scholarly journals Enhanced recovery after cystectomy in patients with preoperative narcotic use

2021 ◽  
Vol 15 (11) ◽  
Author(s):  
Saum Ghodoussipour ◽  
Alireza Ghoreifi ◽  
Behdod Katebian ◽  
Brian H. Cameron ◽  
Anirban P. Mitra ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Radical Cystectomy ◽  
Enhanced Recovery ◽  
Opioid Use ◽  
Gastrointestinal Complications ◽  
Median Hospital Stay ◽  
Pain Scores ◽  
History Of ◽  
Open Radical Cystectomy ◽  
Eras Protocol

Introduction: The aim of this study was to evaluate the outcomes of radical cystectomy with an enhanced recovery after surgery (ERAS) protocol in patients with a history of chronic preoperative narcotic use compared to narcotic-naive patients. Methods: We identified 553 patients who underwent open radical cystectomy with ERAS. Preoperative narcotic use was identified in 34 patients who were then matched to 68 narcotic-naive patients. Postoperative outcomes, opioid use, and visual analog scale (VAS) pain scores were analyzed and compared. All routes of opioid use were recorded and converted to a morphine equivalent dose (MED). Results: Patients with preoperative narcotic use reported higher median VAS pain scores per day (POD1: 5.2 vs. 3.9, p=0.003; POD2: 5.1 vs. 3.6, p<0.001; POD3: 4.6 vs. 3.8, p=0.004) and used significantly more opioids (median MED) per day (POD1: 13.2 vs. 10.0, p=0.02; POD2: 11.3 vs. 6.4, p=0.003; POD3: 10.2 vs. 5.0, p=0.005) following surgery. Preoperative narcotic users were noted to have a significantly higher incidence of 90-day readmissions (41.2% vs. 20.6%, p=0.03). There was no difference in median hospital stay (4 vs. 4 days, p=0.6), 30- or 90-day complications (64.7% vs. 60.3%, p=0.8 and 82.4% vs. 75.0%, p=0.4, respectively) or gastrointestinal complications (29.4% vs. 26.5%, p=0.8), including postoperative ileus (11.8% vs. 20.6%, p=0.2). Conclusions: Patients with preoperative narcotic exposure report higher pain scores and require more opioid use following radical cystectomy with ERAS and are more likely to be readmitted within 90 days. However, there was no observed difference in hospital stay or complications.

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.

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study

2020 ◽  
Vol 0 (0) ◽  
Author(s):  
G. Niraj ◽  
Zubair Tariq ◽  
Ashani Ratnayake ◽  
Benjamin. L Jackson ◽  
Mehar Ahson ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Radical Cystectomy ◽  
Postoperative Ileus ◽  
Enhanced Recovery ◽  
Length Of Hospital Stay ◽  
Erector Spinae ◽  
Opioid Analgesia ◽  
The Novel ◽  
Thoracic Epidural ◽  
Open Radical Cystectomy

AbstractObjectivesBowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23–40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy.MethodsWe performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening.ResultsCombined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes.ConclusionsESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

scholarly journals Challenging boundaries: an enhanced recovery programme for radical cystectomy

2013 ◽  
Vol 95 (3) ◽  
pp. 200-206 ◽  
Author(s):  
S Mukhtar ◽  
BE Ayres ◽  
R Issa ◽  
MJ Swinn ◽  
MJA Perry
Keyword(s):  
Hospital Stay ◽  
Radical Cystectomy ◽  
Outcome Measures ◽  
Enhanced Recovery ◽  
Length Of Hospital Stay ◽  
Operation Time ◽  
Secondary Outcome ◽  
Complication Rates ◽  
Icu Stay ◽  
Open Radical Cystectomy

Introduction The implementation of enhanced recovery programmes (ERPs) in colorectal surgery has seen improvements in the length of inpatient stay with no increase in complications. We investigated the role of ERP in radical cystectomy at our institution. Methods Prospective data were collected from 26 consecutive patients prior to the introduction of the ERP and 51 patients who underwent open radical cystectomy within an ERP. Individuals in the ERP cohort did not receive bowel preparation or nasogastric drainage but received preoperative carbohydrate drinks, perioperative epidural analgesia and immediate mobilisation on day 1. Primary outcome measures included duration of intensive care unit (ICU) stay and length of hospital stay. Secondary outcome measures included the time to the passage of flatus and faeces, and time to mobilisation. Other measures that were analysed included operation time and complications. Results Baseline characteristics for both groups were similar. The median length of hospital stay fell from 11.5 days to 10.4 days and the mean ICU stay dropped from 2.4 days to 1.0 days (p=0.01). Time to removal of nasogastric tube, and time to passage of flatus and faeces were significantly shorter in the ERP group, as was the time to full oral diet. Clavien complication rates and 30-day mortality rates were similar in both groups. There were no readmissions. Conclusions ERP in radical cystectomy is safe and not associated with any increase in complications or readmissions. It is associated with reductions in ICU stay, and could also reduce length of hospital stay and duration of postoperative ileus.

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 Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial

2021 ◽  
Vol 6 (1) ◽  
pp. e000698
Author(s):  
Vijayan Purushothaman ◽  
Pratyusha Priyadarshini ◽  
Dinesh Bagaria ◽  
Mohit Joshi ◽  
Narendra Choudhary ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Controlled Trial ◽  
Bowel Function ◽  
Emergency Laparotomy ◽  
Duration Of Hospital Stay ◽  
Randomized Controlled ◽  
Pain Scores ◽  
Eras Protocol

BackgroundThe role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma.MethodsIn this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate.ResultsThirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups.ConclusionERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications.Level of evidenceLevel 1, randomized controlled trial, care management.Trial registration numberClinical Trials Registry of India (CTRI/2019/06/019533).

Usage of Intravenous Lidocaine Infusion with Enhanced Recovery Pathway in Patients Scheduled for Open Radical Cystectomy: A Randomized Trial

2019 ◽  
Vol 2 (22.2) ◽  
pp. E71-E81
Author(s):  
Seham M. Moeen
Keyword(s):  
Radical Cystectomy ◽  
Enhanced Recovery ◽  
Length Of Hospital Stay ◽  
Bowel Function ◽  
Control Group ◽  
Double Blind ◽  
Lidocaine Group ◽  
Enhanced Recovery Pathway ◽  
Pain Scores ◽  
Open Radical Cystectomy

Background: Intravenous lidocaine infusion (IVLI) reduces postoperative pain and hastens the return of bowel function. Objectives: We aimed to compare the effects of adding lidocaine infusion to enhanced recovery pathway (ERP) on acute rehabilitation protocol. Study Design: This study uses a double-blind, randomized design with allocation concealment in a 2-armed parallel group format among patients undergoing open radical cystectomy (RC). Setting: The study was conducted at Assiut University Hospital, Asyut, Egypt. The study duration was March 2017 to July 2018. Methods: After ethics committee approval, 111 patients, American Society of Anesthesiologists (ASA) physical status II-III, aged 45-65 years, scheduled for open RC with urinary diversion under an ERP, were randomly selected in a double-blind manner to receive IVLI 2 mg/minute for 4 hours or an equal volume of normal saline solution 0.9%. Postoperative pain scores, rescue analgesic consumption, times to return of bowel sounds, first flatus, first defecation, resuming of regular diet, length of hospital stay, in-hospital complications, and patient satisfaction were recorded. Results: Patients in the lidocaine group experienced significantly lower pain scores after surgery at 6 hours (P = 0.005) and 12 hours (P = 0.001) at rest, and in the first 18 hours during mobilization (P < 0.05), with less paracetamol (P = 0.04) and meperidine (P = 0.02) consumption than in the control group. Between the lidocaine and the control group, mean times to return of bowel sounds (23.7 vs. 26.7 hours; P = 0.001), first flatus (76.5 vs. 86.5 hours; P = 0.001), first defecation (92.7 vs. 106.9 hours; P = 0.001) and resuming of regular diet (80.7 vs. 92.8 days; P = 0.001) were significantly shorter in the lidocaine group. Length of hospital stay, in-hospital complications, and patient satisfaction were similar in both groups. Limitations: Limitations of this study include lack of previous research that compare the additive effects of IVLI to ERP in patients undergoing open RC. Also, the inability to measure the serum lidocaine concentration in our patients. Conclusions: Adding IVLI to ERP improved postoperative analgesia and bowel function after open RC with urinary diversion. Clinical trial registration: NCT03047057. Key words: Lidocaine infusion, ileus, enhanced recovery pathway, acute rehabilitation, open radical cystectomy

scholarly journals “Enhanced recovery after surgery – ERAS in elective craniotomies-a non-randomized controlled trial”

BMC Neurology ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Anirudh Elayat ◽  
Sritam S. Jena ◽  
Sukdev Nayak ◽  
R. N. Sahu ◽  
Swagata Tripathy
Keyword(s):  
Randomized Controlled Trial ◽  
Glycemic Control ◽  
Hospital Stay ◽  
Enhanced Recovery ◽  
Enhanced Recovery After Surgery ◽  
Controlled Trial ◽  
Early Recovery ◽  
Randomized Controlled ◽  
Pain Scores ◽  
High Dependency

Abstract Background Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care bundle aimed at the early recovery of patients. Well accepted in gastric and pelvic surgeries, there is minimal evidence in neurosurgery and neurocritical care barring spinal surgeries. We wished to compare the length of intensive care unit (ICU) or high dependency unit (HDU) stay of patients undergoing elective craniotomy for supratentorial neurosurgery: ERAS protocol versus routine care. The secondary objective was to compare the postoperative pain scores, opioid use, glycemic control, and the duration of postoperative hospital stay between the two groups. Methods In this pragmatic non-randomized controlled trial (CTRI/2017/07/015451), consenting adult patients scheduled for elective supratentorial intracranial tumor excision were enrolled prospectively after institutional ethical clearance and consent. Elements-of-care in the ERAS group were- Preoperative –family education, complex-carbohydrate drink, flupiritine; Intraoperative – scalp blocks, limited opioids, rigorous fluid and temperature regulation; Postoperative- flupiritine, early mobilization, removal of catheters, and initiation of feeds. Apart from these, all perioperative protocols and management strategies were similar between groups. The two groups were compared with regards to the length of ICU stay, pain scores in ICU, opioid requirement, glycemic control, and hospital stay duration. The decision for discharge from ICU and hospital, data collection, and analysis was by independent assessors blind to the patient group. Results Seventy patients were enrolled. Baseline demographics – age, sex, tumor volume, and comorbidities were comparable between the groups. The proportion of patients staying in the ICU for less than 48 h after surgery, the cumulative insulin requirement, and the episodes of VAS scores > 4 in the first 48 h after surgery was significantly less in the ERAS group – 40.6% vs. 65.7%, 0.6 (±2.5) units vs. 3.6 (±8.1) units, and one vs. ten episodes (p = 0.04, 0.001, 0.004 respectively). The total hospital stay was similar in both groups. Conclusion The study demonstrated a significant reduction in the proportion of patients requiring ICU/ HDU stay > 48 h. Better pain and glycemic control in the postoperative period may have contributed to a decreased stay. More extensive randomized studies may be designed to confirm these results. Trial registration Clinical Trial Registry of India (CTRI/2018/04/013247), registered retrospectively on April 2018.

scholarly journals The Association between Implementation an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

2021 ◽  
Author(s):  
Jennifer A. McCoy ◽  
Sarah Gutman ◽  
Rebecca F. Hamm ◽  
Sindhu K. Srinivas
Keyword(s):  
Cesarean Delivery ◽  
Pain Control ◽  
Enhanced Recovery ◽  
Median Number ◽  
Baseline Survey ◽  
Quality Improvement Initiative ◽  
Opioid Use ◽  
Pain Scores ◽  
Patient Reported ◽  
Hospital Patients

Objective This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use. Study Design We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge. Results Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90–195] PRE to 114 [range: 45–168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5–8] vs. POST 5 [range: 3–7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16–30] vs. POST 17.5 [range: 4–25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2–6] vs. POST 3[range: 1–5], p = 0.03). Conclusion Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients. Key Points

Stereotactic Electroencephalography Is Associated With Reduced Pain and Opioid Use When Compared with Subdural Grids: A Case Series

2021 ◽  
Author(s):  
Jonathan P Scoville ◽  
Evan Joyce ◽  
Joshua Hunsaker ◽  
Jared Reese ◽  
Herschel Wilde ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Chart Review ◽  
Statistical Tests ◽  
Case Series ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Opioid Use ◽  
Pain Scores ◽  
Surgical Methods ◽  
Significant Difference

Abstract BACKGROUND Minimally invasive surgery (MIS) has been shown to decrease length of hospital stay and opioid use. OBJECTIVE To identify whether surgery for epilepsy mapping via MIS stereotactically placed electroencephalography (SEEG) electrodes decreased overall opioid use when compared with craniotomy for EEG grid placement (ECoG). METHODS Patients who underwent surgery for epilepsy mapping, either SEEG or ECoG, were identified through retrospective chart review from 2015 through 2018. The hospital stay was separated into specific time periods to distinguish opioid use immediately postoperatively, throughout the rest of the stay and at discharge. The total amount of opioids consumed during each period was calculated by transforming all types of opioids into their morphine equivalents (ME). Pain scores were also collected using a modification of the Clinically Aligned Pain Assessment (CAPA) scale. The 2 surgical groups were compared using appropriate statistical tests. RESULTS The study identified 43 patients who met the inclusion criteria: 36 underwent SEEG placement and 17 underwent craniotomy grid placement. There was a statistically significant difference in median opioid consumption per hospital stay between the ECoG and the SEEG placement groups, 307.8 vs 71.5 ME, respectively (P = .0011). There was also a significant difference in CAPA scales between the 2 groups (P = .0117). CONCLUSION Opioid use is significantly lower in patients who undergo MIS epilepsy mapping via SEEG compared with those who undergo the more invasive ECoG procedure. As part of efforts to decrease the overall opioid burden, these results should be considered by patients and surgeons when deciding on surgical methods.

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