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

Abstract

Background: 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. Hypothesis: 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. Study Design: Cohort study; Level of evidence, 3. Methods: 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. Results: 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. Conclusion: 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.

Comparison of efficacy of intrathecal hyperbaric ropivacaine and hyperbaric bupivacaine in terms of enhanced recovery after surgery (ERAS) for ACL reconstructions

“…7 Hailey Hampton conducted a study to analyze the application of ERAS protocols in ACL cases and concluded that after ERAS protocol application the patients were more comfortable and pain-free and could be ambulated earlier with hastened recovery. 8 R. Ramlogan et al in their study compared local anesthetic infiltration with peripheral nerve blocks and reported that the longer pain-free period and better control of the operated limb facilitated early mobilization and better patient satisfaction. 9,10 Lee etal studied a dose response curve of ropivacaine in lower limb surgeries and concluded that a comparative lower dose (ED 95 of 11.4 mg) to be effective in lower limb surgeries lasting for about 50 mins.…”

Advanced Nurse Practice: Present and Future: Where to now?

“…In orthopaedic care, Hampton et al [57] explore the benefits of implementing ERAS protocols in orthopaedic surgery due to their ability to control pain adequately in the immediate postoperative window, allowing for earlier mobilisation, shorter hospital stays, and fewer complications. Virginia Commonwealth University created a multimodal pain management approach that has potential for ANPs to extend their practice.…”