Enhanced recovery after surgery multimodality pain regimen performs similar to PRN narcotics on outcomes and pain control after cardiac surgery: A quality improvement project

Abstract

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 psychoemotional 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 pro re nata (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 four-time points after 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 > .244). There were no differences between ERAS and PRN groups for surgery characteristics (all p > .060), inpatient outcomes (all p > .658), or after-discharge outcomes (all p > .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 > .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.

The Enhanced Recovery after Surgery Approach in Heart Valve Surgery: A Systematic Review of Clinical Studies

“…We identified 2312 papers in the literature search, and their abstracts were reviewed. There were 14 studies that fulfilled the final search criteria and were ultimately included in the review [15][16][17][18][19][20][21][22][23][24][25][26][27][28] (Table 1). The PRISMA search flow diagram and checklist are available in Supplemental Figure S1 and Supplemental Table S1.…”

“…Overall, 5142 patients were identified in the 14 studies, with 2501 patients who underwent cardiac surgery following an ERAS protocol and 2641 patients representing control groups. One study was an RCT and included 209 patients [15], four studies provided propensity-match analyses [22,[26][27][28] (2416 patients), and the remaining nine papers were observational cohort studies [16][17][18][19][20][21][23][24][25] (2495 patients). Seven experiences exclusively included patients who underwent heart valve surgery [20,21,23,24,[26][27][28], while mixed case series were reported in the remaining papers with a prevalence of heart valve procedures ranging from 10% up to 50%.…”

“…Several experiences recommended shortening the nihil per os period and allowed the consumption of clear fluid until 2-4 h before surgery [15,[17][18][19]22,25,26,28] and solid food until 6-8 h preoperatively [19,26,28]. A carbohydrate drink of 200 mL or 400 mL was prescribed 2-6 h before surgery [15][16][17][18][19]22,25,26] as an adjunct to maintain gut motility and to be used as an energy source (protein-sparing effect) [17].…”

“…Multimodal analgesia has been embedded in most of the studies included in this review [15,[19][20][21][22][23][24][25][26]28], with wide heterogeneity according to the choice of drugs and the timing and dose of administration. Seven protocols contemplated preoperative analgesia starting before the transfer to the operative theatre, aiming for a reduction in opioid use in the postoperative period [16][17][18][19][20]22,24]. This pre-emptive analgesia usually included paracetamol (acetaminophen), gabapentin or pregabalin.…”

“…The prevention of nausea and vomiting represented a key action in the postoperative period in several experiences [15][16][17][18][19]22,25,26]. Different protocols were provided with the use of stat doses or the continuous infusion of i.v.…”