Defining Enhanced Recovery Pathway with or without Liposomal Bupivacaine in DIEP Flap Breast Reconstruction

Abstract Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

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Do Patient Expectations of Discharge Affect Length of Stay after Deep Inferior Epigastric Perforator Flap for Breast Reconstruction?

Journal of Reconstructive Microsurgery ◽

10.1055/s-0041-1727201 ◽

2021 ◽

Author(s):

Ravinder Bamba ◽

Jordan E. Wiebe ◽

Christopher A. Ingersol ◽

Steven Dawson ◽

Mithun Sinha ◽

...

Keyword(s):

Length Of Stay ◽

Breast Reconstruction ◽

Enhanced Recovery ◽

Perforator Flap ◽

Patient Expectations ◽

Outcome Variable ◽

Diep Flap ◽

Group I ◽

Group Ii ◽

Eras Protocol

Abstract Introduction Deep inferior epigastric artery perforator (DIEP) flap is a common method of breast reconstruction. Enhanced recovery after surgery (ERAS) postoperative protocols have been used to optimize patient outcomes and facilitate shorter hospital stays. The effect of patient expectations on length of stay (LOS) after DIEP has not been evaluated. The purpose of this study was to investigate whether patient expectations affect LOS. Methods A retrospective chart review was performed for patients undergoing DIEP flaps for breast reconstruction from 2017 to 2020. All patients were managed with the same ERAS protocol. Patients were divided in Group I (early expectations) and Group II (standard expectations). Group I patients had expectations set for discharge postoperative day (POD) 2 for unilateral DIEP and POD 3 for bilateral DIEP. Group II patients were given expectations for POD 3 to 4 for unilateral DIEP and POD 4 to 5 for bilateral. The primary outcome variable was LOS. Results The study included 215 DIEP flaps (45 unilateral and 85 bilateral). The average age was 49.8 years old, and the average body mass index (BMI) was 31.4. Group I (early expectations) included 56 patients (24 unilateral DIEPs, 32 bilateral). Group II (standard expectations) had 74 patients (21 unilateral, 53 bilateral). LOS for unilateral DIEP was 2.9 days for Group I compared with 3.7 days for Group II (p = 0.004). Group I bilateral DIEP patients had LOS of 3.5 days compared with 3.9 days for Group II (p = 0.02). Immediate timing of DIEP (Group I 42.9 vs. Group II 52.7%) and BMI (Group I 32.1 vs. Group II 30.8) were similar (p = 0.25). Conclusion Our study found significantly shorter hospital stay after DIEP flap for patients who expected an earlier discharge date despite similar patient characteristics and uniform ERAS protocol. Patient expectations should be considered during patient counseling and as a confounding variable when analyzing ERAS protocols.

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Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

The Breast ◽

10.1016/j.breast.2021.08.010 ◽

2021 ◽

Author(s):

N. Gort ◽

B.G.I. van Gaal ◽

H.J.P. Tielemans ◽

D.J.O. Ulrich ◽

S. Hummelink

Keyword(s):

Breast Reconstruction ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Diep Flap ◽

Positive Effects ◽

Eras Protocol

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Liposomal Bupivacaine Transversus Abdominis Plane Block Versus Epidural Analgesia in a Colon and Rectal Surgery Enhanced Recovery Pathway

Diseases of the Colon & Rectum ◽

10.1097/dcr.0000000000001211 ◽

2018 ◽

Vol 61 (10) ◽

pp. 1196-1204 ◽

Cited By ~ 28

Author(s):

Daniel R. Felling ◽

Miles W. Jackson ◽

Jane Ferraro ◽

Michael A. Battaglia ◽

Jeremy J. Albright ◽

...

Keyword(s):

Epidural Analgesia ◽

Enhanced Recovery ◽

Rectal Surgery ◽

Transversus Abdominis Plane Block ◽

Transversus Abdominis ◽

Colon And Rectal Surgery ◽

Transversus Abdominis Plane ◽

Enhanced Recovery Pathway ◽

Liposomal Bupivacaine

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1607 Seeing White: Management of TIVA During Autologous Breast Reconstruction

British Journal of Surgery ◽

10.1093/bjs/znab259.735 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

P Vigneswaran ◽

R Clancy ◽

S Choo ◽

S Love-Jones ◽

P Jackson ◽

...

Keyword(s):

Breast Reconstruction ◽

Enhanced Recovery ◽

Standard Operating Procedure ◽

Venous Drainage ◽

Cephalic Vein ◽

Diep Flap ◽

Anaesthetic Agents ◽

Free Flap Surgery ◽

Ensure Patient Safety ◽

Effective Delivery

Abstract Background Free flap surgery has inherent risks, and the venous drainage of the Deep Inferior Epigastric Perforator (DIEP) flap is particularly vulnerable to congestion. In these cases, an algorithm for flap salvage should be followed and one of the final steps in this process is a cephalic vein transposition. Case Report We describe two patients undergoing mastectomy and immediate bilateral DIEP breast reconstruction, where cephalic vein transposition was required. As part of the Enhanced Recovery After Surgery (ERAS) pathway, patients are anaesthetised with a continuous propofol infusion (Total Intravenous Anaesthesia; TIVA). When the cephalic vein was identified, the propofol infusion was visible within the vein, which would have interrupted TIVA if harvested. To maintain continuous TIVA infusion, the cannula was resited prior to harvest of the cephalic vein. The cephalic vein was anastomosed to the superficial inferior epigastric vein and resolution of the venous congestion was noted. Conclusions These cases although rare highlight the importance of robust preoperative planning and communication between the team and preparation for all eventualities to ensure patient safety and successful outcomes. These cases highlight the potential effects vein harvesting or transposition may have on the safe and effective delivery of anaesthetic agents and other medication. We hope these cases prompt a discussion in the preoperative stage for alternate strategies for monitoring and intravenous access in response to diversions from the standard operating procedure.

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