Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy

Abstract

BackgroundEnhanced Recovery After Surgery (ERAS) pathways have been shown in multiple surgical disciplines to improve outcomes, including reduced opioid consumption, length of stay, and post-operative nausea and vomiting (PONV). However, very few studies describe the application of ERAS to breast surgery and even fewer describe ERAS for outpatient surgery. We describe the implementation and efficacy of an Enhanced Recovery After Surgery (ERAS) pathway for total skin-sparing mastectomy with immediate reconstruction in an outpatient setting.MethodsWe implemented an evidence-based, multimodal ERAS pathway for all patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction at a single 23-h stay surgery center. Highlights of the ERAS pathway included: preoperative acetaminophen, gabapentin, and scopolamine; regional anesthesia for the breast (Pectoral blocks type 1 and 2 or paravertebral block); and intraoperative dexamethasone and ondansetron. This retrospective study included all American Society of Anesthesiology (ASA) Class 1–3 patients undergoing total skin-sparing mastectomy surgery with immediate reconstruction between July 2013 and April 2016. We compared 96 patients who were in the ERAS pathway (ERAS group) to a retrospective cohort of 276 patients (Pre group). The primary outcome was total perioperative opioid consumption. Secondary outcomes were highest postoperative pain scores, incidence of PONV, and length of stay.ResultsPatients in the ERAS group had significantly lower total perioperative opioid consumption compared to the Pre group (mean (SD): 111.4 mg (46.0) vs. 163.8 mg (73.2) oral morphine equivalents, p < 0.001). Patients in the ERAS group also had a lower incidence of PONV (28% vs. 50%, p < 0.001). Patients in the ERAS group reported less pain in the recovery room, with a two-point decrease in highest pain score (median [interquartile range (IQR)]: 4 [2,6] in ERAS group vs. 6 [4,7] in Pre group, p < 0.001). There was no clinically significant difference in length of stay (median [IQR]: 1144 min [992, 1259] in ERAS group vs. 1188 [1058, 1344] in Pre group, p = 0.006).ConclusionImplementation of an ERAS pathway for total skin-sparing mastectomy with reconstruction that incorporates regional anesthesia is feasible in a 23-h-stay hospital. Patients in the ERAS pathway had improved post-operative analgesia and reduced post-operative nausea and vomiting.Electronic supplementary materialThe online version of this article (10.1186/s12871-018-0505-9) contains supplementary material, which is available to authorized users.

Enhanced Recovery after Surgery in Breast Reconstruction: A Systematic Review

“…Studies were performed between 2011 and 2018 and comprised 11 cohort studies, 3 of which included a single cohort of ERAS patients, whereas 8 included a traditional pathway control cohort. [9][10][11][12][13][14][15][16][17][18][19] The traditional cohort was collected through retrospective chart review of recent patients who underwent breast reconstruction with the perioperative standard of care. 11,12,[14][15][16][17][18][19] Significant differences between cohorts in terms of patient and surgical characteristics were rare, as shown in individual tables present in each manuscript.…”

“…The majority of patients underwent tissue expander placement (518, 84.8%), and a minority underwent direct-to-implant reconstruction using allo-or autodermis to complete implant coverage (93, 15.2%). [17][18][19] The majority of alloplastic cases were unilateral (373, 75.8%) and immediate (609, 99.7%).…”

“…12,13 Alloplastic Reconstruction: Protocol Details Preoperative education and counseling regarding the procedure and enhanced recovery were described in all studies. [17][18][19] The majority limited preoperative fasting, with clear liquids permitted up to 2 hours prior to anesthetic induction. 18,19 A multimodal pain control regimen was administered preoperatively in all protocols in which preoperative pain control was discussed (n ¼ 2), including acetaminophen (2/2), gabapentin (2/2), celecoxib (1/2), and an oral opioid (1/2).…”

“…[17][18][19] The majority limited preoperative fasting, with clear liquids permitted up to 2 hours prior to anesthetic induction. 18,19 A multimodal pain control regimen was administered preoperatively in all protocols in which preoperative pain control was discussed (n ¼ 2), including acetaminophen (2/2), gabapentin (2/2), celecoxib (1/2), and an oral opioid (1/2). Intraoperatively, pain control was most often left to the anesthesiologist's discretion.…”

“…Intraoperatively, pain control was most often left to the anesthesiologist's discretion. 18,19 Dumestre et al utilized local nerve blocks around the breast with bupivacaine, and Chiu et al utilized pectoralis or paravertebral blockade with ropivacaine. 18,19 Goal-directed fluid management targeting euvolemia was stressed.…”