scholarly journals Implementation of an Enhanced Recovery After Spine Surgery program at a large cancer center: a preliminary analysis

2018 ◽  
Vol 29 (5) ◽  
pp. 588-598 ◽  
Author(s):  
Roxana M. Grasu ◽  
Juan P. Cata ◽  
Anh Q. Dang ◽  
Claudio E. Tatsui ◽  
Laurence D. Rhines ◽  
...  
Keyword(s):  
Spine Surgery ◽  
Enhanced Recovery ◽  
Recovery Process ◽  
Postoperative Recovery ◽  
Opioid Consumption ◽  
Pelvic Surgery ◽  
Cancer Center ◽  
Team Approach ◽  
Pain Scores ◽  
The Impact

OBJECTIVEEnhanced Recovery After Surgery (ERAS) programs follow a multimodal, multidisciplinary perioperative care approach that combines evidence-based perioperative strategies to accelerate the functional recovery process and improve surgical outcomes. Despite increasing evidence that supports the use of ERAS programs in gastrointestinal and pelvic surgery, data regarding the development of ERAS programs in spine surgery are scarce. To evaluate the impact of an Enhanced Recovery After Spine Surgery (ERSS) program in a US academic cancer center, the authors introduced such a program and hypothesized that ERSS would have a significant influence on meaningful clinical measures of postoperative recovery, such as pain management, postoperative length of stay (LOS), and complications.METHODSA multimodal, multidisciplinary, continuously evolving team approach was used to develop an ERAS program for all patients undergoing spine surgery for metastatic tumors at The University of Texas MD Anderson Cancer Center from April 2015 through September 2016. This study describes the introduction of that ERSS program and compares 41 patients who participated in ERSS with a retrospective cohort of 56 patients who underwent surgery before implementation of the program. The primary objectives were to assess the effect of an ERSS program on immediate postoperative pain scores and in-hospital opioid consumption. The secondary objectives included assessing the effect of ERSS on postoperative in-hospital LOS, 30-day readmission rates, and 30-day postoperative complications.RESULTSThe ERSS group showed a trend toward better pain scores and decreased opioid consumption compared with the pre-ERSS group. There were no significant differences in LOS, 30-day readmission rate, or 30-day complication rate observed between the two groups.RESULTSAn ERSS program is feasible and potentially effective on perioperative pain control and opioid consumption, and can expedite recovery in oncological spine surgery patients. Larger-scale research on well-defined postoperative recovery outcomes is needed.

scholarly journals Influence of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain, and quality of recovery after adult spine surgery

2018 ◽  
Vol 28 (1) ◽  
pp. 119-126 ◽  
Author(s):  
Lauren K. Dunn ◽  
Marcel E. Durieux ◽  
Lucas G. Fernández ◽  
Siny Tsang ◽  
Emily E. Smith-Straesser ◽  
...  
Keyword(s):  
Spine Surgery ◽  
Rating Scale ◽  
Psychological Intervention ◽  
Opioid Consumption ◽  
Anxiety And Depression ◽  
Opioid Use ◽  
Quality Of Recovery ◽  
Pain Scores ◽  
The Impact

OBJECTIVEPerception of perioperative pain is influenced by various psychological factors. The aim of this study was to determine the impact of catastrophizing, anxiety, and depression on in-hospital opioid consumption, pain scores, and quality of recovery in adults who underwent spine surgery.METHODSPatients undergoing spine surgery were enrolled in this study, and the preoperatively completed questionnaires included the verbal rating scale (VRS), Pain Catastrophizing Scale (PCS), Hospital Anxiety and Depression Scale (HADS), and Oswestry Disability Index (ODI). Quality of recovery was assessed using the 40-item Quality of Recovery questionnaire (QoR40). Opioid consumption and pain scores according to the VRS were recorded daily until discharge.RESULTSOne hundred thirty-nine patients were recruited for the study, and 101 completed the QoR40 assessment postoperatively. Patients with higher catastrophizing scores were more likely to have higher maximum pain scores postoperatively (estimate: 0.03, SE: 0.01, p = 0.02), without increased opioid use (estimate: 0.44, SE: 0.27, p = 0.11). Preoperative anxiety (estimate: 1.18, SE: 0.65, p = 0.07) and depression scores (estimate: 1.06, SE: 0.71, p = 0.14) did not correlate with increased postoperative opioid use; however, patients with higher preoperative depression scores had lower quality of recovery after surgery (estimate: −1.9, SE: 0.56, p < 0.001).CONCLUSIONSCatastrophizing, anxiety, and depression play important roles in modulating postoperative pain. Preoperative evaluation of these factors, utilizing a validated tool, helps to identify patients at risk. This might allow for earlier psychological intervention that could reduce pain severity and improve the quality of recovery.

scholarly journals Introduction of an enhanced recovery protocol into a laparoscopic living donor nephrectomy programme

2020 ◽  
Vol 102 (3) ◽  
pp. 204-208 ◽  
Author(s):  
T Brown ◽  
F Magill ◽  
N Beckett ◽  
S Kanabar ◽  
J Monserez ◽  
...  
Keyword(s):  
Living Donor ◽  
Enhanced Recovery ◽  
Postoperative Recovery ◽  
Donor Nephrectomy ◽  
Fluid Restriction ◽  
Potential Donor ◽  
Living Donor Nephrectomy ◽  
Pain Scores ◽  
Enhanced Recovery Protocol ◽  
The Impact

Introduction Living-donor renal transplantation is the optimal treatment for patients with end-stage renal disease. The rate of living donation in the UK is sub-optimal, and potential donor concerns regarding postoperative recovery may be contributory. Enhanced recovery programmes are well described for a number of surgical procedures, but experience in living-donor surgery is sparse. This study reports the impact of introducing an enhanced recovery protocol into a living-donor renal transplant programme. Materials and methods All consecutive patients undergoing laparoscopic living-donor nephrectomy over a 25-month period were included. The principles of enhanced recovery were fluid restriction, morphine sparing and expectation management. Outcome measures were postoperative pain scores and complications for donor and recipients. Results Standard care was provided for 24 (30%) patients and 57 (70%) followed an enhanced recovery pathway. The latter group received significantly less preoperative intravenous fluid (0ml vs 841ml p < 000.1) and opiate medication (14.83mg vs 23.85mg p = 0.001). Pain scores, postoperative complications and recipient transplant outcomes were comparable in both groups. Conclusions Enhanced recovery for living-donor nephrectomy is a safe approach for donors and recipients. Application of these techniques and further refinement should be pursued to enhance the experience of living donors.

scholarly journals Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

2019 ◽  
Vol 46 (4) ◽  
pp. E8 ◽  
Author(s):  
Ellen M. Soffin ◽  
Douglas S. Wetmore ◽  
James D. Beckman ◽  
Evan D. Sheha ◽  
Avani S. Vaishnav ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Spine Surgery ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Opioid Consumption ◽  
Postoperative Phase ◽  
Matched Cohort ◽  
Spinal Decompression ◽  
Process Measures ◽  
Pain Scores

OBJECTIVEEnhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).METHODSThe authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.RESULTSThere was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).CONCLUSIONSOFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.

scholarly journals Adoption of Enhanced Surgical Recovery (ESR) Protocol for Lumbar Fusion Decreases In-Hospital Postoperative Opioid Consumption

2021 ◽  
pp. 219256822110156
Author(s):  
Ehsan Jazini ◽  
Alexandra E. Thomson ◽  
Andre D. Sabet ◽  
Leah Y. Carreon ◽  
Rita Roy ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Length Of Stay ◽  
Transition Period ◽  
Urinary Catheter ◽  
Lumbar Fusion ◽  
Secondary Analysis ◽  
Opioid Consumption ◽  
Catheter Removal ◽  
Pain Scores ◽  
The Impact

Study Design: Retrospective observational cohort. Objectives: We sought to evaluate the impact of ESR on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. Methods: We evaluated patients undergoing lumbar fusion surgery at a single, multi-surgeon center in the transition period prior to (N = 174) and after (N = 116) adoption of ESR, comparing in-hospital and 90-day postoperative opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ESR and length of stay, urinary catheter removal and ambulation after surgery. Results: Mean age study participants was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the Pre-ESR and ESR groups. ESR patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ESR patients. There was no difference in 90-day opioid consumption between the 2 groups. Regression analysis showed that ESR was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in Morphine Milligram Equivalents (MME). In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Pre-op pain sores were associated with 90-day opioid consumption. Secondary analysis showed that ESR was associated with a shorter length of stay and earlier ambulation. Conclusions: This study showed ESR has the potential to improve recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

2021 ◽  
pp. 1-9
Author(s):  
Marie-Jacqueline Reisener ◽  
Alexander P. Hughes ◽  
Ichiro Okano ◽  
Jiaqi Zhu ◽  
Artine Arzani ◽  
...  
Keyword(s):  
Side Effects ◽  
Spine Surgery ◽  
Effect Size ◽  
Lumbar Fusion ◽  
Opioid Consumption ◽  
Opioid Use ◽  
Chi Square ◽  
Opioid Prescribing ◽  
Pain Scores ◽  
Stewardship Program

OBJECTIVE Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. METHODS The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0–10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher’s exact tests) and multivariable (Wald’s chi-square test) analyses. RESULTS In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20–60 mg] vs 20 mg [IQR 11–39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188–575 mg] vs 199 mg [100–372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60–135 mg] vs 60 mg [IQR 45–80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3–6] vs 5 [IQR 3–6], p = 0.33), nursing floor pain scores (4 [IQR 3–5] vs 4 [IQR 3–5], p = 0.93), or total LOS (118 hours [IQR 81–173 hours] vs 103 hours [IQR 81–132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald’s chi square = 9.45, effect size −52.4, 95% confidence interval [CI] −86 to −19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald’s chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald’s chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). CONCLUSIONS A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

The Impact of Alvimopan on Return of Bowel Function After Major Spine Surgery – A Prospective, Randomized, Double-Blind Study

Neurosurgery ◽  
2019 ◽  
Vol 85 (2) ◽  
pp. E233-E239
Author(s):  
Lauren K Dunn ◽  
Robert H Thiele ◽  
Michelle C Lin ◽  
Edward C Nemergut ◽  
Marcel E Durieux ◽  
...  
Keyword(s):  
Spine Surgery ◽  
Bowel Movement ◽  
Bowel Function ◽  
Blind Study ◽  
Double Blind Study ◽  
Opioid Use ◽  
Double Blind ◽  
Pain Scores ◽  
Significant Difference ◽  
The Impact

Abstract BACKGROUND Pain management following major spine surgery requires high doses of opioids and is associated with a risk of opioid-induced constipation. Peripheral mu-receptor antagonists decrease the gastrointestinal complications of perioperative systemic opioid administration without antagonizing the analgesic benefits of these drugs. OBJECTIVE To investigate the impact of alvimopan in opioid-naive patients undergoing major spine surgery. METHODS Patients undergoing >3 levels of thoracic and/or lumbar spine surgery were enrolled in this prospective, randomized, double-blind study to receive either alvimopan or placebo prior to and following surgery. Opioid consumption; pain scores; and time of first oral intake, flatus, and bowel movement were recorded. RESULTS A total of 24 patients were assigned to the active group and 25 were assigned to the placebo group. There was no significant difference in demographics between the groups. Postoperatively, the alvimopan group reported earlier time to first solid intake [median (range): alvimopan: 15 h (3-25) vs placebo: 17 h (3-46), P < .001], passing of flatus [median (range): alvimopan: 22 h (7-63) vs placebo: 28 h (10-58), P < .001], and first bowel movement [median (range): alvimopan: 50 h (22-80) vs placebo: 64 h (40-114), P < .001]. The alvimopan group had higher pain scores (maximum, minimum, and median); however, there was no significant difference between the groups with postoperative opioid use. CONCLUSION This study shows that the perioperative use of alvimopan significantly reduced the time to return of bowel function with no increase in postoperative opioid use despite a slight increase in pain scores.

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

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

scholarly journals The Impact of NSAID Use After Lumbar Fusion Surgery on Fusion Rate and Complications: A Meta-Analysis

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Yahya Othman ◽  
Avani Vaishnav ◽  
Steven Mcanany ◽  
Sravisht Iyer ◽  
Todd Albert ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Spine Surgery ◽  
Spinal Surgery ◽  
Meta Analysis ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
The Impact

Abstract INTRODUCTION The purpose of this study is to compile data presented in literature regarding the efficacy of incorporating NSAIDs in the postoperative course for patients undergoing spine surgery, in particular its impact on pain levels, opioid use, complications, and hospital length of stay METHODS This is a meta-analysis and systematic review. A literature search was conducted using the backbone search [spinal surgery] [Nsaid] [complications]. Criteria for inclusion are as follows: use of NSAIDs for postoperative pain management of spinal surgery, comparison between NSAID and NSAID-free cohort, and reporting on any of pain scores, hospital opioid use, hospital length of stay, complications rate, and operative outcomes. RESULTS Out of 799 studies, 19 studies met the inclusion criteria. A total of 1522 patient were included in this analysis. The studies included randomized controlled trials, Prospective and retrospective cohorts. Operations included discectomies, laminectomies, and fusions. Most commonly regimens included the NSAID Ketorelac, as in injection given immediately postoperatively. Patients that received NSAID analgesia postoperatively had significantly lower VAS pain scores at 1 and 12 h postoperatively. This group also had a significantly lower opioid consumption and shorter hospital length of stay. A total of 7 fusion studies reported on arthrodesis, showing a significantly lower odds of fusion after NSAIDs use, however after subgrouping according to smoking, this difference proves to be no longer significant. CONCLUSION Incorporation of NSAIDs into the postoperative regimen for analgesia in patients undergoing spine surgery is an effective approach in reducing hospital length of stay, patient reported pain scores, hospital opioid use, and has no increased risk of complications. Furthermore, use of NSAIDs in the nonsmoking population does not seem to affect arthrodesis rates in patients undergoing spine surgery.

scholarly journals Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and none-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study

2021 ◽  
Author(s):  
Zhong-En Li ◽  
Shi-Bao Lu ◽  
Chao Kong ◽  
Wen-Zhi Sun ◽  
Peng Wang ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Elderly Patients ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Postoperative Recovery ◽  
Demographic Characteristics ◽  
Care Group ◽  
Pain Scores ◽  
Lumbar Arthrodesis ◽  
Traditional Care

Abstract Background: Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over none-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with none-ERAS traditional care.Methods: During January 2018 to December 2018, patients enrolled received none-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected.Result: A total of 127 patients were enrolled, including 67 patients in the none-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6±4.0 days) was significantly less than that of patients treated with none-ERAS traditional care (15.6±3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the none-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%.Conclusions: Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than none-ERAS traditional care.

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