Pharmacotherapeutic prophylaxis and post-operative outcomes within an Enhanced Recovery After Surgery (ERAS®) program: A randomized retrospective cohort study

Abstract

Background Pharmacotherapy prophylaxis embedded in Enhanced Recovery After Surgery (ERAS®) protocols is largely unknown because data related to agent choice, dosing, timing, and duration of treatment currently are not collected in the ERAS Interactive Audit System (EIAS®). This exploratory retrospective randomized cohort study characterized pharmacologic regimens pertaining to prophylaxis of surgical site infections (SSI), venous thromboembolism (VTE), and post-operative nausea and vomiting (PONV). Materials and methods The records of 250 randomly-selected adult patients that underwent elective colorectal (CR) and gynecologic/oncology procedures (GO) at an ERAS® site in North America were abstracted using REDCap. In addition to descriptive statistics, bivariate associations between categorical variables were compared. Results Rates of SSI, VTE, & PONV were 3.3%, 1.1%, and 53.6%, respectively. Mean length of stay (LOS) for CR was 6.9 days and for GO, 3.5 days (p < 0.001). The most common antibiotic prophylaxis was one-time combination cefazolin 2 g and metronidazole 500 mg between 16 and 30 min preoperatively after chlorhexidine skin preparation. The most frequent VTE prophylaxis was tinzaparin 4500 units SC daily continued for at least 7 days after hospital discharge in oncology patients. PONV was related to longer LOS in both groups. Total morphine milligram equivalents (MME) was positively related to PONV and LOS in both CR & GO groups. Conclusion Guideline-consistent pharmacologic prophylaxis for SSI and VTE for both CR and GO patients was associated with low complication, LOS, and readmission rates. LOS in both groups was highly influenced by total MME, incidence of PONV and multi-modal anesthesia.

Enhanced recovery after surgery (ERAS®) Society abdominal and thoracic surgery recommendations: A systematic review and comparison of guidelines for perioperative and pharmacotherapy core items

“…Comparative pharmacotherapy research has recently been conducted to assess perioperative-related WORLD JOURNAL OF SURGERY -519 regimens in colorectal and gynecologic/oncology procedures as well as the prevention of common postoperative complications. [26][27][28] ERAS ® guidelines are written by experts in various surgical and perioperative specialties from across the world and are somewhat "drug selection-agnostic" because of the variation of pharmaceutical availability in different markets as well as a built-in flexibility to account for drug shortages. While application of ERAS ® guidelines have been shown to increase favorable patient outcomes, 5 additional benefits may be derived by standardizing pharmacotherapy for ATS.…”

“…Also, ERAS ® guidelines have not been developed for all types of surgeries, including thyroid and parathyroid glands, renal transplantation, and pediatric surgeries (other than neonatal). Comparative pharmacotherapy research has recently been conducted to assess perioperative‐related regimens in colorectal and gynecologic/oncology procedures as well as the prevention of common postoperative complications 26–28 . ERAS ® guidelines are written by experts in various surgical and perioperative specialties from across the world and are somewhat “drug selection‐agnostic” because of the variation of pharmaceutical availability in different markets as well as a built‐in flexibility to account for drug shortages.…”

Effect of Pharmacoprophylaxis on Postoperative Outcomes in Adult Elective Colorectal Surgery: A Multi-Center Retrospective Cohort Study within an Enhanced Recovery after Surgery Framework

“…The adoption of enhanced recovery after surgery (ERAS ® ) core items has been shown to decrease serious postoperative complications (POCs) and reduce postoperative hospital length of stay (LOS), readmission rates, and overall hospital costs [1][2][3][4][5][6][7][8][9]. Protocolized prophylaxis of common POCs with pharmacotherapy, such as surgical site infection (SSI) with appropriate antibiotics [10][11][12][13], venous thromboembolism (VTE) with anticoagulants [14][15][16][17], and postoperative nausea and vomiting (PONV) using multi-modal approaches [18][19][20][21][22][23], among others, coupled with preoperative risk assessments [24][25][26][27][28][29][30][31][32][33][34], has become more prevalent in surgical practice.…”

“…Protocolized prophylaxis of common POCs with pharmacotherapy, such as surgical site infection (SSI) with appropriate antibiotics [10][11][12][13], venous thromboembolism (VTE) with anticoagulants [14][15][16][17], and postoperative nausea and vomiting (PONV) using multi-modal approaches [18][19][20][21][22][23], among others, coupled with preoperative risk assessments [24][25][26][27][28][29][30][31][32][33][34], has become more prevalent in surgical practice. Still, elucidation of pharmacotherapy regimens associated with lower POCs, LOS, and readmission remains somewhat nascent [5,13,16,35,36]. Moreover, estimates of the impact of pharmacotherapy prophylaxis on the attainment of positive patient outcomes in hospitals with "homegrown" enhanced recovery audit and feedback systems are publicly non-existent unless reported on public-facing hospital webpages, which, according to some reports, may be misleading information [37,38].…”

Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews

“…Enhanced postoperative recovery programs are evidence-based, multimodal, multidisciplinary approaches to the care of a surgical patient that involves a perioperative team aimed at reducing operative stress responses by increasing patient resilience, preventing and minimizing postoperative complications, and decreasing hospitalization [ 1 , 2 ]. The pharmacotherapy embedded into enhanced recovery programs and protocols (ERPs) has only recently received attention in the scientific and professional literature [ 3 , 4 , 5 , 6 , 7 , 8 ]. Often conducted outside of ERAS ® Society sites and protocols, many reports are retrospective and single-center in nature, and earlier reports evaluated programmatic compliance with consensus-generated guidelines and recommendations from various perioperative groups.…”