Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol

Razi, Syed S.; Stephens-McDonnough, Joy A.; Haq, Safi; Fabbro, Michael; Sanchez, Aliercy Nunez; Epstein, Richard H.; Villamizar, Nestor; Nguyen, Dao M.

doi:10.1016/j.jtcvs.2019.12.137

Cited by 53 publications

(48 citation statements)

References 26 publications

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“…Razi et al (2020) investigated an Enhanced Recovery after Thoracic Surgery (ERATS) protocol for patients undergoing thoracotomies and robotic thoracoscopies which focused on a multimodal pain management strategy including the use of opioid-sparing analgesics and regional anesthesia. Implementation of the ERATS protocol resulted in a drastic reduction of new persistent opioid use without adversely affecting outcomes [13]. Similar longitudinal results have been reported in liver surgery [14], indicating potentially unrealized benefits of ERAS protocols that extend beyond discharge.…”

Section: Perioperative Protocols/clinical Pathwayssupporting

confidence: 63%

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

Burns

Urman

Pian

et al. 2021

Curr Pain Headache Rep

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Purpose of Review This review aims to summarize interventions used in the perioperative period to reduce the development of new persistent postoperative opioid use in opioid-naïve patients. Recent Findings The development of new persistent opioid use after surgery has recently been identified as a common postoperative complication. The existing literature suggests that interventions across the continuum of care have been shown to decrease the incidence of new persistent postoperative opioid use. Specific preoperative, intraoperative, and postoperative interventions will be reviewed, as well as the use of clinical pathways and protocols that span throughout the perioperative period. Common to many of these interventions include the use of multimodal analgesia throughout the perioperative period and an emphasis on a patient-centered, evidence-based approach to the perioperative pain management plan. Summary While the incidence of new persistent postoperative opioid use appears to be high, the literature suggests that there are both small- and large-scale interventions that can be used to reduce this. Technological advances including prescription monitoring systems and mobile applications have enabled studies to monitor opioid consumption after discharge. Interventions that occur preoperatively, such as patient education and expectation setting regarding postoperative pain management, and interventions that occur postoperatively, such as the implementation of procedure-specific, evidence-based prescribing guidelines and protocols, have been shown to reduce post-discharge opioid consumption. The use of multimodal analgesia and opioid-sparing adjuncts throughout the perioperative period is central to many of these interventions and has essentially become standard of care for management of perioperative pain.

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Section: Perioperative Protocols/clinical Pathwayssupporting

confidence: 63%

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

Burns

Urman

Pian

et al. 2021

Curr Pain Headache Rep

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“…Ever since the discovery of cocaine's local anesthetic properties in the mid-19th century, local anesthetics (LAs) have been used in surgery and modern anesthesiologic interventions (eg, epidural or spinal anesthesia, local nerve and wound infiltration) would not be possible without them. [1][2][3] In recent years, several studies have shown significant immunomodulation with LAs caused by interactions with polymorphonuclear granulocytes (PMNs). Although PMNs are considered to be electrically non-excitable, the predominant mechanisms [4][5][6][7][8] for the modulations are thought to be the inactivation of voltage-gated sodium channel 1.3 (NaV 1.3), non-canonical effects such as the blocking of inflammatory mediators, antiapoptotic effects or reduced vascular adhesion, and trans-endothelial migration capacity.…”

Section: Introductionmentioning

confidence: 99%

Potential Impact of Local Anesthetics Inducing Granulocyte Arrest and Altering Immune Functions on Perioperative Outcome

Kolle¹,

Metterlein²,

Gruber³

et al. 2021

JIR

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“…While the components of ERATS work synergistically to provide the most optimal outcomes, effective thoracic pain control with an opioid-sparing strategy, coupled with posterior intercostal nerve blocks and surgical wound infiltration with long-acting local anesthetic preparation liposomal bupivacaine, plays an essential role. Since the initial reports by Rice and Mehran of the MD Anderson Cancer Center (9,10) that described and popularized this technique within the context of ERATS, many medical centers, including our own, have described successful implementation of ERATS with significant improvement of a wide range of outcome metrics such as reduced pain and opioid requirements, postoperative complications, and postoperative hospital length of stay (LOS) (1,2,(11)(12)(13).…”

Section: Introductionmentioning

confidence: 99%

“…Within the context of a well-implemented ERATS program, Krebs and colleagues have demonstrated equivalent short-term outcomes (LOS, complication rates, postoperative pain scores) of patients undergoing pulmonary lobectomy either by MITS or thoracotomy approaches (11). The most important effect of ERATS is the ability to reduce both in-hospital and post-discharge opioid requirements while maintaining adequate pain control (2,12,13). Exposure to potent opioids (those classified as schedule II by the FDA such as morphine, oxycodone, hydromorphone) increases the risk of dependency (14,15) and if made available outside the hospital setting would increase the risk of inappropriate use, especially in the current setting of the opioid crisis in the United States (16)(17)(18)(19).…”

Section: Introductionmentioning

confidence: 99%

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

Kodia¹,

Stephens-McDonnough²,

Alnajar³

et al. 2021

J Thorac Dis

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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.

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Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol

Cited by 53 publications

References 26 publications

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

Reducing New Persistent Opioid Use After Surgery: A Review of Interventions

Potential Impact of Local Anesthetics Inducing Granulocyte Arrest and Altering Immune Functions on Perioperative Outcome

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

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