The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer

Rogers, Luke; Bleetman, David; Messenger, David E.; Joshi, Natasha; Wood, Lesley; Rasburn, Neil; Batchelor, Tim

doi:10.1016/j.jtcvs.2017.10.151

Cited by 212 publications

(173 citation statements)

References 32 publications

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“…32 High compliance has been associated with shorter LOS and superior outcomes in large trials of ERAS in other surgical disciplines. 2,24 In light of this, our findings that 13% of the cohort received an opioid analgesic in the PACU for an NRS score ≤ 4 and a further 13% received intravenous opioid were unexpected. Our ERAS pathway stratifies pain scores and opioid prescribing, and as structured, an NRS score ≤ 4 is treated with nonopioid analgesics, and escalation to intravenous opioid is contingent on assessment by the anesthesiologist.…”

Section: Fig 3 Leftmentioning

confidence: 88%

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

Soffin

Wetmore

Beckman

et al. 2019

Neurosurgical Focus

111

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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.

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Section: Fig 3 Leftmentioning

confidence: 88%

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

Soffin

Wetmore

Beckman

et al. 2019

Neurosurgical Focus

111

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“…ERAS programs have previously been scrutinized due to the increased risk of readmission particularly in colorectal cancer surgery [44], possibly due to early discharge [45]. However, this concern has not been realized in urological [46], gynaecological [47], and lung surgery [48]. This observed difference could be because gastric cancer surgery is intrinsically a higher-risk surgery, with complication rates reported in the literature to be as high as 45% [49,50].…”

Section: Discussionmentioning

confidence: 99%

Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials

et al. 2019

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Introduction Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain. Methods A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888). Results Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI − 3.06 to − 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI − 1.02 to − 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI − USD$ 5580 to − USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively. Conclusion Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.

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“…Attempts to parse out the specific, high-impact components of an individual ERP on outcomes have been made 18 but it remains challenging to look at each intervention's statistical impact in a multifaceted, multidisciplinary quality improvement program. This will be an ongoing challenge as many programs seek to add ERP to their institution, and want to know which aspects are most valuable.…”

Section: Resultsmentioning

confidence: 99%

Enhanced Recovery after Thoracic Surgery

Martin

2020

Semin Respir Crit Care Med

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Enhanced recovery programs (ERPs) aim to reduce psychological and physiological stress related to surgery, and minimize opioid use. This article describes the tenets of enhanced recovery, the guidelines for ERP in lung surgery, and the University of Virginia experience with developing and implementing a program. The impact of these strategies on short-term patient outcomes and potential long-term benefits including influence on lung cancer-specific outcomes are reviewed. The opioid crisis is of utmost importance; this article will explore how ERPs may be a mitigating factor.

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The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer

Abstract: Increased compliance with an Enhanced Recovery After Surgery pathway is associated with improved clinical outcomes after resection for primary lung cancer. Several elements, including early mobilization, appear to be more influential than others.

Cited by 212 publications

References 32 publications

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

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

Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials

Enhanced Recovery after Thoracic Surgery

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