Reduction in opioid use and postoperative pain scores after elective laparotomy with implementation of enhanced recovery after surgery protocol on a gynecologic oncology service

Abstract

ObjectiveEnhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol.MethodsA retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014–7/27/2016) with comparison to a historical cohort (6/23/2013–9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher’s exact, and chi squared tests.ResultsOne hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates.ConclusionsERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.

A Comparative Study of Enhanced Recovery After Surgery (ERAS) Program and None-ERAS Traditional Care in Elderly Patients Undergoing Lumbar Arthrodesis

“…The close and timely communication of the ERAS team helps to identify potential di culties and optimize ERAS procedures. Recent studies have shown that continual auditing of the protocol can help to improve compliance [31].…”

“…It is necessary to weigh the side effects against the strong potency of opioids. Although some guidelines and reviews mentioned about multimodal analgesia in ERAS program, there are still some controversies, such as the application of patient-speci c multimodal analgesia programs for elderly patients and multimodal analgesic management for preoperative opioid users[10,28,31,32].…”

Impact of transversus abdominis plane blocks versus non-steroidal anti-inflammatory on post-operative opioid use in ERAS ovarian cancer surgery

“…Our granular opioid use data over the post-operative period are the first to show a sustained and significant reduction in opioid use by NSAIDs, while adjusting for significant confounders. Multimodal analgesia is a tenet of ERAS protocols and ERAS implementation has been found to decrease post-operative opioid consumption 27 28. Although greater compliance with ERAS elements is associated with improved patient outcomes,29 data on which individual elements are most crucial to patient benefit are currently limited.…”

Enhanced recovery pathways and patient‐reported outcome measures in gynaecological oncology

“…One key element of the enhanced recovery pathway is to decrease opioid use through increased utilisation of multimodal pain control (Table 1). As a result of implementing enhanced recovery pathways with multimodal analgesia, multiple single‐centre studies have shown significant reductions of peri‐operative opioid requirements and lower reported pain scores in gynaecologic patients who underwent laparotomy when compared with historical controls who had the same procedure without a pathway in place [28–30]. Studies have also reported statistically significant reductions in 30‐day surgical site infection risk among patients undergoing these procedures and have reported success with specific interventions including: setting patient and caregiver expectations; early patient education; pre‐operative antimicrobial washing; and timely administration of prophylactic antibiotics before surgery [31–33].…”