Effect of anesthesia technique on intra-operative and post-operative morphine equivalent daily dose (MEDD) in open gynecologic surgery in an enhanced recovery after surgery (ERAS) pathway

ObjectiveTo examine the effect of anesthesia technique in an enhanced recovery after surgery (ERAS) pathway on post-operative opioid use.MethodsPatients undergoing open gynecologic surgery under an ERAS pathway from November 2014 through December 2018 were included retrospectively. All patients received pre-operative analgesia consisting of oral acetaminophen, pregabalin, celecoxib, and tramadol extended release, unless contraindicated. Patients received local wound infiltration with bupivacaine; the post-operative analgesic regimen was standardized. Patients were categorized by anesthesia technique: (1) inhalational, (2) total intravenous anesthesia (TIVA), and (3) combined technique. The primary outcome was post-operative opioid consumption measured as morphine equivalent dose, recorded as the total opioid dose received post-operatively, including doses received through post-operative day 3.ResultsA total of 1184 patients underwent general anesthesia using either inhalational (386, 33%), TIVA (349, 29%), or combined (449, 38%) techniques. Patients who received combined anesthesia had longer surgery times (p=0.005) and surgical complexity was higher among patients who underwent TIVA (moderate/higher in 76 patients, 38%) compared with those who received inhaled anesthesia (intermediate/higher in 41 patients, 23%) or combined anesthesia (intermediate/higher in 72 patients, 30%). Patients who underwent TIVA anesthesia consumed less post-operative opioids than those managed with inhalational technique (0 (0–46.3) vs 10 (0–72.5), p=0.009) or combined anesthesia (0 (0–46.3) vs 10 (0–87.5), p=0.029). Similarly, patients who underwent the combined technique had similar opioid consumption post-operatively compared with those who received inhalational anesthesia (10 (0–87.5) vs 10 (0–72.5), p=0.34).ConclusionsTIVA technique is associated with a decrease in post-operative consumption of opioids after open gynecologic surgery in patients on an ERAS pathway.

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Use of pregabalin for preemptive analgesia in an enhanced recovery after surgery program.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.30_suppl.265 ◽

2018 ◽

Vol 36 (30_suppl) ◽

pp. 265-265

Author(s):

Katherine Cain ◽

Nhi Hoang ◽

Maria Iniesta ◽

Brandelyn Pitcher ◽

Camila Corzo ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Multimodal Analgesia ◽

Preemptive Analgesia ◽

Gynecologic Surgery ◽

Continuous Variables ◽

Opioid Use ◽

Fourth Dose ◽

Chronic Opioid Use ◽

Morphine Equivalent

265 Background: A key component of any Enhanced Recovery After Surgery (ERAS) program is standardized multimodal analgesia to minimize opioid use. Our program utilizes acetaminophen, nonsteroidal anti-inflammatory agents and gabapentanoids perioperatively. The primary aim of our study was to evaluate pregabalin use after surgery and impact on total morphine equivalent daily dose (MEDD). Methods: Data was collected retrospectively on consecutive ERAS patients who underwent open gynecologic surgery from 3/4/2016 through 2/22/2018. We excluded any patient identified as a chronic opioid user. Standard preoperative medications included 300 mg tramadol ER, 75 mg pregabalin, and 400 mg celecoxib per institutional guidelines. Standard postoperative pain regimen included scheduled oral acetaminophen, ibuprofen and pregabalin unless contraindicated with rescue oral oxycodone and IV hydromorphone as needed. Pregabalin was ordered 75 mg twice daily for 4 doses. Recommended exceptions to pregabalin included hypersensitivity or age greater than 65 years. Median and range were calculated to summarize continuous variables. Spearman’s rank was used to test the correlation between post-operative pregabalin dose and MEDD. Results: A total of 533 patients were included for analysis. Twelve patients were excluded for chronic opioid use. 38% of patients received all four post-operative pregabalin doses (207/533). 32.8% of patients received no pregabalin (175/533). The fourth dose was the most common missed dose (274/533, 51.4%). The top reasons dose 4 was missed included not being ordered (58.8%) and patient already discharged (12.4%). There were 202 patients older than 65 years, the majority of these patients received no post-operative pregabalin (123/202, 60.9%). There was no difference in the amount of MEDD between those who received all pregabalin doses compared to those who received none (90.75 mg [4-663.5 mg] vs 82.5 mg [4-634.5 mg]; p = 0.269). Conclusions: Pregabalin for preemptive analgesia in an ERAS program does not decrease MEDD.

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Implementation of enhanced recovery after surgery in gynecological operations: a randomized controlled trial

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-020-00116-4 ◽

2020 ◽

Vol 12 (1) ◽

Author(s):

Amr Nady Abdelrazik ◽

Ahmad Sameer Sanad

Keyword(s):

Hospital Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Controlled Trial ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Complication Rates ◽

Control Groups ◽

Analog Scale ◽

Randomized Controlled

Abstract Background To investigate the effects of enhanced recovery after surgery (ERAS) in patients undergoing gynecologic surgery on length of hospital stay, pain management, and complication rate. Results The length of hospital stay was reduced in ERAS groups when compared with the control groups (3.46 days vs 2.28 days; P < 0.0001; CI − 1.5767 to − 0.7833 for laparotomy groups and 2.18 vs 1.76 days; P = 0.0115; CI − 0.7439 to − 0.0961 for laparoscopy groups respectively). Intraoperative fluid use was reduced in both ERAS groups compared to the two control groups (934 ± 245 ml and 832 ± 197 ml vs 1747 ± 257 ml and 1459 ± 304 respectively; P < 0.0001) and postoperative fluid use was also less in the ERAS groups compared to the control groups (1606 ± 607 ml and 1210 ± 324 ml vs 2682 ± 396 ml and 1469 ± 315 ml respectively; P < 0.0001). Pain score using visual analog scale (VAS) on postoperative day 0 was 4.8 ± 1.4 and 4.1 ± 1.2 (P = 0.0066) for both laparotomy control and ERAS groups respectively, while in the laparoscopy groups, VAS was 3.8 ± 1.1 and 3.2 ± 0.9 (P = 0.0024) in control and ERAS groups respectively. Conclusion Implementation of ERAS protocols in gynecologic surgery was associated with significant reduction in length of hospital stay, associated with decrease intravenous fluids used and comparable pain control without increase in complication rates.

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Impact of a tiered discharge opioid algorithm on prescriptions and patient-reported outcomes after open gynecologic surgery

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2021-002674 ◽

2021 ◽

pp. ijgc-2021-002674

Author(s):

Sarah Huepenbecker ◽

Robert Tyler Hillman ◽

Maria D Iniesta ◽

Tsun Chen ◽

Katherine Cain ◽

...

Keyword(s):

Patient Reported Outcomes ◽

Enhanced Recovery ◽

Symptom Burden ◽

Equivalent Dose ◽

Hospital Length Of Stay ◽

Gynecologic Surgery ◽

Post Discharge ◽

Opioid Prescribing ◽

Patient Reported ◽

Morphine Equivalent

ObjectiveTo compare discharge opioid refills, prescribed morphine equivalent dose and quantity, and longitudinal patient-reported outcomes before and after implementation of a tiered opioid prescribing algorithm among women undergoing open gynecologic surgery within an enhanced recovery after surgery program.MethodsWe compared opioid prescriptions, clinical outcomes, and patient-reported outcomes among 273 women. Post-discharge symptom burden was collected up to 42 days after discharge using the validated 27-item MD Anderson Symptom Inventory and analyzed using linear mixed effects models and Kaplan–Meier curves for symptom recovery.ResultsAmong 113 pre-implementation and 160 post-implementation patients there was no difference in opioid refills (9.7% vs 11.3%, p=0.84). The post-implementation cohort had a significant reduction in median morphine equivalent dose (112.5 mg vs 225 mg, p<0.01), with no difference in median hospital length of stay (3 days vs 3 days, p=1.0) or 30-day readmission rate (9.4% vs 7.1%, p=0.66). There was no difference in patient-reported pain between the pre- and post-implementation cohorts on the day of discharge (severity 4.93 vs 5.14, p=0.53) or in any patient-reported symptoms, interference measures, or composite scores by post-discharge day 7. The median recovery time for most symptoms was 7 days, except for pain (14 days), fatigue (18 days), and physical interference (21 days), with no differences between cohorts.ConclusionsAfter implementation of a tiered opioid prescribing algorithm, the quantity and dose of discharge opioids prescribed decreased with no change in post-operative refills and without negatively impacting patient-reported symptom burden or interference, which can be used to educate and reassure patients and providers.

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PROPER—PRehabilitatiOn Plus Enhanced Recovery after surgery versus enhanced recovery after surgery in gynecologic oncology: a randomized clinical trial

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2021-003170 ◽

2021 ◽

pp. ijgc-2021-003170

Author(s):

Andre Lopes ◽

Alayne Magalhães Trindade Domingues Yamada ◽

Thais de Campos Cardenas ◽

Jaqueline Nunes de Carvalho ◽

Emília de Azevedo Oliveira ◽

...

Keyword(s):

Hospital Stay ◽

Functional Capacity ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Preoperative Care ◽

Gynecologic Surgery ◽

Calorie Intake ◽

Control Group ◽

Gynecological Surgery ◽

The Impact

BackgroundPrehabilitation is a process that occurs before surgery and aims to improve patient functional capacity and enhance surgical recovery. This process includes medical, nutritional, physical, and psychological interventions that may reduce the duration of hospital stay and provide postoperative physical benefits.Primary ObjectiveTo evaluate the impact of a prehabilitation program on postoperative recovery time for patients who will undergo gynecological surgery following the Enhanced Recovery After Surgery (ERAS) guidelines.Study HypothesisA multidisciplinary, preoperative prehabilitation program for patients who will undergo gynecological surgery leads to a reduction in the length of hospital stay and improves patient functional capacity.Trial DesignProspective, interventionist, and randomized controlled trial in a 1:1 ratio, open to multidisciplinary team and patients, blinded to surgeons and anesthesiologists. The control group will undergo ERAS standard preoperative care while the intervention group will have ERAS standard preoperative care plus prehabilitation.Major Inclusion CriteriaPatients scheduled to undergo gynecologic surgery performed by laparotomy with a preoperative schedule that allows prehabilitation intervention for 2 to 3 weeks.Primary EndpointTo compare time between surgery and the day the patient is ready for discharge in patients who underwent the prehabilitation process versus those who did not. Readiness for discharge is defined as the ability to take care of one’s-self, to walk alone, and to ingest at least 75% of daily recommended calorie intake.Sample Size194 participantsEstimated Dates for Completing Accrual and Presenting ResultsAt present, 30 patients have been recruited. Accrual should be completed by 2023–24.Trial RegistrationThe study is approved by the IBCC – São Camilo Oncologia ethics committee (reference number 4.256.553) and is registered at clinicaltrials.gov (NCT04596800).

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Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000268 ◽

2019 ◽

Vol 29 (4) ◽

pp. 810-815 ◽

Cited By ~ 4

Author(s):

Basile Pache ◽

Jonas Jurt ◽

Fabian Grass ◽

Martin Hübner ◽

Nicolas Demartines ◽

...

Keyword(s):

Hospital Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Complication Rates ◽

Prolonged Length ◽

Academic Center ◽

The Impact

IntroductionEnhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.MethodsRetrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.ResultsA total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I–V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).ConclusionsCompliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

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Role and impact of multimodal prehabilitation for gynecologic oncology patients in an Enhanced Recovery After Surgery (ERAS) program

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000597 ◽

2019 ◽

Vol 29 (8) ◽

pp. 1235-1243 ◽

Cited By ~ 7

Author(s):

Ester Miralpeix ◽

Gemma Mancebo ◽

Sonia Gayete ◽

Marta Corcoy ◽

Josep-Maria Solé-Sedeño

Keyword(s):

Functional Capacity ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Psychological Support ◽

Gynecologic Surgery ◽

Nutritional Counseling ◽

Oncology Patients ◽

Operative Recovery ◽

Eras Protocol

Patients undergoing major surgery are predisposed to a decrease in functional capacity as a response to surgical stress that can delay post-operative recovery. A prehabilitation program consists of patient preparation strategies before surgery, and include pre-operative measures to improve functional capacity and enhance post-operative recovery. Multimodal prehabilitation may include exercise, nutritional counseling, psychological support, and optimization of underlying medical conditions, as well as cessation of unfavorable health behaviors such as smoking and drinking. Currently, there are no standardized guidelines for prehabilitation, and the existent studies are heterogeneous; however, multimodal approaches are likely to have a greater impact on functional outcomes than single management programs. We have reviewed the literature on prehabilitation in general, and in gynecologic surgery in particular, to identify tools to establish an optimal prehabilitation program within an Enhanced Recovery After Surgery (ERAS) protocol for gynecologic oncology patients. We suggest a safe, reproducible, functional, and easy-to-apply multimodal prehabilitation program for gynecologic oncology practice based on patient-tailored pre-operative medical optimization, physical training, nutritional counseling, and psychological support. The analysis of the prehabilitation program implementation in an ERAS protocol should undergo further research in order to test the efficacy on surgical outcome and recovery after surgery.

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