Implementation of an enhanced recovery after thoracic surgery care pathway for thoracotomy patients—achieving better pain control with less (schedule II) opioid utilization

Abstract

Background: Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra-and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy. Methods: This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record. Results: A total of 98 patients (43 pre-and 55 post-protocol implementation) were included in this study.There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5-16.5) (ERATS) vs. 19.5 (12.6-36.0) (pre-ERATS), P<0.0001]. More importantly, a drastic reduction of total and schedule II opioids dispensed at discharge was noted in the ERATS group [total MME: 150 (100.0-330.0) vs. 800.0 (450.0-975.0), P<0.0001 and schedule II MME: 90.0 (0-242.2) vs. 800.0 (450.0-975.0), P<0.0001; ERATS vs. pre-ERATS respectively]. A shorter hospital stay (median difference of 1 day, P=0.0012 and a mean difference of 2.4 days, P=0.0054) was observed in the enhanced recovery group. Conclusions: Implementation of an enhanced recovery protocol for thoracotomy patients is safe and associated with elimination of thoracic epidural analgesia, decreased postoperative pain, shorter hospitalization, drastic reduction of post-discharge opioid dispensed and decreased dependence on addiction-prone schedule II narcotics.

Ultrasound-guided medial branch of the superior laryngeal nerve block to reduce peri-operative opioids dosage and accelerate patient recovery

“…ERAS aims to reduce the length of hospital stay, reduce medical costs and improve treatment satisfaction by adopting a series of interventions during perioperative management to avoid postoperative physiological and psychological adverse reactions of patients, and the ERAS programs have been successful in the past two decades [ 21 , 22 ]. The ERAS protocol encourages multimodal analgesia and recommends the use of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and gabapentin to limit opioids use to prevent postoperative ileus [ 23 ]. Good perioperative pain management can help eliminate acute pain caused by surgical trauma, improve patients’ sleep, enhance immune function, make patients dare to cough and excrete sputum, get out of bed early, reduce the incidence of postoperative complications such as pulmonary infection, venous embolism of lower limbs, intestinal adhesion, and shorten the length of hospital stay and reduce the hospitalization costs [ 24 , 25 ].…”

Effects of exposure to ambient air pollution on pulmonary function impairment in Korea: the 2007-2017 Korea National Health and Nutritional Examination Survey

“…The multivariate linear regression analysis included the same covariates as the multivariate logistic regression analysis. The low-rank regression splines were specified in the framework of generalized additive models and fitted to the penalized likelihood estimation (GAMPL in SAS) to observe changes in pulmonary function with increasing concentrations of air pollutants [ 20 ].…”

Postoperative day 1 discharge following robotic thoracoscopic pulmonary anatomic resections in the era of enhanced recovery protocol: A single-institution experience

“…Our group implemented ERATS in February 2018 11 , 12 and has continued to optimize our protocol to improve its performance to achieve high incidences of opioid-free and pain-free recovery after robotic thoracoscopic procedures. 13 Our current ERATS protocol is the optimized version that was implemented in January 1, 2020.…”