recovery After Surgery protocol for the surgical management of craniosynostosis: Lausanne experience.

Over the past decade, the Enhanced Recovery After Surgery (ERAS) program has demonstrated its effectiveness and efficiency in improving postoperative care and enhancing recovery across various surgical fields. Preliminary results of ERAS protocol implementation in craniosynostosis surgery are presented. An ERAS protocol was developed and implemented for cranial pediatric neurosurgery, focusing on craniosynostosis repair. The study incorporated a pre-ERAS group consisting of a consecutive series of patients who underwent craniosynostosis repair surgery prior to the implementation of the ERAS protocol; the results were compared with a consecutive group of patients who had been prospectively collected since the introduction of the ERAS for craniosynostosis protocol. The safety, feasibility, and efficiency of the ERAS protocol in pediatric neurosurgery was evaluated, through the collection of clinical data from the pre-, intra-, and postoperative phase. Surgery-related complications were evaluated according to the Clavien-Dindo classification. Costs of the stays were obtained using a microcosting approach. A total of 35 pre-ERAS patients and 10 ERAS patients were included. Scaphocephaly was the most common pathology in both groups. The overall compliance with the pre-, intra-, and postoperative criteria significantly increased-from 35.5%, 64.4%, and 54.7%, respectively, in each phase to 94%, 90%, and 84% (p < 0.001). The authors noticed a reduction in the average opioid dose used per patient in the ERAS group (p = 0.004), and they observed a trend toward a decreased mean length of stay from 5.2 days in the pre-ERAS group to 4.6 days in the ERAS group, without an increase of the rate of readmission within 30 days of surgery. The rate of complications decreased but this difference was not statistically significant. The hospital costs lowered significantly: from 21,958 Confederatio Helvetica Francs (CHF) in the pre-ERAS group to 18,936 CHF in the ERAS group (p = 0.02). The ERAS protocol represents a safe and cost-effective tool for the perioperative management of craniosynostosis. It showed its positive impact on the analgesia provided and on the reduction of in-hospital costs for these patients. ERAS protocols may thus be interesting options in the pediatric neurosurgical field.

Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness.

Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patientsatisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review.

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS).

Enhanced recovery after surgery (ERAS) protocols have largely been incorporated into practice in high-income settings due to proven improvement in perioperative outcomes. We aimed to review the implementation of ERAS protocols and other perioperative optimisation strategies in low- and middle-income countries (LMICs) and their impact on length of hospital stay (LOS). We searched MEDLINE, PubMed, Global Health (CABI), WHO Global Index Medicus, Index Medicus, and Latin American and Caribbean Health Sciences Literature (LILACS) for studies incorporating ERAS or other prehabilitation approaches in LMICs. We conducted a pooled analysis of LOS using a random-effects model to evaluate the impact of such programs. This systematic review was pre-registered on PROSPERO. We screened 1205 studies and included 70 for a full-text review; six were eligible for inclusion and five for quantitative analysis, two of which were randomised controlled trials. ERAS was compared to routine practice in all included studies, while none implemented prehabilitation or other preoperative optimisation strategies. Pooled analysis of 290 patients showed reduced LOS in the ERAS group with a standardised mean difference of -2.18 (95% confidence interval (CI) = -4.13, -.0.05, P < 0.01). The prediction interval was wide (95% CI = -7.85, 3.48) with substantial heterogeneity (I2 = 94%). Perioperative optimisation is feasible in LMICs and appears to reduce LOS, despite high levels of between-study heterogeneity. There is a need for high-quality data on perioperative practice in LMICs and supplementary qualitative analysis to further understand barriers to perioperative optimisation implementation. PROSPERO: CRD42021279053.

Enhanced Recovery After Surgery (ERAS) protocols following emergency intra-abdominal surgery: A systematic review and meta-analysis protocol.

The aim of this systematic review and meta-analysis is to evaluate whether the implementation of Enhanced Recovery After Surgery (ERAS) protocols for adult patients undergoing emergency intra-abdominal surgery decreases postoperative length of stay, postoperative morbidity, and mortality compared to conventional perioperative care. A systematic review and meta-analysis will be performed and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). It has been registered on the International Prospective Register for Systematic Reviews (PROSPERO; CRD42023391709). A comprehensive, electronic search strategy will be used to identify studies published and indexed in MEDLINE, EMBASE, Web of Science, CENTRAL, and Pubmed databases since their inception. Trial registries and references of included studies and pertinent previous systematic reviews will also be searched. Studies will be included if they are randomized controlled trials or cohort studies evaluating adult patients undergoing emergency intra-abdominal surgery and comparing ERAS or modified ERAS protocols to conventional perioperative care and report one of the following outcomes: postoperative length of stay, overall 30-day morbidity, 30-day mortality, 30-day infectious morbidity, prolonged postoperative ileus, return of bowel function, and 30-day readmissions. A meta-analysis will be performed using a random effects model for all comparative data using Cochrane Review Manager 5.3 (London, United Kingdom). ERAS protocols have become standard of care for patients undergoing elective surgery. Their use in the setting of emergency surgery is far less common. The aim of this systematic review and meta-analysis is to assess whether there are benefits in patient important outcomes with the implementation of ERAS protocols for patients undergoing emergency intra-abdominal surgery. Ultimately, we hope to promote their use and further large randomized controlled trials evaluating emergency surgery ERAS programs. CRD42023391709.

Readmissions trends following radical cystectomy for bladder cancer unchanged in the era of enhanced recovery after surgery (ERAS) protocols.

To provide nationally representative estimates of contemporary trends in readmission rates, readmission location (index vs. nonindex hospital), and causes of readmission following radical cystectomy (RC) in the era of enhanced recovery after surgery (ERAS) protocol implementation. Patients with bladder cancer who underwent RC were identified in the Nationwide Readmissions Database (2016-2019). Yearly trends in 30-day and 90-day readmission rates and readmission causes were assessed in the whole cohort and subset of patients who underwent RC at high volume centers (>22 RCs/year). Multivariable logistic regression was used to determine predictors of index readmission, nonindex readmission, death during readmission, and experiencing a second readmission. Among the 20,957 RC patients, the 30-day and 90-day readmission rates were 23.5% (n = 4,931) and 39.1% (n = 7,987), respectively. For 90-day readmissions, 27.6% (n = 2,206) were to nonindex hospitals. During the study period, there was no significant change in the yearly 30-day or 90-day readmission rates and percentage of readmissions to nonindex hospitals (all p > 0.05). This was also true in the subset of patients who underwent RC at high volume centers. The only significant change in causes of readmission during the study period was wound readmissions (2.7% in 2016 vs. 5.1% of readmissions in 2019, p = 0.02). During the era of ERAS protocol implementation, in this nationally representative study, most causes of readmission and both 30 and 90-day readmission rates were unchanged, even at high volume RC centers. Moving forward, novel interventions are needed which focus on the postdischarge recovery period to help decrease readmission rates following RC.

An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay

Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery. A total of 79 patients who underwent single-stage facial feminization surgery before (n=38) or after (n=41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes. Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p<0.001), reported lower pain scores (2.5±1.8 versus 3.7±1.6, p=0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1]h, p<0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery. The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.

Results following implementation of a cardiac surgery ERAS protocol.

Adequate peri-operative care is essential to ensuring a satisfactory outcome in cardiac surgery. In this study, we look at the impact of evidence-based protocols implemented at Stanford Hospital. This study is a single-center, retrospective analysis. Enhanced recovery after surgery (ERAS) protocols were implemented for CABG/Valve and open Aortic operations on 11/1/2017 and 6/1/2018, respectively. Propensity-score matched analysis was used to compare 30-day mortality and morbidity of patients from the pre- and post-implementation cohorts. Secondary endpoints included the following: total hospital length of stay (LOS), ICU LOS, time until extubation, and time until urinary catheter removal. After the implementation of the ERAS protocols for CABG/Valve operations, the median post-op LOS decreased from 7.0 days to 6.1 days (p<0.001), and median ICU LOS decreased from 69.9 hours to 54.0 (p = 0.098). There was no significant decrease in 30-day mortality (4% to 3.3%, p = 0.47). However, the incidence of post-op ventilator associated pneumonia (VAP) decreased from 5.0% to 2.1% (p = 0.003) and post-op urinary tract infections (UTIs) from 8.3% to 3.6% (p<0.001). Patients who underwent open aortic procedures experienced an improvement in 30-day mortality (7% to 3.5%, p = 0.012), decrease in median ICU LOS (91.7 hours to 69.6 hours, p<0.001), and a decrease in duration of mechanical ventilation (79.3 hours to 46.3 hours, p = 0.003). There was a decrease in post-op LOS, post-op VAP, and post-op UTI, although statistical significance was not attained. At Stanford Hospital, ERAS pathways have led to decreased morbidity and LOS while simultaneously improving mortality amongst our critically ill patient population.

Enhanced Recovery After Surgery (ERAS) Protocols for Improving Outcomes for Patients Undergoing Major Colorectal Surgery.

Enhanced Recovery After Surgery (ERAS) protocols have gained recognition as a perioperative care approach for patients undergoing major colorectal surgery. This systematic review aims to evaluate the effects of ERAS protocols on outcomes in this patient population. A systematic search was conducted in PubMed, Cochrane Library, and Embase databases for studies published between January 2010 and September 2021. Inclusion criteria encompassed studies assessing the impact of ERAS protocols on patients undergoing major colorectal surgery. Data were extracted, and a qualitative synthesis of the included studies was performed. A total of 18 studies met the inclusion criteria. The implementation of ERAS protocols was associated with several positive outcomes. Compared to traditional care, ERAS protocols significantly reduced the length of hospital stay (mean difference [MD]: -1.64 days, 95% confidence interval [CI]: -2.21 to -1.08, p<0.00001), postoperative complications (odds ratio [OR]: 0.57, 95% CI: 0.46 to 0.71, p<0.00001), and readmission rates (OR: 0.57, 95% CI: 0.38 to 0.85, p=0.006). ERAS protocols also led to a shorter time to return of bowel function (MD: -0.74 days, 95% CI: -1.03 to -0.45, p<0.00001), time to first mobilization (MD: -0.55 days, 95% CI: -0.82 to -0.28, p<0.0001), and time to first oral intake (MD: -0.62 days, 95% CI: -0.95 to -0.28, p=0.0003). Additionally, patients reported higher satisfaction levels with the implementation of ERAS protocols (MD: 1.02, 95% CI: 0.19 to 1.86, p=0.02). This systematic review demonstrates that the implementation of ERAS protocols in major colorectal surgery is associated with improved outcomes. ERAS protocols lead to reduced hospital stays, lower postoperative complications, and decreased readmission rates. Furthermore, they facilitate faster recovery of bowel function, mobilization, and oral intake. Patients also express higher satisfaction levels with ERAS implementation. Healthcare providers should consider adopting ERAS protocols to optimize perioperative care in patients undergoing major colorectal surgery.

Significant Reduction in Length of Stay in Deep Inferior Epigastric Perforator Flap Breast Reconstruction With Implementation of Multimodal ERAS Protocol.

Enhanced Recovery After Surgery (ERAS) implementation achieves earlier recovery, reduced hospital length of stay (LOS) and improved outcomes in patients undergoing deep inferior epigastric perforator (DIEP) free flaps. We sought to review our ERAS protocols and their impact on our patients' LOS compared with the literature. This was a retrospective review of a single surgeon's experience from 2017 to 2021 of patients undergoing DIEP free-flap breast reconstruction with LOS as the primary outcome. Complication rates and patient demographics are described as secondary outcomes. One hundred twenty-one patients underwent DIEP free-flap breast reconstruction. After adapting ERAS protocols, there has been a 0.98 [SD, 0.17; confidence interval [CI], -1.3 to -0.64; P < 0.001) day decrease in length of stay comparing pre-ERAS to post-ERAS implementation. Length of stay has routinely decreased from an average discharge on day 4.17 (SD, 1.1; range, 3-8 days) in 2017 to discharge on day 2.91 (SD, 1.1; range, 1-5 days) in 2021. Seventy-five percent of patients in 2021 were hospitalized for 3 or fewer days compared with 75% of patients in 2017 hospitalized for 4 or more days. One patient experienced a flap failure. Our study supports successful discharge on postoperative days 2-3 compared with postoperative days 3-4 in the current literature. The implementation of our ERAS protocol for DIEP free-flap breast reconstruction has resulted in a shorter LOS compared with contemporary literature. The ERAS protocols can be efficiently adopted in microsurgical DIEP breast reconstruction to achieve a shorter LOS without jeopardizing patient outcomes.

Adjusted enhanced recovery after surgery (ERAS) protocol in colorectal surgery at dr. Cipto Mangunkusumo General Hospital, Jakarta

Background: The Enhanced Recovery After Surgery (ERAS) strategy has been proven to be successful in lowering hospital perioperative problem rates and postoperative length of stay (LOS) in colorectal surgery. The inability of dr. Cipto Mangunkusumo General Hospital's to implement all of the components of the ERAS protocol was attributed to three major factors: patient-related (compliance), physician-related (silo mentality), and hospital-related (long waiting lists and inability to provide required facilities). This study aims to determine how well the ERAS procedure can be partially implemented to achieve the ERAS objective. Methods: This study is a cross-sectional study involving sixty-three colorectal patients who underwent surgical procedures between 2015 and 2017 were evaluated retrospectively for complete ERAS protocol implementation. The complete implementation is the ability to accomplish all 15 ERAS components. Demographic, clinical, and total LOS data were also collected from medical records. These samples were analyzed using univariate analysis and Pearson correlation tests to determine the relationship between the number of ERAS components that accomplish per subject and the LOS of the patient. Results: Eleven out of 15 ERAS components were implemented on 63 patients. The majority of the cohort were female (male-to-female ratio of 1:1.2) with an average age of 53 years, 0% mortality, 7.9% morbidity (1.6%, 1.6%, and 4.8% due to surgical site infection, pneumonia, and urinary retention, respectively), and underwent conventional rather than laparoscopic surgery (84.1% vs. 15.9%). The most common location of tumors and procedures were sigmoid (47.6%) and colostomy closure (25.4%). None of the patients was able to comply with all components of the ERAS protocol; however, the results from 6 patients who implemented ten or more components of the ERAS protocol showed a higher reduction rate of the total LOS from 8−12 days to only five days (a reduction rate of 62.5%) compared to patients who completed less than 10 components (p&lt;0.01, r=−0.568). Conclusion: Implementing at least 10 ERAS components may have a similar impact to fully implementing the ERAS protocol regarding how patients who have colorectal surgery are managed. These ten components are subsequently called the adjusted ERAS protocol for colorectal surgery.

MP06-16 PERCEIVED NURSING BARRIERS TO IMPLEMENTATION OF ENHANCED RECOVERY AFTER SURGERY PATHWAYS

You have accessJournal of UrologyCME1 Apr 2023MP06-16 PERCEIVED NURSING BARRIERS TO IMPLEMENTATION OF ENHANCED RECOVERY AFTER SURGERY PATHWAYS Akshay Thaper, Melinda Z. Fu, Kevin Chua, Hiren V. Patel, Raeesa Islam, Thomas L. Jang, and Saum Ghodoussipour Akshay ThaperAkshay Thaper More articles by this author , Melinda Z. FuMelinda Z. Fu More articles by this author , Kevin ChuaKevin Chua More articles by this author , Hiren V. PatelHiren V. Patel More articles by this author , Raeesa IslamRaeesa Islam More articles by this author , Thomas L. JangThomas L. Jang More articles by this author , and Saum GhodoussipourSaum Ghodoussipour More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003217.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Enhanced recovery after surgery (ERAS) protocols are evidence-based multimodal perioperative care pathways that have shortened hospital stays, optimized pain control, led to earlier mobility and recovery, and reduced rates of postoperative complications across several surgical specialties. However, adherence to and implementation of ERAS protocols is not universal. Our study aimed to identify barriers nursing staff face in implementing ERAS protocols in patients undergoing radical cystectomy. METHODS: A survey was sent to preoperative, post-anesthesia care unit (PACU), and surgical oncology med/surg nurses about the effectiveness, ease, and frequency of ERAS implementation in the preoperative and early postoperative phase of care. Respondents rated each statement on a 5-point Likert scale and were able to provide narrative responses. RESULTS: The survey was completed by 31 nurses (8 preoperative, 10 PACU and 13 surgical oncology nurses). The majority (80%) of surgical oncology nurses had prior ERAS training and 100% knew where to find additional resources about ERAS. Only 50% of PACU nurses and 33% of preoperative nurses reported they had received ERAS training. Approximately half of nurses surveyed agreed that ERAS improves workflow by standardizing care and setting clear expectations for staff. On POD 0, 21% of nurses reported chewing gum as slightly effective or not effective at all, with 36% never implementing it. Daily weight was seen as slightly effective or not effective at all by 17% of nurses. For at least 85% of nurses, it was somewhat or extremely easy to administer a standing pain regimen, bowel regimen, and antiemetics on POD 0. 75% of nurses believed ERAS improves patient experience, citing faster recovery time and better pain control. Lack of personnel (79%), time (68%), and resources (68%) were commonly identified by nurses as barriers to implementing ERAS (Figure 1). CONCLUSIONS: Consensus on the effectiveness and ease of implementation of ERAS protocols remains varied. Equipping nursing staff with sufficient resources, education and training is necessary for widespread successful implementation of ERAS. Source of Funding: Grant from the National Cancer Institute (P30CA072720) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e59 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Akshay Thaper More articles by this author Melinda Z. Fu More articles by this author Kevin Chua More articles by this author Hiren V. Patel More articles by this author Raeesa Islam More articles by this author Thomas L. Jang More articles by this author Saum Ghodoussipour More articles by this author Expand All Advertisement PDF downloadLoading ...

Doctors' knowledge and perceptions of perioperative nutrition support; results from a large Australian tertiary referral Centre.

Nutritional optimisation in the perioperative period is essential in the prevention and treatment of malnutrition, a state of poor bodily function caused by a lack of nutritional intake, thereby altering body composition.1 Although identification and treatment of malnutrition is well recognized as a key component of Enhanced Recovery After Surgery (ERAS) guidelines, it is still highly prevalent, and significantly associated with poor outcomes. Studies have shown that up to 50% of patients undergoing abdominal surgery are malnourished.2-5 These patients are further at risk due to reduced recognition, combined with poor clinician understanding of treatment strategies due to their lack of knowledge and experience.6-10 To identify how we can improve on surgical nutrition management within our surgical units, we performed a survey within a large tertiary referral hospital in Melbourne, Australia. The project was approved by the Western Health Office of Research (QA2020.13_61439). A purpose-built, 23-item anonymous online REDCap survey was distributed to all doctors (including interns, residents, registrars, fellows and consultants) working across all general surgical units at Western Health. As our recruitment strategy involved advertising the survey at the weekly surgical morbidity and mortality meeting and via email distribution, response rate calculation was not feasible. The survey, developed by a team of senior academic dietitians and surgeons, included Likert scale ‘agree/disagree’ questions as well as clinical multiple-choice questions to assess doctor's perceptions and knowledge of perioperative nutritional support within general surgery. Of the 50 respondents, the majority were junior doctors (11 [22%] interns and 17 [34%] residents), 11 were registrars (22%) and a further 11 were consultant surgeons (22%). Only 24% (12) of respondents reported any prior training on perioperative nutritional support. While all respondents agreed on the importance of perioperative nutrition training (100%) and 94% (47) agreed on the need for nutritional assessment both before and after abdominal surgery, only 46% (23) felt confident in being able to initiate enteral or parenteral support according to evidence based guidelines. This was reflected when only approximately half of respondents correctly identified the correct timing to commence enteral (62%; 31) and total parenteral nutrition (50%; 25). Early identification of patients with nutritional deficits is important to ensure appropriate and timely interventions, however only a small proportion (20%; 10) of doctors surveyed were confident in identifying malnutrition and only 34% (17) were able to identify the common risks of malnutrition in a surgical patient. Only 38% (19) of doctors understood that the commonly used ‘fast from midnight’ order was unnecessary.11 These findings correspond with the nutritional knowledge gaps that have been observed across the world amongst medical students, junior medical staff and surgeons.6-10 Many hospitalized patients suffer from malnutrition, and those undergoing abdominal surgery, especially emergency cases, are at risk of deterioration owing to prolonged fasting and slow return to adequate nutritional intake. A recent British audit showed that patients undergoing emergency surgery are more likely to fast for longer periods of time (more than 12 h for clear fluids, and 24 h for food) compared with elective patients.11 Whilst we have shown the majority of doctors understand the importance of nutrition optimisation, they may not be equipped with the knowledge of when and how to do so. The implementation of ERAS protocols which include nutrition components can help standardize nutrition supplementation.12 A recent study also showed a lack of nutrition related education in British postgraduate training curriculums, suggesting a potential solution of implementing nutritional based objectives in all postgraduate training programs.7, 13 We recommend that doctors should be encouraged to make use of available hospital resources, in particular involvement of dietitians and the multidisciplinary team to help with early identification of patients at risk of malnutrition. Embedded education in both undergraduate and postgraduate training could help improve on doctors understanding and management of nutritional deficiencies. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. Howard H. Y. Tang: Formal analysis; writing – original draft; writing – review and editing. Danielle Taylor: Data curation; investigation; methodology; writing – review and editing. Irene Deftereos: Conceptualization; methodology; writing – review and editing. Aurora Ottaway: Methodology; writing – review and editing. Justin M. C. Yeung: Conceptualization; supervision; visualization; writing – review and editing.