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

Abstract

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

Impact of Gabapentin on Postoperative Hypotension in Enhanced Recovery after Surgery Protocols for Microvascular Breast Reconstruction

“…In the field of microvascular reconstruction, the ERAS protocol has earned a reputation for decreasing postoperative LOS, thereby reducing costs, and enhancing patient satisfaction. [9][10][11][12][13]15,16,18 Our study lends further credence to this claim, as both ERAS cohorts displayed significant reductions in key postoperative milestones, including the timepoint of Foley catheter removal, postoperative return to a customary diet, and LOS. As both ERAS cohorts performed similarly across these three variables, Gaba's use did not seem to be associated with them.…”

“…Originating as a fast-track recovery method in 1994 to improve coronary artery bypass surgery outcomes through the bundling of perioperative treatments, 1–3 ERAS was found to reduce the length of intensive care unit stays by approximately 20%. 1 Subsequent investigations further validated ERAS’s efficacy in various surgical domains, including microvascular breast reconstruction, 4–16 leading to the establishment of the ERAS society. This group asserted that the quality of perioperative care is as consequential as the surgery itself in determining patient outcomes.…”

“…17 Today, ERAS has earned wide acceptance across numerous surgical subspecialties, and it is notably recognized for its ability to decrease length of stay (LOS) and inpatient narcotic use without any statistical difference in morbidity. [4][5][6][7][8][9][10][11][12][13][14][15][16] Thus, the ERAS protocol has become a cornerstone in delivering patient-centered, cost-effective care in contemporary surgical practice. Despite ERAS's transformative nature on surgical outcomes and perioperative patient care, a potential area of concern is the increased rates of postoperative hypotension after microvascular breast reconstruction.…”

Enhanced Recovery after Surgery Protocol Decreases Length of Stay and Postoperative Narcotic Use in Microvascular Breast Reconstruction

“…[14][15][16] Although there is emerging literature on the subject, most of these studies either have a small sample size, differences in cohort demographics, or the absence of a comparison group. [14][15][16] Nonetheless, some studies do not have these drawbacks and overall support ERAS implementation; however, only a few have been published to date. [17][18][19][20][21] Recognizing this gap, we sought to re-evaluate the observed impact of the ERAS pathway on perioperative outcomes in comparison with a non-ERAS pathway.…”

“…Despite wide acceptance, the ERAS pathway remains to be implemented as the mainstay for postoperative treatment in patients undergoing microvascular breast reconstruction due in part to the limited number of studies on the topic. [14][15][16] Although there is emerging literature on the subject, most of these studies either have a small sample size, differences in cohort demographics, or the absence of a comparison group. [14][15][16] Nonetheless, some studies do not have these drawbacks and overall support ERAS implementation; however, only a few have been published to date.…”