Enhanced Recovery After Surgery – ERAS in Elective Craniotomies-a Non-randomized Controlled Trial

Abstract

Background: Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care bundle aimed at early recovery of patients. Well accepted in gastric and pelvic surgeries, there is minimal evidence in neurosurgery and neurocritical care barring spinal surgeries. We wished to compare the length of intensive care unit (ICU) or high dependency unit (HDU) stay of patients undergoing elective craniotomy for supratentorial neurosurgery: ERAS protocol versus routine care. The secondary objective was to compare the postoperative pain scores, opioid use, glycemic control, and the duration of postoperative hospital stay between the two groups.Methods: This was a pragmatic non-randomized controlled trial (CTRI/2017/07/015451). Consenting adult patients scheduled for elective supratentorial intracranial tumor excision were enrolled prospectively after institutional ethical clearance and consent. Patients in the ERAS group received a fixed bundle of care. Pre-operative –family education,, complex-carbohydrate drink, scalp blocks, and flupiritine ; Intraoperative –limited opioids,fluid and temperature regulation; Post operative- early mobilization, removal of catheters and initiation of feeds. In the control group, standard practice and protocols of perioperative care were followed. The two groups were compared with regards to the length of ICU stay, pain scores in ICU, opioid requirement, glycemic control and the overall duration of stay in the hospital. Results: Seventy patients were enrolled. Baseline demographics – age, sex, tumor volume and comorbidities were comparable between the groups. The proportion of patients staying in the ICU for less than 48 hrs after surgery, the cumulative insulin requirement and the episodes of VAS scores > 4 in first 48 hours after surgery was significantly less in the ERAS group – 40.6% vs 65.7%, 0.6 (±2.5) units vs 3.6 (±8.1 ) units and 1 vs 10 episodes ( p= 0.04, 0.001, 0.004 respectively). The total hospital stay was similar in both groups.Conclusion: The study demonstrated a significant reduction in the proportion of patients requiring ICU/ HDU stay > 48 hrs. Better pain and glycemic control in the postoperative period may have contributed to a decreased stay. More extensive randomized studies may be designed to confirm these results.