Enhanced recovery after cesarean: impact on postoperative opioid use and length of stay

Background Enhanced Recovery after Surgery (ERAS) principles have received focused attention in breast reconstruction. Many protocols have been described in the literature for both autologous and alloplastic reconstruction. This systematic review serves to better characterize successful ERAS protocols described in the literature for potential ease of adoption at institutions desiring implementation. Methods A systematic review of ERAS protocols for autologous and alloplastic breast reconstruction was conducted using Medline, the Cochrane Database, and Web of Science. Results Eleven cohort studies evaluating ERAS protocols for autologous (n = 8) and alloplastic (n = 3) breast reconstruction were included for review. The majority compared with a retrospective cohort of traditional perioperative care. All studies described the full spectrum of implemented ERAS protocols including preoperative, intraoperative, and postoperative phases of care. Most frequently reported significant outcomes were reduced length of stay and opioid use with ERAS implementation. No significant change in major complication or readmission rate was demonstrated. Conclusion Based on this systematic review, several core elements that make up a successful perioperative enhanced recovery protocol for breast reconstruction have been identified. Elements include patient counseling and education, limited preoperative fasting, appropriate thromboprophylaxis and antibiotic prophylaxis dependent on reconstructive method, preoperative antiemetics, multimodal analgesia and use of local anesthetic, goal-directed intravenous fluid management, prompt removal of drains and catheters, early diet advancement, and encouragement of ambulation postoperatively. Implementation of ERAS protocols in both autologous and alloplastic breast reconstruction can positively enhance patient experience and improve outcomes by reducing length of stay and opioid use, without compromising successful reconstructive outcomes.

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Adoption of enhanced recovery after surgery and intraoperative transverse abdominis plane block decreases opioid use and length of stay in very large open ventral hernia repairs

The American Journal of Surgery ◽

10.1016/j.amjsurg.2021.02.025 ◽

2021 ◽

Author(s):

Jenny M. Shao ◽

Eva B. Deerenberg ◽

Tanu Prasad ◽

Colleen Dunphy ◽

Paul D. Colavita ◽

...

Keyword(s):

Length Of Stay ◽

Ventral Hernia ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Opioid Use ◽

Transverse Abdominis

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Implementation of an Enhanced Recovery after Surgery Pathway to Reduce Inpatient Opioid Consumption after Cesarean Delivery

American Journal of Perinatology ◽

10.1055/s-0041-1732450 ◽

2021 ◽

Author(s):

Jared L. Tepper ◽

Olivia M. Harris ◽

Jourdan E. Triebwasser ◽

Stephanie H. Ewing ◽

Aasta D. Mehta ◽

...

Keyword(s):

Length Of Stay ◽

Cesarean Delivery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Opioid Consumption ◽

Quality Improvement Initiative ◽

Adjusted Relative Risk ◽

Opioid Use ◽

Opioid Prescription ◽

The Impact

Objective Opioid prescription after cesarean delivery is excessive and can lead to chronic opioid use disorder. We assessed the impact of an enhanced recovery after surgery (ERAS) pathway on inpatient opioid consumption after cesarean delivery. Study Design An ERAS pathway was implemented as a quality improvement initiative in December 2019. Preintervention (PRE) data were collected from March to May 2019 to assess baseline opioid consumption. Postintervention (POST) data were collected from January to March 2020. The primary outcome was inpatient postoperative opioid consumption in morphine milligram equivalents (MME). Secondary outcomes included the consumption of any opioids, postpartum length of stay, and opioid prescription at discharge. Results A total of 92 women were in the PRE group and 91 were in the POST group. Inpatient opioid consumption decreased by 87.3% from PRE to POST, from 124.7 (interquartile range [IQR]: 10–181.6) MME to 15.8 (IQR: 0–75) MME (p < 0.001). There was no difference in median postpartum length of stay (3.4 days PRE vs. 3.3 days POST; p = 0.12). The proportion of women who did not consume any opioids increased by 75.4% from PRE to POST (p = 0.02). The proportion of women discharged with an opioid prescription decreased by 25.6% from PRE to POST (p = 0.007), despite no formal change to prescribing practices. After adjustment for differences in race/ethnicity and gravidity, there was still a reduction in total inpatient opioid consumption (p < 0.001) and an increase in the proportion of women not consuming any opioids (adjusted relative risk (RR): 2.14, 95% confidence interval [CI]: 1.18–3.87), but the difference in rate of prescription of opioids at discharge was no longer statistically significant (adjusted RR: 0.70, 95% CI: 0.48–1.02). Conclusion Adoption of an ERAS pathway for cesarean delivery resulted in a marked reduction in inpatient opioid consumption. Such a pathway can be implemented across institutions and may be a powerful tool in combating the opioid epidemic. Key Points

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Enhanced Recovery after Partial and Radical Nephrectomy Reduces Length of Stay, Opioid Use and Cost

Urology Practice ◽

10.1097/upj.0000000000000070 ◽

2020 ◽

Vol 7 (1) ◽

pp. 41-46

Author(s):

Daniel Swerdloff ◽

Demitri Podolski ◽

Rachel E. Smith ◽

Donald Lee ◽

Michael Swerdloff ◽

...

Keyword(s):

Length Of Stay ◽

Radical Nephrectomy ◽

Enhanced Recovery ◽

Opioid Use

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Reduction of Postoperative Opioid Use After Elective Spine and Peripheral Nerve Surgery Using an Enhanced Recovery After Surgery Program

Pain Medicine ◽

10.1093/pm/pnaa233 ◽

2020 ◽

Vol 21 (12) ◽

pp. 3283-3291

Author(s):

Tracy M Flanders ◽

Joseph Ifrach ◽

Saurabh Sinha ◽

Disha S Joshi ◽

Ali K Ozturk ◽

...

Keyword(s):

Length Of Stay ◽

Peripheral Nerve ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Foley Catheter ◽

Control Group ◽

Opioid Use ◽

Historical Cohort ◽

Eras Protocol ◽

Nerve Surgery

Abstract Objective Enhanced recovery after surgery (ERAS) pathways have previously been shown to be feasible and safe in elective spinal procedures. As publications on ERAS pathways have recently emerged in elective neurosurgery, long-term outcomes are limited. We report on our 18-month experience with an ERAS pathway in elective spinal surgery. Methods A historical cohort of 149 consecutive patients was identified as the control group, and 1,141 patients were prospectively enrolled in an ERAS protocol. The primary outcome was the need for opioid use one month postoperation. Secondary outcomes were opioid and nonopioid consumption on postoperative day (POD) 1, opioid use at three and six months postoperation, inpatient pain scores, patient satisfaction scores, postoperative Foley catheter use, mobilization/ambulation on POD0–1, length of stay, complications, and intensive care unit admissions. Results There was significant reduction in use of opioids at one, three, and six months postoperation (38.6% vs 70.5%, P < 0.001, 36.5% vs 70.9%, P < 0.001, and 23.6% vs 51.9%, P = 0.008) respectively. Both groups had similar surgical procedures and demographics. PCA use was nearly eliminated in the ERAS group (1.4% vs 61.6%, P < 0.001). ERAS patients mobilized faster on POD0 compared with control (63.5% vs 20.7%, P < 0.001). Fewer patients in the ERAS group required postoperative catheterization (40.7% vs 32.7%, P < 0.001). The ERAS group also had decreased length of stay (3.4 vs 3.9 days, P = 0.020). Conclusions ERAS protocols for all elective spine and peripheral nerve procedures are both possible and effective. This standardized approach to patient care decreases opioid usage, eliminates the use of PCAs, mobilizes patients faster, and reduces length of stay.

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Effect of implementing an enhanced recovery protocol for pediatric colorectal surgery on complication rate, length of stay, and opioid use in children

Journal of Pediatric Surgery ◽

10.1016/j.jpedsurg.2022.01.004 ◽

2022 ◽

Author(s):

Jessica A. George ◽

Andres J. Gonzalez Salazar ◽

Ahmer Irfan ◽

Laura Prichett ◽

Isam W. Nasr ◽

...

Keyword(s):

Colorectal Surgery ◽

Length Of Stay ◽

Complication Rate ◽

Enhanced Recovery ◽

Opioid Use ◽

Enhanced Recovery Protocol

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Development and Impact of an Institutional Enhanced Recovery Program on Opioid Use, Length of Stay, and Hospital Costs Within an Academic Medical Center

Anesthesia & Analgesia ◽

10.1213/ane.0000000000005182 ◽

2020 ◽

Vol Publish Ahead of Print ◽

Author(s):

Robert H. Thiele ◽

Bethany M. Sarosiek ◽

Susan C. Modesitt ◽

Timothy L. McMurry ◽

Mohamed Tiouririne ◽

...

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Medical Center ◽

Academic Medical Center ◽

Hospital Costs ◽

Opioid Use ◽

Enhanced Recovery Program ◽

Academic Medical ◽

Recovery Program

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Enhanced Recovery With Paravertebral and Transversus Abdominis Plane Blocks in Microvascular Breast Reconstruction

Breast Cancer Basic and Clinical Research ◽

10.1177/1178223420967365 ◽

2020 ◽

Vol 14 ◽

pp. 117822342096736

Author(s):

Ryan Guffey ◽

Grace Keane ◽

Austin Y Ha ◽

Rajiv Parikh ◽

Elizabeth Odom ◽

...

Keyword(s):

Length Of Stay ◽

Breast Reconstruction ◽

Regional Anesthesia ◽

Enhanced Recovery ◽

Paravertebral Block ◽

Transversus Abdominis ◽

Opioid Use ◽

Transversus Abdominis Plane ◽

Pain Scores ◽

Independent Ambulation

Purpose: We have shown previously that a preoperative paravertebral nerve block is associated with improved postoperative recovery in microvascular breast reconstruction. The purpose of this study was to compare the outcomes of a complete enhanced recovery after surgery (ERAS) protocol with complete regional anesthesia coverage to our traditional care with paravertebral block. Patients and methods: This was a retrospective cohort study of 83 patients who underwent autologous breast reconstruction by T.M.M. between May 2014 and February 2018 at a tertiary academic center. Patients in the ERAS group were additionally administered acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, a transversus abdominis plane block (liposomal or plain bupivacaine), and primarily oral opioids postoperatively. The patients were mobilized earlier with more rapid diet progression. All patients received a preoperative paravertebral block. Results: Forty-four patients in the ERAS cohort were compared with 39 retrospective controls. The 2 groups were similar with respect to demographics and comorbidities. The ERAS cohort required significantly less opioids (291 vs 707 mg oral morphine equivalent, P < .0001) with unchanged postoperative pain scores and a shorter time to oral only opioid use (16.0 vs 78.2 hours, P < .0001). Median length of stay (3.20 vs 4.62, P < .0001) and time to independent ambulation (1.86 vs 2.88, P < .0001) were also significantly decreased in the ERAS cohort. Liposomal bupivacaine use did not significantly affect the results ( P ⩾ .2). Conclusions: Implementation of a robust enhanced recovery protocol with complete regional anesthesia coverage was associated with significantly decreased opioid use despite unchanged pain scores, with improved markers of recovery including length of stay, time to oral only narcotics, and time to independent ambulation.

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