Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection

Abstract

Background Enhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol. Methods Electronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre-and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach. Results A total of 64 pre-and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p \ 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p \ 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p \ 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005). Conclusions Implementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization.

Updates to Thoracic Procedures: Perioperative Care and Anesthetic Considerations

“…And while improving the quality of patient recovery remains the focus, the speed and efficiency of postoperative recovery is also improved with ERATS pathways, as demonstrated by a statistically significant decrease in postoperative time to removal of chest drains, time to enteral nutrition, and time to ambulation [9]. The net result of these improvements is a reduction in hospital and ICU length of stay as well as an overall decrease in hospital costs [10,11]. For patients undergoing pulmonary resections for malignancy, this quicker return to baseline also means a quicker return to intended oncologic treatments, positively affecting the ability of those patients to initiate and complete adjuvant chemotherapy and radiation [4].…”

“…In 2018, the ERAS® Society and the European Society of Thoracic Surgeons (ESTS) released recommendations for enhanced recovery after lung surgery [5]. However, ERATS protocols remain largely institution specific in the United States [11].…”

“…Gamma-aminobutyric acid (GABA) analogs such a gabapentin and pregabalin, target neuropathic pain pathways, and while they have demonstrated efficacy in multiple neuropathic pain conditions, multiple studies have failed to show that these agents reduce either acute or chronic postoperative pain following thoracic surgery [5,11,32,37]. Furthermore, it was not shown to alleviate the ipsilateral shoulder pain commonly seen in patients receiving TEA [5].…”

The effect of intraoperative goal-directed fluid therapy combined with enhanced recovery after surgery program on postoperative complications in elderly patients undergoing thoracoscopic pulmonary resection: a prospective randomized controlled study

“…Enhanced recovery after surgery (ERAS) integrates perioperative interventions to maintain physiological function, decrease postoperative complications and facilitate postoperative recovery. In thoracic and lung surgery, ERAS program could reduce intensive care unit (ICU) admission, shorten thoracic drainage duration, ICU and hospitalization LOS [5,6], decrease postoperative pulmonary and cardiovascular complications [7][8][9]. Perioperative uid management is one key component of ERAS program, restrictive uid therapy (RFT) was recommended within ERAS program in lung surgery [10].…”

It’s Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate

“…Enhanced Recovery After Surgery protocols are evidence based, multidisciplinary, multimodal perioperative pathways designed to improve patient safety and surgical outcomes with the goal of faster recovery and decreased hospitalization 24 . Enhanced Recovery After Surgery protocols are well established in fields such as colorectal 25,26 and thoracic surgery, 27 but they are not as commonplace in craniofacial surgery 28–30 . It is hypothesized that the current ERAS protocol with use of trephine drill harvest ICBG and iliac crest donor site pain pumps results in a short hospital LOS, low pain scores, and few re-operations or readmissions.…”