Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

Abstract

Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Increased Opioid Consumption following DIEP Flap Breast Reconstruction: Effect of Depression and Anxiety

“…37 Introduction and changes to protocols take significant amounts of time, especially with complex pathways such as ERAS. 38 For this reason, it is important to take note of psychiatric comorbidities in our patient population and to enact changes as soon as we can. Proposing changes to ERAS protocols to include psychiatry or psychology involvement as standard of care would help to diminish the stigma that patients may feel related to these psychotherapy practices.…”

Hyponatremia after Autologous Breast Reconstruction: A Cohort Study Comparing Two Fluid Management Protocols

“…20,27 This has led to early cessation of balanced crystalloid IV fluids, replaced by non-physiologically balanced, oral water / "clear fluid" intake. 8,10,20,25,27 This study is the first to highlight that hyponatremia following autologous breast reconstruction may be under-recognized. On retrospective review in the reporting institute, 37% of patients were hyponatremic with 11% displaying symptoms, which could have reflected symptomatic hyponatremia.…”

“…Since 2015, ERAS protocols have been used in this field and are continually evolving. 8,[10][11][12][19][20][21][22] Evidence strongly supports a recommendation that over-resuscitation or under-resuscitation of fluids should be avoided and water and electrolyte balance should be maintained peri-operatively. 8,23 Balanced crystalloid solutions are recommended and goal-directed therapy is supported.…”

“…3 Recent work has supported a reduction in intraoperative fluid use, supporting vasopressor use if needed. [4][5][6][7][8][9][10] The trend is towards early initiation of oral fluids but little attention has been paid to post-operative fluid choice and the risk of causing hyponatremia. 7,[10][11][12] Post-operative hyponatremia is a potentially life-threatening diagnosis.…”

“…The rationale for such high post-operative fluid intake cannot be determined and could be further evaluated. Previous studies have shown staff-, patient-, or resource related issues can be responsible for discrepancies in ERAS delivery 10 .…”