Implementation of an Enhanced Surgical Recovery Programme (ESRP) gynaecologic oncology: How much did intra-operative opioid administration decrease in first year post implementation?

Abstract

Objectives: Radical cystectomy is associated with significant morbidity, ranging between 30 and 60% 1 . Before 2015, we have implemented some ERAS items for cystectomy patients without a prospective database. We evaluated the results and compliance with the ERAS protocol using the ERAS Interactive Audit System (EIAS) database (Encare®) one year after implementation of a full ERAS protocol. Methods: We compared the results of 2014 (pre-ERAS) and 2015 (after implementation of full ERAS protocol) with regards to length of stay, complications and compliance to ERAS items. The results of 2014 were collected retrospectively by patient chart review as a part of the ERAS implementation programme. Data from 2015 were collected prospectively in the EIAS database. Results: The main outcomes are shown in the table. There was a trend towards a reduction in overall complications. Length of stay and highgrade complications were unchanged in the first year of our ERAS programme. Conclusion:The implementation of a full ERAS protocol including the use of a prospective database has not reduced length of stay or high-grade complications. While we achieved 100% for some of the ERAS items (e.g. PONV prophylaxis, no bowel preparation, no sedatives), some items in the postoperative period have been difficult to implement. The use of a prospective database is e helpful tool to monitor results and compliance to the ERAS protocol.Objectives: Blood loss is a potential complication during oesophagectomy, and may be confounded by pre-existing anaemia. Intraoperative transfusion is associated with poorer late term outcomes in oesophageal cancer 1 and vasopressors used to treat hypotension may impact anastomotic perfusion 2 . We assessed transfusion and fluid optimisation (GDFT) during oesophagectomy and its effect on perioperative noradrenaline (NA) use.Methods: 258 consecutive sets of notes from patients undergoing oesophagectomy between 2012 and 2015 were audited. Results: The mean haemoglobin (Hb) was 124±17 g/L. 38 patients (14.7%) received packed red blood cells (PRBC) within 48 hours of surgery. The likelihood of transfusion increased with lower starting Hb (p¼0.003). Where starting Hb was below 120 g/L (Group A), 10 of 93 patients received intraoperative PRBC (11%). With a starting Hb above 120 g/L (Group B), 11 of 165 patients received intraoperative PRBC (6.7%). The median volume transfused was the same in both groups (580 vs. 589 ml). In Group A, NA use at 24 hours post-op decreased from 22.9% (19/83 cases) to 0% with PRBC (0/10 cases; p<0.05); whereas in Group B, NA use increased from 22.1% (34/154 cases) to 72.7% with PRBC (8/11 cases; p<0.001). Where GDFT was used to guide overall fluid administration, NA use was decreased from 40% to 12.5% intraoperatively and from 34% to 14% postoperatively. Conclusion: Two distinct groups received intraoperative transfusion. Patients with a starting Hb >120 g/L received PRBC due to acute blood loss, were unstable had a higher incidence of requirement for post-op NA. Those with a starting Hb 120...