Post-Cesarean Opioid Use after Implementation of Enhanced Recovery after Surgery Protocol

2020 ◽  
Author(s):  
Caitlin A. MacGregor ◽  
Mark Neerhof ◽  
Mary J. Sperling ◽  
David Alspach ◽  
Beth A. Plunkett ◽  
...  
Keyword(s):  
Pain Management ◽  
Pain Score ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Opioid Use ◽  
Trial Of Labor ◽  
Cesarean Deliveries ◽  
Preoperative Diet ◽  
Eras Protocol ◽  
Postoperative Morphine

Objective This study aimed to evaluate whether implementation of an enhanced recovery after surgery (ERAS) protocol is associated with lower maternal opioid use after cesarean delivery (CD). Study Design We performed a pre- and postimplementation (PRE and POST, respectively) study of an ERAS protocol for cesarean deliveries. ERAS is a multimodal, multidisciplinary perioperative approach. The four pillars of our protocol include education, pain management, nutrition, and early ambulation. Patients were counseled by their outpatient providers and given an educational booklet. Pain management included gabapentin and acetaminophen immediately prior to spinal anesthesia. Postoperatively patients received scheduled acetaminophen and ibuprofen. Oxycodone was initiated as needed 24 hours after spinal analgesia. Preoperative diet consisted of clear carbohydrate drink consumed 2 hours prior to scheduled operative time with advancement as tolerated immediately postoperation. Women with a body mass index (BMI) <40 kg/m2 and scheduled CD were eligible for ERAS. PRE patients were randomly selected from repeat cesarean deliveries (RCDs) at a single site from October 2017 to September 2018, BMI <40 kg/m2, without trial of labor. The POST cohort included women who participated in ERAS from October 2018 to June 2019. PRE and POST demographic and clinical characteristics were compared. Primary outcome was total postoperative morphine milligram equivalents (MMEs). Secondary outcomes included length of stay (LOS) and maximum postoperative day 2 (POD2) pain score. Results All women in PRE (n = 70) had RCD compared with 66.2% (49/74) in POST. Median total postoperative MMEs were 140.0 (interquartile range [IQR]: 87.5–182.5) in PRE compared with 0.0 (IQR: 0.0–72.5) in POST (p < 0.001). Median LOS in PRE was 4.02 days (IQR: 3.26–4.27) compared with 2.37 days (IQR: 2.21–3.26) in POST (p < 0.001). Mean maximum POD2 pain score was 5.28 (standard deviation [SD] = 1.86) in PRE compared with 4.67 (SD = 1.63) in POST (p = 0.04). Conclusion ERAS protocol was associated with decreased postoperative opioid use, shorter LOS, and decreased pain after CD. Key Points

scholarly journals Oral Versus Intravenous Acetaminophen within an Enhanced Recovery after Surgery Protocol in Colorectal Surgery

2020 ◽  
Vol 1;23 (1;1) ◽  
pp. 57-64 ◽  
Author(s):  
Joseph H. Marcotte
Keyword(s):  
Pain Management ◽  
Colorectal Surgery ◽  
Postoperative Nausea ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Postoperative Nausea And Vomiting ◽  
Opioid Use ◽  
Patient Controlled Analgesia ◽  
Pain Scores ◽  
Eras Protocol

Background: Multimodal pain management within enhanced recovery after surgery (ERAS) protocols is designed to decrease opioid use, promote mobilization, and decrease postoperative complications. Objectives: To evaluate the role of intravenous (IV) versus oral (PO) acetaminophen within an established ERAS protocol in colorectal surgery. Study Design: This was a retrospective observational study. Setting: This research took place within an established perioperative colorectal surgery protocol. Methods: A total of 91 consecutive elective colorectal resections performed according to an ERAS protocol using only IV acetaminophen (IV group) were compared with 84 consecutive resections performed using one dose of IV acetaminophen followed by subsequent administration of oral acetaminophen (PO group). Our multimodal pain management strategy also included transverse abdominis plane blocks, celecoxib, and ketorolac medications for both groups. Opioid requirements, maximum and average daily pain scores by the Visual Analog Scale, and postoperative outcomes were compared between groups. Results: There were no differences in maximum or average pain scores on postoperative days 0-3 or at time of discharge between IV and PO groups. Compared with the IV acetaminophen only group, the PO group received significantly more perioperative opioids through 72 hours postoperatively (68.8 oral morphine equivalents [OME] IV group vs. 93.7 OME PO group; P < 0.0001), were more likely to require opioid patient-controlled analgesia (8.9% IV group vs. 46.4% PO group; P < 0.0001), and were more likely to experience postoperative nausea and vomiting (33.0% IV group vs. 48.8% PO group; P = 0.0449). Limitations: Significant limitations include the studies’ retrospective nature and that it was performed at a single institution. Conclusions: Restriction of IV acetaminophen within an ERAS protocol in colorectal surgery was associated with increased opioid use, greater need for opioid patient-controlled analgesia, and increased incidence of postoperative nausea and vomiting. IV acetaminophen may be superior to oral acetaminophen in the early postoperative setting. Key words: Perioperative pain management, enhanced recovery after surgery, acetaminophen, multimodal pain control, nonopioid

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

Pain Medicine ◽  
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 &lt; 0.001, 36.5% vs 70.9%, P &lt; 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 &lt; 0.001). ERAS patients mobilized faster on POD0 compared with control (63.5% vs 20.7%, P &lt; 0.001). Fewer patients in the ERAS group required postoperative catheterization (40.7% vs 32.7%, P &lt; 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.

scholarly journals The Clinical Efficacy and Safety of Enhanced Recovery After Surgery for Cesarean Section: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

2021 ◽  
Vol 8 ◽  
Author(s):  
Xianhua Meng ◽  
Kai Chen ◽  
Chenchen Yang ◽  
Hui Li ◽  
Xiaohong Wang
Keyword(s):  
Postoperative Pain ◽  
Postoperative Complications ◽  
Pain Score ◽  
Observational Studies ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Efficacy And Safety ◽  
Opioid Use ◽  
Randomized Controlled ◽  
Postoperative Pain Score

Background: Enhanced recovery after surgery (ERAS) has been adopted in some maternity units and studied extensively in cesarean section (CS) in the last years, showing encouraging results in clinic practice. However, the present evidence assessing the effectiveness of ERAS for CS remains weak, and there is a paucity in the published literature, especially in improving maternal outcomes. Our study aimed to systematically evaluate the clinical efficacy and safety of ERAS protocols for CS.Methods: A systematic literature search using Embase, PubMed, and the Cochrane Library was carried out up to October 2020. The appropriate randomized controlled trials (RCTs) and observational studies applying ERAS for patients undergoing CS were included in this study, comparing the effect of ERAS protocols with conventional care on length of hospital stay (LOS), readmission rate, incidence of postoperative complications, postoperative pain score, postoperative opioid use, and cost of hospitalization. All statistical analyses were conducted with the RevMan 5.3 software.Results: Ten studies (four RCTs and six observational studies) involving 16,391 patients were included. ERAS was associated with a decreased LOS (WMD −7.47 h, 95% CI: −8.36 to −6.59 h, p &lt; 0.00001) and lower incidence of postoperative complications (RR: 0.50, 95% CI: 0.37 to 0.68, p &lt; 0.00001). Moreover, pooled analysis showed that postoperative pain score (WMD: −1.23, 95% CI: −1.32 to −1.15, p &lt; 0.00001), opioid use (SMD: −0.46, 95% CI: −0.58 to −0.34, p &lt; 0.00001), and hospital cost (SMD:−0.54, 95% CI: −0.63 to −0.45, p &lt; 0.00001) were significantly lower in the ERAS group than in the conventional care group. No significant difference was observed with regard to readmission rate (RR: 0.86, 95% CI: 0.48 to 1.54, p = 0.62).Conclusions: The available evidence suggested that ERAS applying to CS significantly reduced postoperative complications, lowered the postoperative pain score and opioid use, shortened the hospital stay, and potentially reduced hospital cost without compromising readmission rates. Therefore, protocols implementing ERAS in CS appear to be effective and safe. However, the results should be interpreted with caution owing to the limited number and methodological quality of included studies; hence, future large, well-designed, and better methodological quality studies are needed to enhance the body of evidence.

scholarly journals Pain Management in Enhanced Recovery after Surgery (ERAS) Protocols

2019 ◽  
Vol 32 (02) ◽  
pp. 121-128 ◽  
Author(s):  
J. Simpson ◽  
Xiaodong Bao ◽  
Aalok Agarwala
Keyword(s):  
Colorectal Surgery ◽  
Pain Control ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Postoperative Nausea And Vomiting ◽  
Bowel Function ◽  
Opioid Therapy ◽  
Opioid Use ◽  
Early Return ◽  
Eras Protocol

AbstractPain control is an integral part of Enhanced Recovery after Surgery (ERAS) protocols for colorectal surgery. While opioid therapy remains the mainstay of therapy for postsurgical pain, opioids have undesired side effects including delayed recovery of bowel function, respiratory depression, and postoperative nausea and vomiting. A variety of nonopioid systemic medical therapies as well as regional and neuraxial techniques have been described as improving pain control while reducing opioid use. Multimodal and preemptive analgesia as part of an ERAS protocol facilitates early mobility and early return of bowel function and decreases postoperative morbidity. In this review, we examine several multimodal therapies and their impact on postoperative analgesia, opioid use, and recovery for patients undergoing colorectal surgery.

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

2019 ◽  
Vol 29 (5) ◽  
pp. 935-943 ◽  
Author(s):  
Amanda Rae Schwartz ◽  
Stephanie Lim ◽  
Gloria Broadwater ◽  
Lauren Cobb ◽  
Fidel Valea ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Oral Morphine ◽  
Gynecologic Surgery ◽  
Complication Rates ◽  
Opioid Use ◽  
Pain Scores ◽  
Significant Difference ◽  
Eras Protocol

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.

scholarly journals Multidisciplinary Cooperation Alleviates Postoperative Pain after Elective Craniotomies: A Prospective Randomized Controlled Study of Neurosurgical Enhanced Recovery After Surgery (ERAS) program

2020 ◽  
Author(s):  
Liang Qu ◽  
Yuan Wang ◽  
Bolin Liu ◽  
Haitao Zhang ◽  
Zhengmin Li ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Score ◽  
Rating Scale ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Conventional Care ◽  
Controlled Study ◽  
Control Group ◽  
Postoperative Pain Score ◽  
Eras Protocol

Abstract Objective: To prospectively evaluate the efficacy of neurosurgical enhanced recovery after surgery (ERAS) protocol on the management of postoperative pain after elective craniotomies. Methods: This randomised controlled trial was conducted in the neurosurgical center of Tangdu Hospital (Fourth Military Medical University, Xi’an, China). A total of 129 patients undergoing craniotomies between October 2016 and July 2017 were enrolled in a randomized clinical trial comparing ERAS protocol and conventional care. The primary outcome was the postoperative pain score assessed by a verbal numerical rating scale (NRS). Results: Patients in the ERAS group had a significant reduction in postoperative pain score on POD 1 compared to patients in the control group (mean NRS 3.12 vs. 4.44, OR 0.0968, 95% CI 0.3299 to 2.317, p = 0.010). More patients (n = 44, 68.8%) in the ERAS group experienced mild pain (NRS: 1 to 3) on POD1 compared with patients (n = 23, 35.4%) in the control group (p < 0.05). A significant reduction in pain score was observed on POD 2 and POD 3 in the ERAS group compared with that in the control group (POD2: mean NRS 2.85 vs. 4.32, OR 0.2628, 95% CI 0.5619 to 2.379, p=0.002. POD3: mean NRS 2.32 vs. 4.03, OR 0.1468, 95% CI 0.9537 to 2.458, p < 0.001, respectively). In addition, the median postoperative length of hospital stay was significantly decreased with the incorporation of ERAS protocol compared to the controls (ERAS: 4 days, control: 7 days, P<0.001). Conclusion: Implementation of the neurosurgical ERAS protocol for elective craniotomy patients have significant benefits in alleviating postoperative pain and enhancing recovery after surgery compared to the conventional care. Further evaluation of this protocol in larger, multi-center studies is warranted.

scholarly journals Enhanced Recovery After Surgery Multi-Modality Pain Regimen Performs Similar to PRN Narcotics on Outcomes and Pain Control After Cardiac Surgery: A Quality Improvement Project

2021 ◽  
Author(s):  
David Blitzer ◽  
Chad T. Blackshear ◽  
Jameika Stuckey ◽  
Leslie Kruse ◽  
Lawrence L. Creswell ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Quality Improvement ◽  
Pain Management ◽  
Pain Control ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Quality Improvement Project ◽  
Improvement Project ◽  
Patient Reported ◽  
Eras Protocol

Background: While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psycho-emotional outcomes while decreasing the use of opioids in the hospital and after discharge. Methods: As part of a 7-month quality improvement project, cardiac surgery patients on a fast tracked to extubate pathway were assigned PRN narcotic pain management for 3 months (n=49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n=34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at 4 time-points post-surgery. Results: Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p>0.244). There were no differences between ERAS and PRN groups for surgery characteristics (all p>0.060), inpatient outcomes (all p>0.658), or after-discharge outcomes (all p>0.397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p>0.075). Conclusions: An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.

Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy

2021 ◽  
pp. 000313482110246
Author(s):  
Arad Abadi ◽  
Robbin Cohen
Keyword(s):  
Cardiac Surgery ◽  
Pain Management ◽  
Length Of Stay ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Intercostal Nerve ◽  
Opioid Use ◽  
Intercostal Nerve Block ◽  
Multimodal Pain Management ◽  
Management Protocol

Background Recent guidelines for perioperative care in cardiac surgery recommend multimodal pain management to decrease opioid use. We evaluated the effect of multimodal pain management including parasternal intercostal nerve block on pain control and opioid use in patients who underwent coronary artery bypass grafting (CABG) requiring sternotomy and cardiopulmonary bypass. Study Design Medical records of consecutive patients who underwent CABG from 2018 to 2019 at Huntington Hospital were retrospectively queried. Patients were divided in 2 groups based on whether an Enhanced Recovery After Surgery (ERAS) pain management protocol including parasternal intercostal nerve blocks was employed. Outcomes, including length of stay, pain scores, and opioid use, were compared. Results There was no difference in length of stay (days) 5.43 vs. 5.38 ( P = .45 and average pain score 2.23 vs. 3.27 ( P = .137) for patients in the ERAS and non-ERAS groups. Maximum pain score, 7.74 to 6.15 ( P = .015), and opioid use (total morphine mg equivalent), 149.64 to 32.01 ( P < .01), were reduced in the ERAS group. Conclusion The ERAS multimodal pain management protocol utilizing intraoperative parasternal blocks appears to reduce pain and decrease opioid use after CABG.

Enhanced Recovery After Surgery Protocol with Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption

2021 ◽  
Author(s):  
David M Straughan ◽  
John T Lindsey ◽  
Michelle McCarthy ◽  
Davey Legendre ◽  
John T Lindsey
Keyword(s):  
Pain Management ◽  
Postoperative Pain ◽  
Plastic Surgery ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Ultrasound Guided ◽  
Pain Scores ◽  
Average Pain ◽  
Eras Protocol ◽  
Regional Anesthetic

Abstract Background Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain. Objective This paper aims to be the first to assess the efficacy of an ERAS protocol inclusive of ultrasound-guided, surgeon-led regional blocks for outpatient plastic surgery patients. Methods A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, anti-nausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain had ultrasound-guided anesthetic blocks. Results There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioids (332.3 vs. 100.3 morphine milligram equivalents (MME)/patient; p &lt; 0.001), anti-nausea (664 vs. 16.3mg of promethazine/patient; p &lt; 0.001), and antispasmodic (401.3 vs. 31.2mg of cyclobenzaprine/patient; p &lt; 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient post-operatively. Average pain scores in this group peaked at 5.32 on POD1 and then decreased significantly daily. Conclusions Implementation of an ERAS protocol for outpatient plastic surgery patients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy.

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