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Uhlman K, Behroozian T, Lewandowski N, Yuan M, Kim P, Hatchell A, Voineskos S, Temple-Oberle C, Thoma A. Quality of plastic surgery Enhanced Recovery After Surgery (ERAS) studies: A systematic review. J Plast Reconstr Aesthet Surg 2025; 101:106-118. [PMID: 39729950 DOI: 10.1016/j.bjps.2024.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 11/25/2024] [Indexed: 12/29/2024]
Abstract
BACKGROUND In effort to improve post-operative outcomes, enhanced recovery after surgery (ERAS) protocols have gained popularity. The objective of this systematic review was to assess the reporting and methodological quality of plastic surgery ERAS studies. METHODS All plastic surgery ERAS implementation studies, published between January 1, 2020, to November 20, 2023, were included. The primary outcome was reporting quality based on "The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist" (40 points). Secondary outcomes included methodology quality as per ERAS® Society endorsed guidelines (Breast 18 points; Head and Neck (H&N) 24 points). RESULTS Fifty ERAS studies were included (breast reconstruction: 29, 58%; head and neck: 7, 14%; craniofacial: 6, 12%; aesthetic: 5, 10%; other: 3, 6%). Average reporting quality was 22.6/40 (56.7%). ERAS protocol elements least adhered to included: patient warming strategy (8/50, 16%), management of post-operative fluids (14/50, 28%), and post-discharge outcome tracking (14/50, 28%). Evaluation of breast methodological quality revealed average compliance of 9.2/18 (51.3%). The least complied with elements included preoperative computed tomography angiography (4/23, 17.4%), intraoperative warming (6/23, 26.1%), and post-operative wound management (2/23, 8.7%). For head and neck studies, average compliance was 9.1/23 (39.6%). The least complied with elements included pre-anesthesia pain medications (1/7, 14.3%), post-operative wound care (0/7, 0%), and urinary catheterization removal (1/7, 14.3%). CONCLUSIONS ERAS implementation studies in plastic surgery are highly variable, with overall low reporting and methodology quality. Plastic surgeons should be cautious when adopting published ERAS protocols that do not adhere to the recommended and official ERAS® Society guidelines.
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Affiliation(s)
- Kathryn Uhlman
- Division of Plastic, Reconstructive, and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tara Behroozian
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Natalia Lewandowski
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Morgan Yuan
- Division of Plastic, Reconstructive, and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Patrick Kim
- McMaster University, Department of Surgery, Division of Plastic Surgery, Hamilton, ON, Canada
| | | | - Sophocles Voineskos
- Division of Plastic, Reconstructive, and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, Unity Health, Toronto, ON, Canada
| | | | - Achilles Thoma
- McMaster University, Department of Surgery, Division of Plastic Surgery, Hamilton, ON, Canada; McMaster University, Department of Health Research Methods, Evidence and Impact (HEI), Hamilton, ON, Canada.
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Wong JH, Na Y, Parsa FD. Evolving Toward Non-narcotic Perioperative Enhanced Recovery After Surgery and Opioid-Free Analgesia in the Management of Postoperative Pain. Cureus 2024; 16:e76605. [PMID: 39881918 PMCID: PMC11775738 DOI: 10.7759/cureus.76605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2024] [Indexed: 01/31/2025] Open
Abstract
Opioid medications are commonly employed for perioperative and postoperative pain management. However, these medications can negatively impact the body's innate pain management system, specifically the action of beta-endorphins. By impairing the function of mu-opioid receptors and inhibiting the release of beta-endorphin, opioids may exacerbate and prolong postoperative pain. Additionally, opioid use is associated with numerous side effects, including nausea, vomiting, constipation, excessive sedation, clouded sensorium, dizziness, respiratory depression, and addiction, all of which may impede postoperative patient recovery and outcome quality. The purpose of this article is to explore the intricate relationship between opioid medications and endogenous beta-endorphins, examine nonopioid modalities for postoperative pain control, and elucidate the applications of non-narcotic perioperative enhanced recovery after surgery protocols in improving patient outcomes.
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Affiliation(s)
- Justin H Wong
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - Yujin Na
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
| | - Fereydoun D Parsa
- Department of Surgery, Division of Plastic Surgery, University of Hawaii John A. Burns School of Medicine, Honolulu, USA
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Cata JP, Zaidi Y, Guerra-Londono JJ, Kharasch ED, Piotrowski M, Kee S, Cortes-Mejia NA, Gloria-Escobar JM, Thall PF, Lin R. Intraoperative methadone administration for total mastectomy: A single center retrospective study. J Clin Anesth 2024; 98:111572. [PMID: 39180867 PMCID: PMC11917523 DOI: 10.1016/j.jclinane.2024.111572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 06/15/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Breast cancer is the most frequent type of cancer and the second leading cause of cancer-related mortality in women. Mastectomies remain a key component of the treatment of non-metastatic breast cancer, and strategies to treat acute postoperative pain, a complication affecting nearly all patients undergoing surgery, continues to be an important clinical challenge. This study aimed to determine the impact of intraoperative methadone administration compared to conventional short-acting opioids on pain-related perioperative outcomes in women undergoing a mastectomy. METHODS This single-center retrospective study included adult women undergoing total mastectomy. The primary outcome of this study was postoperative pain intensity on day 1 after surgery. Secondary outcomes included perioperative opioid consumption, perioperative non-opioid analgesics use, duration of surgery and anesthesia, time to extubation, pain intensity in the postanesthesia care unit (PACU), anti-emetic use in PACU, and length of stay in hospital. We used the propensity score-based nearest matching with a 1:3 ratio to balance the patient baseline characteristics. RESULTS 133 patients received methadone, and 2192 patients were treated with short-acting opioids. The analysis demonstrated that methadone was associated with significantly lower intraoperative and postoperative opioid consumption as measured by oral morphine equivalents and lower average pain intensity scores in the postanesthesia care unit. Moreover, methadone was also shown to reduce the use of non-opioid analgesia during surgery. CONCLUSION Our study suggests that the unique pharmacological properties of methadone, including a short onset of action when given intravenously, long-acting pharmacokinetics, and multimodal effects, are associated with better acute pain management after a total mastectomy.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America; Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States of America; Anesthesiology and Surgical Oncology Research Group, Houston, TX, United States of America.
| | - Yusuf Zaidi
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Juan Jose Guerra-Londono
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America; Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Evan D Kharasch
- Department of Anesthesiology, Duke University, Durham, NC, United States of America
| | - Matthew Piotrowski
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Spencer Kee
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Nicolas A Cortes-Mejia
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Jose Miguel Gloria-Escobar
- Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, TX, United States of America
| | - Peter F Thall
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, United States of America
| | - Ruitao Lin
- Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States of America
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Esparham A, Shoar S, Whittington J, Shafaee Z. National Trends and In-Hospital Outcomes for Immediate Implant-Based Versus Autologous-Based Breast Reconstruction: A Propensity Score-Matched Analysis. Ann Surg Oncol 2024:10.1245/s10434-024-16255-z. [PMID: 39341914 DOI: 10.1245/s10434-024-16255-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 09/10/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Breast reconstruction consists primarily of two methods: autologous breast reconstruction (ABR) and implant-based breast reconstruction (IBR). Each of these methods has its advantages and disadvantages. The current study used the National Inpatient Sample (NIS), the largest inpatient database in the United States, to explore the trends, complications, and disparities in the use of IBR and ABR. METHODS The current study used the NIS database from 2016 to 2020, including the International Classification of Diseases, 10th version (ICD-10) codes. A propensity score-matching (1:1) analysis was used to match the IBR and ABR groups. RESULTS The percentage of breast reconstruction increased from 58.8% in 2016 to 63.4% by 2020. The trend of ABR was upward, and the trend of IBR was downward. In addition, the ABR group had significantly higher rates of cardiovascular complications (odds ratio [OR], 1.29), respiratory complications (OR, 4.26), vascular complications requiring surgery (OR, 7.82), blood transfusions (OR, 3.44), vasopressor need (OR, 1.409), and acute kidney injury (OR, 1.68). However, the ABR group had significantly lower rates of wound infection (OR, 0.430), wound dehiscence (OR, 0.213), wound seroma (OR, 0.602), and sepsis (OR, 0.252). A significant disparity was found in using ABR for different subgroups based on age, hospital teaching status, racial background, socioeconomic status, and hospital bed size. CONCLUSION The current study showed an upward trend in the utilization of ABR and a downward trend for IBR. Although ABR had a higher rate of pulmonary, cardiovascular, vascular, and bleeding complications, it had a lower rate of wound-related complications.
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Affiliation(s)
- Ali Esparham
- Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Shoar
- Department of Clinical Research, Scientific Writing Corporation, Houston, TX, USA
| | - Jennifer Whittington
- Department of Surgery, Icahn School of Medicine, New York, NY, USA
- Elmhurst Hospital, NYC Health + Hospitals, New York, NY, USA
| | - Zahra Shafaee
- Department of Surgery, Icahn School of Medicine, New York, NY, USA.
- Elmhurst Hospital, NYC Health + Hospitals, New York, NY, USA.
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Tarr JT, Coomer CL, Kim SY, Ng M. Overnight to Outpatient: A Single Institution's Experience With Mastectomy and Reconstruction Before and After the Start of the COVID-19 Pandemic. Ann Plast Surg 2024; 93:43-47. [PMID: 38885164 DOI: 10.1097/sap.0000000000003922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
PURPOSE Minimizing resource use while optimizing patient outcomes has become an ever-growing component in modern healthcare, especially in the era of COVID-19. One essential component of this is deciding whether patients need hospital admission following elective procedures. The aim of this study is to investigate operative factors and patient outcomes when mastectomies with or without reconstruction are performed as ambulatory procedures versus planned inpatient admissions. METHODS Patient charts for those undergoing mastectomy with or without reconstruction were retrospectively analyzed ranging from March 2019 until February 2021. Factors such as demographic information, operative type, operating room time, cancer stage, total stay time in the medical environment, and postoperative complications were assessed and compared between the 2 groups. RESULTS A total of 89 patient charts were reviewed, 46 from before the COVID-19 pandemic and 43 from after the start of the pandemic. No differences were observed in demographic factors between the 2 groups. After surgical cases resumed a significant proportion, 79%, of mastectomies with or without reconstruction were performed in the ambulatory center, versus just 2% pre-COVID-19. Similarly, of all of these cases performed, only 19% resulted in hospital admission versus the previous rate of 100% (P < 0.00001). Together, these changes resulted in a significant reduction in length of stay of 39.77 ± 19.2 hours pre-COVID-19 versus 14.81 ± 18.4 hours afterward (P < 0.00001). Unfortunately, a higher number of patients who received surgery after the start of the pandemic elected to forego immediate reconstruction 49% versus 72% (P = 0.032). Most importantly, there were no observable differences found in 7-day readmission, reoperation, or emergency department visit between groups. There was also no difference in 30-day complication rate between groups. CONCLUSIONS Mastectomy with or without reconstruction can be safely performed in the ambulatory setting without additional risk of complications or negative patient factors. This divergence from traditional the protocol of inpatient overnight admission may contribute positively toward patient comfort, minimize the use of healthcare costs and resources, and allow for increased scheduling flexibility for patient and provider alike.
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Affiliation(s)
- Joseph T Tarr
- From the Northwell Health, Division of Plastic and Reconstructive Surgery, Great Neck, NY
| | - Cynara L Coomer
- Texas Health Harris Methodist Fort Worth City, Fort Worth, TX
| | - Sara Y Kim
- Scripps Clinical Medical Group, La Jolla, CA
| | - Marilyn Ng
- Northwell Health, Division of Plastic and Reconstructive Surgery, Staten Island, NY
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Hatchell A, Osman M, Bielesch J, Temple-Oberle C. Acceptance of outpatient enhanced recovery after surgery (ERAS©) protocols for implant-based breast reconstruction nudged on by the COVID-19 pandemic. Breast 2024; 74:103689. [PMID: 38368765 PMCID: PMC10884541 DOI: 10.1016/j.breast.2024.103689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024] Open
Abstract
We retrospectively identified 295 women undergoing outpatient implant breast reconstruction (IBR) who received standardized ERAS care pre-pandemic (PP; April 2018-March 2020) and during the pandemic (DP; April 2020-March 2022). The majority of IBR was completed as outpatient surgeries DP versus PP (73% versus 38%, p < 0.001). Immediate IBR increased DP versus PP (p < 0.001). Preoperative ERAS© order sets were used 54% of the time. Lack of ERAS© order set use was associated with unplanned admissions (55.3% versus 44.7%, p = 0.02). COVID-19 changed health care and nudged IBR to outpatient procedures. With ERAS© recommendations, IBR can be safely and effectively transitioned to outpatient settings.
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Affiliation(s)
- Alexandra Hatchell
- Section of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.
| | - Mariam Osman
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jody Bielesch
- ERASAlberta Team, Surgery Strategic Clinical Network (SSCN™), Calgary, Alberta, Canada
| | - Claire Temple-Oberle
- Section of Plastic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
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Oostvogels L, Weibel S, Meißner M, Kranke P, Meyer-Frießem CH, Pogatzki-Zahn E, Schnabel A. Erector spinae plane block for postoperative pain. Cochrane Database Syst Rev 2024; 2:CD013763. [PMID: 38345071 PMCID: PMC10860379 DOI: 10.1002/14651858.cd013763.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Acute and chronic postoperative pain are important healthcare problems, which can be treated with a combination of opioids and regional anaesthesia. The erector spinae plane block (ESPB) is a new regional anaesthesia technique, which might be able to reduce opioid consumption and related side effects. OBJECTIVES To compare the analgesic effects and side effect profile of ESPB against no block, placebo block or other regional anaesthetic techniques. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and Web of Science on 4 January 2021 and updated the search on 3 January 2022. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating adults undergoing surgery with general anaesthesia were included. We included ESPB in comparison with no block, placebo blocks or other regional anaesthesia techniques irrespective of language, publication year, publication status or technique of regional anaesthesia used (ultrasound, landmarks or peripheral nerve stimulator). Quasi-RCTs, cluster-RCTs, cross-over trials and studies investigating co-interventions in either arm were excluded. DATA COLLECTION AND ANALYSIS Two review authors independently assessed all trials for inclusion and exclusion criteria, and risk of bias (RoB), and extracted data. We assessed risk of bias using the Cochrane RoB 2 tool, and we used GRADE to rate the certainty of evidence for the primary outcomes. The primary outcomes were postoperative pain at rest at 24 hours and block-related adverse events. Secondary outcomes were postoperative pain at rest (2, 48 hours) and during activity (2, 24 and 48 hours after surgery), chronic pain after three and six months, as well as cumulative oral morphine requirements at 2, 24 and 48 hours after surgery and rates of opioid-related side effects. MAIN RESULTS We identified 69 RCTs in the first search and included these in the systematic review. We included 64 RCTs (3973 participants) in the meta-analysis. The outcome postoperative pain was reported in 38 out of 64 studies; block-related adverse events were reported in 40 out of 64 studies. We assessed RoB as low in 44 (56%), some concerns in 24 (31%) and high in 10 (13%) of the study results. Overall, 57 studies reported one or both primary outcomes. Only one study reported results on chronic pain after surgery. In the updated literature search on 3 January 2022 we found 37 new studies and categorised these as awaiting classification. ESPB compared to no block There is probably a slight but not clinically relevant reduction in pain intensity at rest 24 hours after surgery in patients treated with ESPB compared to no block (visual analogue scale (VAS), 0 to 10 points) (mean difference (MD) -0.77 points, 95% confidence interval (CI) -1.08 to -0.46; 17 trials, 958 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between the groups treated with ESPB and those receiving no block (no events in 18 trials reported, 1045 participants, low-certainty evidence). ESPB compared to placebo block ESPB probably has no effect on postoperative pain intensity at rest 24 hours after surgery compared to placebo block (MD -0.14 points, 95% CI -0.29 to 0.00; 8 trials, 499 participants; moderate-certainty evidence). There may be no difference in block-related adverse events between ESPB and placebo blocks (no events in 10 trials reported; 592 participants; low-certainty evidence). ESPB compared to other regional anaesthetic techniques Paravertebral block (PVB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PVB (MD 0.23 points, 95% CI -0.06 to 0.52; 7 trials, 478 participants; low-certainty evidence). There is probably no difference in block-related adverse events (risk ratio (RR) 0.27, 95% CI 0.08 to 0.95; 7 trials, 522 participants; moderate-certainty evidence). Transversus abdominis plane block (TAPB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to TAPB (MD -0.16 points, 95% CI -0.46 to 0.14; 3 trials, 160 participants; low-certainty evidence). There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.21 to 4.83; 4 trials, 202 participants; low-certainty evidence). Serratus anterior plane block (SAPB) The effect on postoperative pain could not be assessed because no studies reported this outcome. There may be no difference in block-related adverse events (RR 1.00, 95% CI 0.06 to 15.59; 2 trials, 110 participants; low-certainty evidence). Pectoralis plane block (PECSB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to PECSB (MD 0.24 points, 95% CI -0.11 to 0.58; 2 trials, 98 participants; low-certainty evidence). The effect on block-related adverse events could not be assessed. Quadratus lumborum block (QLB) Only one study reported on each of the primary outcomes. Intercostal nerve block (ICNB) ESPB may not have any additional effect on postoperative pain intensity at rest 24 hours after surgery compared to ICNB, but this is uncertain (MD -0.33 points, 95% CI -3.02 to 2.35; 2 trials, 131 participants; very low-certainty evidence). There may be no difference in block-related adverse events, but this is uncertain (RR 0.09, 95% CI 0.04 to 2.28; 3 trials, 181 participants; very low-certainty evidence). Epidural analgesia (EA) We are uncertain whether ESPB has an effect on postoperative pain intensity at rest 24 hours after surgery compared to EA (MD 1.20 points, 95% CI -2.52 to 4.93; 2 trials, 81 participants; very low-certainty evidence). A risk ratio for block-related adverse events was not estimable because only one study reported this outcome. AUTHORS' CONCLUSIONS ESPB in addition to standard care probably does not improve postoperative pain intensity 24 hours after surgery compared to no block. The number of block-related adverse events following ESPB was low. Further research is required to study the possibility of extending the duration of analgesia. We identified 37 new studies in the updated search and there are three ongoing studies, suggesting possible changes to the effect estimates and the certainty of the evidence in the future.
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Affiliation(s)
- Lisa Oostvogels
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Stephanie Weibel
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Michael Meißner
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Management, BG-Universitätsklinikum Bergmannsheil gGmbH, Bochum, Germany
| | - Esther Pogatzki-Zahn
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
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Pierzchajlo N, Zibitt M, Hinson C, Stokes JA, Neil ZD, Pierzchajlo G, Gendreau J, Buchanan PJ. Enhanced recovery after surgery pathways for deep inferior epigastric perforator flap breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2023; 87:259-272. [PMID: 37924717 DOI: 10.1016/j.bjps.2023.10.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/29/2023] [Accepted: 10/07/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach. METHODS Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4). RESULTS A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [-1.30, -0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [-181.43, -26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [-4.43, -2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [-125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant. CONCLUSIONS The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol.
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Affiliation(s)
| | | | - Chandler Hinson
- Frederick P. Whiddon College of Medicine, University of South Alabama, Mobile, AL, USA
| | | | | | | | - Julian Gendreau
- Department of Biomedical Engineering, Johns Hopkins, Baltimore, MD, USA
| | - Patrick J Buchanan
- Plastic, Aesthetic, & Hand/Micro Surgeon, The Georgia Institute for Plastic Surgery, Savannah, GA, USA
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9
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Xia Z, Chen Y, Xie J, Zhang W, Tan L, Shi Y, Liu J, Wang X, Tan G, Zeng A. Faster Return to Daily Activities and Better Pain Control: A Prospective Study of Enhanced Recovery After Surgery Protocol in Breast Augmentation. Aesthetic Plast Surg 2023; 47:2261-2267. [PMID: 37488312 DOI: 10.1007/s00266-023-03504-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/30/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been proven to decrease the amount of opioid use and reduce postoperative pain for a variety of surgeries, including breast reconstruction. However, data on ERAS in breast augmentation is lacking. OBJECTIVES This study aims to investigate the effectiveness and safety of ERAS for breast augmentation. METHODS A standardized ERAS protocol was established with full consideration of all aspects of perioperative care. Patients undergoing implant-based breast augmentation were prospectively recruited between December 2020 and January 2023, and assigned to either the ERAS or non-ERAS group randomly. The primary outcome was the activity of daily living after surgery. The secondary was postoperative pain and other outcomes included time to freely elevation, vomiting frequency, the use of analgesics, and complications. RESULTS A total of 122 patients were included, with 70 in the ERAS group and 52 in the non-ERAS group. Compared to non-ERAS patients, ERAS patients had a shorter time to freely elevation of upper limbs (2.3 d vs. 5.5 d, P < 0.001). For ERAS patients, the pain scores were significantly lower on postoperative days 1 to 3, the activity of daily living index was significantly higher on postoperative days 1 to 3 and the opioids consumption was decreased (7.1 mg vs. 46.2 mg, P = 0.018). No difference was observed in complication and hospital costs between the two groups. CONCLUSION The ERAS protocol significantly reduced postoperative pain and the use of opioids and promoted a return to daily activities without increasing complications in breast augmentation. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Zenan Xia
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Yuliang Chen
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Jiangmiao Xie
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Wenchao Zhang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Linjuan Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Yanping Shi
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Jie Liu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Xiaojun Wang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Gang Tan
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China
| | - Ang Zeng
- Department of Plastic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, P. R. China.
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10
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Taba G, Ceccato V, Fernandes O, Michel S, Darrigues L, Girard N, Gauroy E, Pauly L, Gaillard T, Reyal F, Hotton J. Impact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management. J Plast Reconstr Aesthet Surg 2023; 85:202-209. [PMID: 37524032 DOI: 10.1016/j.bjps.2023.06.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/12/2023] [Accepted: 06/29/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs are associated with improved management, reduced hospital stays, and lower complication rates. OBJECTIVE To evaluate the impact of ERAS on mean length of stay (LOS) and postoperative morbidity in breast reconstruction with latissimus dorsi flap (LDF) compared with conventional recovery program. PATIENTS AND METHOD All patients operated by LDF between December 2014 and October 2020: those managed before April 2018, when the ERAS protocol was introduced, were included in the "no ERAS" group, and beyond in the "ERAS" group. RESULTS Out of 193 patients, 129 were included in the "ERAS" group and 64 in the "no ERAS" group. There was a significant difference between the two groups in LOS (4.2 ± 1.5 days in the "ERAS" group vs. 5.4 ± 1.9 days in the "no ERAS" group; p < 0.001), high-grade complications at 30 days (9.3% in the "ERAS" group vs. 25% in the "no ERAS" group; p = 0.01), reintervention rate (13.9% vs. 26.6%, respectively; p = 0.02), and 30-day rehospitalization rate (6.2% in the "ERAS" group vs. 15.6% in the "no ERAS" group; p = 0.03). CONCLUSION The ERAS protocol has a positive impact on breast reconstruction with LDF without generating additional adverse effects. These results support the democratization of these programs for breast reconstruction surgery.
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Affiliation(s)
- G Taba
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - V Ceccato
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - O Fernandes
- Department of Anesthesia, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - S Michel
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - L Darrigues
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - N Girard
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - E Gauroy
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - L Pauly
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - T Gaillard
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - F Reyal
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France
| | - J Hotton
- Department of Surgical Oncology, Institut Godinot, Rue du Général Koenig, 51100 Reims, France.
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11
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Shao YR, Ke X, Luo LH, Xu JD, Xu LQ. Application of early enteral nutrition nursing based on enhanced recovery after surgery theory in patients with digestive surgery. World J Gastrointest Surg 2023; 15:1910-1918. [PMID: 37901724 PMCID: PMC10600773 DOI: 10.4240/wjgs.v15.i9.1910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/25/2023] [Accepted: 08/02/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Postoperative nursing can improve the restlessness and gastrointestinal function of patients with tracheal intubation under general anesthesia in digestive surgery. Wide application of various nursing methods and routine nursing in perioperative nursing of patients with general anesthesia in digestive surgery. AIM To investigate the impact of early postoperative enteral nutrition nursing based on the enhanced recovery after surgery (ERAS) theory on postoperative agitation and gastrointestinal recovery in patients undergoing general anesthesia that experienced tracheal intubation. METHODS The data of 126 patients with digestive surgery from May 2019 to February 2022 were retrospectively analyzed. According to different nursing methods, they were divided into control group and observation group, with 63 cases in observation group and 63 cases in control group. The patients in the control group had standard perioperative nursing care, whereas those in the observation group got enteral nourishment as soon as possible after surgery in accordance with ERAS theory. Both the rate and quality of gastrointestinal function recovery were compared between the two groups after treatment ended. Postoperative anesthesia-related adverse events were tallied, patients' nutritional statuses were monitored, and the Riker sedation and agitation score (SAS) was used to measure the incidence of agitation. RESULTS When compared to the control group, the awake duration, spontaneous breathing recovery time, extubation time and postoperative eye-opening time were all considerably shorter (P < 0.05). There was no significant difference in the recovery time of orientation force between the two groups (P > 0.05); however, the observation group had a lower SAS score than the control group (P < 0.05). The recovery time for normal intestinal sounds, the time it took to have the first postoperative exhaust, the time it took to have the first postoperative defecation, and the time it took to have the first postoperative half-fluid feeding were all faster in the observation group than in the control group (P < 0.05); Fasting blood glucose was lower in the observation group compared to the control group (P < 0.05), while the albumin and hemoglobin levels were higher on the first and third postoperative days; however, there was no statistically significant difference in the incidence of anesthesia-related adverse reactions between the two groups (P > 0.05). CONCLUSION The extremely early postoperative enteral nutrition nursing based on ERAS theory can reduce the degree of agitation, improve the quality of recovery, promote the recovery of gastrointestinal function, and improve the nutritional status of patients in the recovery period after tracheal intubation under general anesthesia.
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Affiliation(s)
- Yan-Ru Shao
- Department of Anesthesiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510062, Guangdong Province, China
| | - Xia Ke
- Department of Anesthesiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510062, Guangdong Province, China
| | - Li-Hua Luo
- Department of Anesthesiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510062, Guangdong Province, China
| | - Jin-Dong Xu
- Department of Anesthesiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510062, Guangdong Province, China
| | - Li-Qian Xu
- Department of Anesthesiology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510062, Guangdong Province, China
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12
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Brantley RA, Thuman J, Hudson T, Gregoski MJ, Scomacao I, Herrera FA. Same Day Discharge After Mastectomy and Immediate Implant-Based Breast Reconstruction: A Retrospective Cohort Comparison Using the National Surgical Quality Improvement Program Database. Ann Plast Surg 2023; 90:S395-S402. [PMID: 37332211 PMCID: PMC11177554 DOI: 10.1097/sap.0000000000003459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Currently, overnight admission after immediate implant-based breast reconstruction (IBR) is the standard of care. Our study aims to analyze the safety, feasibility, and outcomes of immediate IBR with same-day discharge as compared with the standard overnight stay. METHODS The 2015-2020 National Surgical Quality Improvement Program database was reviewed to identify all patients undergoing mastectomy with immediate IBR for malignant breast disease. Patients were stratified into study (patients discharged day of surgery) and control (patients admitted after surgery) groups. Patient demographics, comorbidities, surgical characteristics, implant type, wound complications, readmission, and reoperation rates were collected and analyzed. Univariate and multivariate logistic regression was used to determine independent predictors of same-day discharge versus admission. In addition, Pearson χ2 test was used for comparison of proportions and t test was used for continuous variables unless distributions required subsequent nonparametric analyses. Statistical significance was defined as a P value less than 0.05. RESULTS A total of 21,923 cases were identified. The study group included 1361 patients discharged same day and the control group included 20,562 patient s admitted for average of 1.4 days (range, 1-86). Average age was 51 years for both groups. Average body mass index for the study group 27 and 28 kg/m2 for the control group, respectively. Total wound complication rates were similar (4.5% study, 4.3% control, P = 0.72). Reoperation rates were lower with same-day discharge (5.7% study, 6.8% control, P = 0.105), though not statistically significant. However, same-day discharge patients had a significantly lower readmission rate compared with the control (2.3% study, 4.2% control, P = 0.001). CONCLUSION National Surgical Quality Improvement Program data analysis over a 6-year period reveals that immediate IBR with same-day discharge is associated with a significantly lower readmission rate when compared with the standard overnight stay. The comparable complication profiles show that immediate IBR with same-day discharge is safe, potentially benefiting both patients and hospitals.
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Affiliation(s)
| | - Jenna Thuman
- Division of Plastic Surgery, Medical University of South Carolina
| | - Todd Hudson
- College of Medicine, Medical University of South Carolina
| | - Mathew J. Gregoski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Isis Scomacao
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
| | - Fernando A. Herrera
- College of Medicine, Medical University of South Carolina
- Division of Plastic Surgery, Medical University of South Carolina
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Sulejmani P, Lunt L, Mazur M, Coogan A, Steuer A, O'Donoghue C, Madrigrano A. Enhanced Recovery After Surgery and Postoperative Nausea and Length of Stay in Mastectomy Patients With Reconstruction. J Surg Res 2023; 289:158-163. [PMID: 37119617 DOI: 10.1016/j.jss.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 01/12/2023] [Accepted: 02/15/2023] [Indexed: 05/01/2023]
Abstract
INTRODUCTION Surgery is a mainstay of curative breast cancer treatment and is associated with postoperative nausea and vomiting (PONV) negatively impacting the patient experience. Enhanced recovery after surgery (ERAS) protocols are a combination of evidence-based strategies applied to traditional perioperative practices with the goal to reduce postoperative complications. ERAS protocols have been traditionally underutilized in breast surgery. We investigated if the implementation of an ERAS protocol was associated with decreased rates of PONV as well as length of stay (LOS) in patients undergoing mastectomy with breast reconstruction. METHODS We conducted a retrospective chart review case-control study in which we compared PONV and LOS between ERAS cases and non-ERAS controls. Our data set consisted of 138 ERAS cases and 96 non-ERAS controls. All patients were >18 y old and underwent mastectomy with immediate implant or tissue expander-based reconstruction between 2018 and 2020. The non-ERAS group consisted of procedure-matched controls that were treated prior to implementation of the ERAS protocol. RESULTS In univariate comparisons, patients who underwent the ERAS protocol had significantly decreased postoperative nausea (mean 37.5% of controls versus 18.1% of ERAS, P < 0.001) and shorter LOS (1.21 versus 1.49 d, P < 0.001). Using a multivariable regression to control for potential confounders, ERAS protocol was associated with less postoperative nausea (odds ratio [OR] = 0.26, 95% confidence interval [CI] = 0.13-0.5), LOS 1 d versus > 1 d (OR = 0.19, 95% CI = 0.1-0.35), and less postoperative ondansetron use (OR = 0.03, 95% CI = 0.01-0.07). CONCLUSIONS Our results indicate that implementation of the ERAS protocol in women undergoing mastectomy with immediate reconstruction is associated with improved patient outcomes in postoperative nausea and LOS.
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Affiliation(s)
| | - Lilia Lunt
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | | | - Alison Coogan
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Adam Steuer
- Department of Occupational Therapy, Rush University Medical Center, Chicago, Illinois
| | - Cristina O'Donoghue
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois
| | - Andrea Madrigrano
- Department of General Surgery, Rush University Medical Center, Chicago, Illinois.
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Enhanced Recovery After Surgery Protocol Allows Safe Same-Day Discharge in Expander Based and Oncoplastic Breast Reconstruction. Ann Plast Surg 2023:00000637-990000000-00190. [PMID: 36880790 DOI: 10.1097/sap.0000000000003492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
PURPOSE Data after enhanced recovery after surgery (ERAS) with same-day discharge in breast reconstruction is limited. This study evaluates early postoperative outcomes after same-day discharge in tissue-expander immediate breast reconstruction (TE-IBR) and oncoplastic breast reconstruction. METHODS A single-institution retrospective review of TE-IBR patients from 2017 to 2022 and oncoplastic breast reconstruction patients from 2014 to 2022 was performed. Patients were divided by procedure and recovery pathway: group 1 (TE-IBR, overnight admission), group 2 (TE-IBR, ERAS), group 3 (oncoplastic, overnight admission), and group 4 (oncoplastic, ERAS). Groups 1 and 2 were subdivided by implant location: groups 1a (prepectoral) and 1b (subpectoral), and groups 2a (prepectoral) and 2b (subpectoral). Demographics, comorbidities, complications, and reoperations were analyzed. RESULTS A total of 160 TE-IBR patients (group 1, 91; group 2, 69) and 60 oncoplastic breast reconstruction patients (group 3, 8; group 4, 52) were included. Of the 160 TE-IBR patients, 73 underwent prepectoral reconstruction (group 1a, 25; group 2a, 48), and 87 underwent subpectoral reconstruction (group 1b, 66; group 2b, 21). There were no differences in demographics and comorbidities between groups 1 and 2. Group 3 had a higher average body mass index than group 4 (37.6 vs 32.2, P = 0.022). There was no significant difference between groups 1a and 2a or between groups 1b and 2b in rates of for rates of infection, hematoma, skin necrosis, wound dehiscence, fat necrosis, implant loss, or reoperations. Group 3 and group 4 showed no significant difference in any complications or in reoperations. Notably, no patients in same-day discharge groups required unplanned hospital admission. CONCLUSIONS Many surgical subspecialities have successfully adopted ERAS protocols into their patient care and have shown both its safety and feasibility. Our research shows that same-day discharge in both TE-IBR and oncoplastic breast reconstruction does not increase risk for major complications or reoperations.
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15
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Stern CS, Plotsker EL, Nelson JA, Matros E, Kalandranis E, Fatterusso D, Mooney C, Chen Y, Velzen J, Mehrara BJ. Optimizing Unilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Quality Improvement Study. J Healthc Qual 2022; 44:354. [PMID: 36036719 PMCID: PMC9633393 DOI: 10.1097/jhq.0000000000000358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Deep inferior epigastric perforator (DIEP) flap surgery commonly involves multiday hospitalization, although data suggest 95% of complications after unilateral DIEP flap breast reconstruction occur within the first 24 hours. The aim of this study was to decrease hospitalization time and optimize care of patients undergoing unilateral DIEP flap breast reconstruction. Our study followed Six Sigma's DMAIC (define, measure, analyze, improve, control) framework. First, we delineated the stakeholders involved in the process and defined workgroups based on temporal relation to the operation. We measured performance according to project SMART (specific, measurable, achievable, relevant, time bound) goals and subsequently conducted an analysis of inefficiencies. We then created new interventions for quality improvement. Control will entail ongoing monitoring to ensure progress is sustained after study completion. Our interventions lasted 6 months and included 70 patients. By actively striving to advance patients through postoperative milestones during their inpatient stay and creating an outpatient nursing roadmap including aspects of inpatient care, we decreased the median length of stay from 67.8 to 44.8 hours ( p < .001). After receiving nursing instruction, 77% of patients agreed that they felt ready to be discharged. Our study suggests that the DMAIC framework can decrease hospitalization time after DIEP surgery and spare resources for additional patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Yigu Chen
- Memorial Sloan-Kettering Cancer Center
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16
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Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4448. [PMID: 35924002 PMCID: PMC9298472 DOI: 10.1097/gox.0000000000004448] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
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17
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Paffile J, McGuire C, Bezuhly M. Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction. Ann Plast Surg 2022; 89:121-136. [PMID: 35749815 DOI: 10.1097/sap.0000000000003062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction. METHODS A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered. RESULTS Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps. CONCLUSIONS Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.
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Affiliation(s)
| | - Connor McGuire
- Division of Plastic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Bezuhly
- Division of Plastic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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18
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Jazini E, Thomson AE, Sabet AD, Sohail O, Carreon LY, Orosz L, Bhatt FR, Roy R, Haines CM, Schuler TC, Good CR. Adoption of enhanced surgical recovery (ESR) protocol for adult spinal deformity (ASD) surgery decreases in-hospital and 90-day post-operative opioid consumption. Spine Deform 2022; 10:443-448. [PMID: 34743304 DOI: 10.1007/s43390-021-00437-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Retrospective observational cohort study of primary adult spinal deformity (ASD) surgery during the transitional period prior to and after the implementation of Enhanced Surgical Recovery (ESR) at a single center. We sought to determine if ESR reduces in-hospital and 90-day post-operative opioid consumption for ASD surgery. METHODS We evaluated patients undergoing primary ASD surgery in the transition period prior to (N = 29) and after (N = 56) adoption of ESR, comparing in-hospital and 90-day post-operative opioid consumption. Regression analysis was used to control for confounders including age, number of surgical levels, surgical approach, staged vs same-day surgery, insurance type and pre-op opioid use. RESULTS Mean age of the cohort was 53 years with 57 (60%) females. Regression analysis showed that pre-operative opioid use and number of levels fused were associated with higher in-hospital and 90-day post-operative opioid consumption, while use of ESR was associated with lower in-hospital and 90-day post-operative opioid consumption. Secondary analysis showed that patients on ESR ambulated earlier (0.6 days vs 1.1, p = 0.028) and had their urinary catheter removed earlier (2.7 days vs 3.9, p = 0.006) compared to non-ESR patients. CONCLUSIONS ESR was associated with a significantly decreased in-hospital and 90-day post-operative opioid consumption and earlier mobilization with earlier urinary catheter removal in patients undergoing primary ASD surgery. These results demonstrate ESR's potential to improve outcomes in ASD perioperative care. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Ehsan Jazini
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA
| | - Alexandra E Thomson
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA.
| | - Andre D Sabet
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA
| | - Omar Sohail
- National Spine Health Foundation, Reston, VA, USA
| | | | - Lindsay Orosz
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA.,National Spine Health Foundation, Reston, VA, USA
| | - Fenil R Bhatt
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA
| | - Rita Roy
- National Spine Health Foundation, Reston, VA, USA
| | - Colin M Haines
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA
| | - Thomas C Schuler
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA
| | - Christopher R Good
- Virginia Spine Institute, 11800 Sunrise Valley Drive, Suite 800, Reston, VA, 20191, USA
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Khawaja ZH, Gendia A, Adnan N, Ahmed J. Prevention and Management of Postoperative Ileus: A Review of Current Practice. Cureus 2022; 14:e22652. [PMID: 35371753 PMCID: PMC8963477 DOI: 10.7759/cureus.22652] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 01/09/2023] Open
Abstract
Postoperative ileus (POI) has long been a challenging clinical problem for both patients and healthcare physicians alike. Although a standardized definition does not exist, it generally includes symptoms of intolerance to diet, lack of passing stool, abdominal distension, or flatus. Not only does prolonged POI increase patient discomfort and morbidity, but it is possibly the single most important factor that results in prolongation of the length of hospital stay with a significant deleterious effect on healthcare costs in surgical patients. Determining the exact pathogenesis of POI is difficult to achieve; however, it can be conceptually divided into patient-related and operative factors, which can further be broadly classified as neurogenic, inflammatory, hormonal, and pharmacological mechanisms. Different strategies have been introduced aimed at improving the quality of perioperative care by reducing perioperative morbidity and length of stay, which include Enhanced Recovery After Surgery (ERAS) protocols, minimally invasive surgical approaches, and the use of specific pharmaceutical therapies. Recent studies have shown that the ERAS pathway and laparoscopic approach are generally effective in reducing patient morbidity with early return of gut function. Out of many studies on pharmacological agents over the recent years, alvimopan has shown the most promising results. However, due to its potential complications and cost, its clinical use is limited. Therefore, this article aimed to review the pathophysiology of POI and explore recent advances in treatment modalities and prevention of postoperative ileus.
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Zhang Z, Hou QQ, Luo X, Li HM, Hou Y. The role of nursing in enhanced recovery after surgery programs in accordance with spine surgery: A mini review. JOURNAL OF INTEGRATIVE NURSING 2022. [DOI: 10.4103/jin.jin_08_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Faulkner HR, Coopey SB, Sisodia R, Kelly BN, Maurer LR, Ellis D. Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery? JPRAS Open 2021; 31:22-28. [PMID: 34869817 PMCID: PMC8626793 DOI: 10.1016/j.jpra.2021.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. Methods A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. Results A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time. Conclusions ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.
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Affiliation(s)
- Heather R Faulkner
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Allegheny Health Network, Wexford, Pennsylvania, USA
| | - Rachel Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget N Kelly
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Gupta S, Rane A. Enhanced Recovery after Surgery: Perspective in Elder Women. J Midlife Health 2021; 12:93-98. [PMID: 34526741 PMCID: PMC8409712 DOI: 10.4103/jmh.jmh_89_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/19/2021] [Accepted: 06/28/2021] [Indexed: 11/04/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients.
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Affiliation(s)
- Sandhya Gupta
- Department of Obstetrics and Gynaecology, James Cook University, Townsville, Australia
| | - Ajay Rane
- Department of Obstetrics and Gynaecology, James Cook University, Townsville, Australia
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Singer KE, Philpott CD, Bercz AP, Phillips T, Salyer CE, Hanseman D, Droege ME, Goodman MD, Makley AT. Impact of a Multimodal Analgesia Protocol on Inpatient and Outpatient Opioid Use in Acute Trauma. J Surg Res 2021; 268:9-16. [PMID: 34280664 DOI: 10.1016/j.jss.2021.05.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/16/2021] [Accepted: 05/29/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Multimodal analgesia protocols have been implemented after elective surgery to reduce opioid use, however there is limited data on utility after polytrauma. Therefore, we investigated the impact of a multimodal analgesia protocol on inpatient and post-discharge outpatient opioid use after polytrauma. METHODS A retrospective review of patients admitted to a Level I trauma center between September 2017-February 2018 (prior to multimodal protocol; "pre-cohort") and October 2018-April 2019 (after multimodal protocol; "post-cohort") was performed. An outpatient controlled substance registry was utilized to capture morphine milligram equivalents (MME) and gabapentin dispensed in the 6 mo after injury. RESULTS 620 patients were included (295 pre-cohort, 325 post-cohort). Total inpatient MME decreased from 177.5 mg-130 mg (P= 0.01) between the cohorts. Daily inpatient MME decreased from 70.8 mg-44.7 mg (P< 0.01). Intravenous hydromorphone decreased from 2 mg in the pre-cohort to 1 mg in the post-cohort (P= 0.02). Inpatient oxycodone decreased from 45 mg-30 mg (P= 0.01). Concurrently, gabapentin increased from 0 mg-400 mg in the post-cohort (P< 0.01). Patients in the post-cohort were prescribed fewer MMEs than the pre-cohort at discharge (P< 0.05). However, the number of patients prescribed gabapentin increased from 6.1%-16% (P< 0.01). CONCLUSION Implementation of an updated multimodal analgesia protocol decreased total MME, daily MME, hydromorphone, and oxycodone consumed while increasing gabapentin use. This suggests that while reducing opioid usage in-hospital is critical to reducing outpatient usage, multimodal pain protocols may lead to an increase in gabapentin prescriptions and utilization after discharge.
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Affiliation(s)
- Kathleen E Singer
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio.
| | | | - Aron P Bercz
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Tabatha Phillips
- Department of Pharmacology, University of Cincinnati, Cincinnati, Ohio
| | - Christen E Salyer
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Dennis Hanseman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Molly E Droege
- Department of Pharmacology, University of Cincinnati, Cincinnati, Ohio
| | - Michael D Goodman
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of General Surgery, University of Cincinnati, Cincinnati, Ohio
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Reducing pain and opioid consumption after body contouring of the breast by application of a perioperative nerve block: a systematic review. Arch Plast Surg 2021; 48:361-365. [PMID: 34352945 PMCID: PMC8342261 DOI: 10.5999/aps.2020.01550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 03/25/2021] [Indexed: 11/08/2022] Open
Abstract
Background Pain in the postoperative body contouring patient has traditionally been managed with narcotic medication. In an effort to minimize side effects and prevent addiction, plastic surgeons are searching for novel ways to provide adequate analgesia, one of which is nerve blocks. This study was conducted with a meta-analysis that evaluates the efficacy of these blocks for patients who undergo breast surgery. Methods A search of the PubMed/MEDLINE database for articles including the terms “postoperative analgesia” OR “postoperative pain management” AND “in plastic surgery” OR “in cosmetic surgery” OR “in elective surgery” in February 2019 generated five studies on elective breast augmentation and reduction mammoplasty that reported pain scores and quantities of opioids consumed. Independent samples t-tests, one-way analysis of variance, and a random effects model were implemented for evaluation. Results A total of 317 patients were identified as having undergone body contouring of the breast, about half of which received a nerve block. Pain scores on a 1–10 scale and opioid dose-equivalents were calculated. Those who were blocked had an average score of 2.40 compared to 3.64 for those who did not (P<0.001), and required an average of 5.20 less narcotic doses (P<0.001). Pain relief following subpectoral augmentation was best achieved with type-II blocks as opposed to type-I and type-II with serratus plane (P<0.001). Conclusions The opioid epidemic has extended to all surgical specialties. Implementation of a nerve block seems to be an efficacious and cost-effective mechanism to not only help with postoperative pain, but also lower the need for narcotics, especially in subpectoral augmentation.
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Pawloski KR, Matar R, Sevilimedu V, Tadros AB, Kirstein LJ, Cody HS, Van Zee KJ, Morrow M, Moo TA. Postdischarge Nonsteroidal Anti-Inflammatory Drugs Are not Associated with Risk of Hematoma after Lumpectomy and Sentinel Lymph Node Biopsy with Multimodal Analgesia. Ann Surg Oncol 2021; 28:5507-5512. [PMID: 34247337 PMCID: PMC8272604 DOI: 10.1245/s10434-021-10446-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDs) are increasingly used in ambulatory breast surgery. The risk of hematoma associated with intraoperative ketorolac is low, but whether concomitant routine discharge with NSAIDs increases the risk of hematoma is unclear. Methods We retrospectively identified patients who underwent lumpectomy and sentinel lymph node biopsy (SLNB), and compared the 30-day risk of hematoma between patients discharged with opioids (opioid period: January 2018–August 2018) and patients discharged with NSAIDs with or without opioids (NSAID period: January 2019–April 2020). The association between study period and hematoma risk was assessed using multivariable models. Covariates included intraoperative ketorolac, home aspirin, and race/ethnicity. During the NSAID period, a survey was used to assess analgesic consumption on postoperative days 1–5. Results In total, 2724 patients were identified: 858 (31%) in the opioid period and 1866 (69%) in the NSAID period. In the NSAID period, 867 (46%) received NSAIDs and opioids, and 999 (54%) received NSAIDs only. Receipt of intraoperative ketorolac was higher in the NSAID period (78 vs. 64%, P < 0.001). The risks of any hematoma (4.1 vs. 3.6%, P = 0.6) and reoperation for bleeding (0.5 vs. 0.6%, P = 0.8) were similar between groups. Study period was not associated with hematoma risk (odds ratio 0.87, 95% confidence interval 0.56–1.35, P = 0.5). Among survey respondents (41%), nonopioid analgesic consumption did not increase after opioids were removed from the discharge regimen (median, 6 pills/group, P = 0.06). Conclusions NSAIDs are associated with a low risk of hematoma after lumpectomy and SLNB, and should be prescribed instead of opioids, unless contraindicated.
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Affiliation(s)
- Kate R Pawloski
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Regina Matar
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Audree B Tadros
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Laurie J Kirstein
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Hiram S Cody
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Tracy-Ann Moo
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
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Jazini E, Thomson AE, Sabet AD, Carreon LY, Roy R, Haines CM, Schuler TC, Good CR. Adoption of Enhanced Surgical Recovery (ESR) Protocol for Lumbar Fusion Decreases In-Hospital Postoperative Opioid Consumption. Global Spine J 2021; 13:1030-1035. [PMID: 34018420 DOI: 10.1177/21925682211015652] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
STUDY DESIGN Retrospective observational cohort. OBJECTIVES We sought to evaluate the impact of ESR on in-hospital and 90-day postoperative opioid consumption, length of stay, urinary catheter removal and postoperative ambulation after lumbar fusion for degenerative conditions. METHODS We evaluated patients undergoing lumbar fusion surgery at a single, multi-surgeon center in the transition period prior to (N = 174) and after (N = 116) adoption of ESR, comparing in-hospital and 90-day postoperative opioid consumption. Regression analysis was used to control for confounders. Secondary analysis was preformed to evaluate the association between ESR and length of stay, urinary catheter removal and ambulation after surgery. RESULTS Mean age study participants was 52.6 years with 62 (47%) females. Demographic characteristics were similar between the Pre-ESR and ESR groups. ESR patients had better 3-month pain scores, ambulated earlier, had urinary catheters removed earlier and decreased in-hospital opioid consumption compared to Pre-ESR patients. There was no difference in 90-day opioid consumption between the 2 groups. Regression analysis showed that ESR was strongly associated with in-hospital opioid consumption, accounting for 30% of the variability in Morphine Milligram Equivalents (MME). In-hospital opioid consumption was also associated with preoperative pain scores, number of surgical levels, and insurance type (private vs government). Pre-op pain sores were associated with 90-day opioid consumption. Secondary analysis showed that ESR was associated with a shorter length of stay and earlier ambulation. CONCLUSIONS This study showed ESR has the potential to improve recovery after lumbar fusion for degenerative conditions with reduced in-hospital opioid consumption and improved postoperative pain scores.
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Affiliation(s)
| | | | | | | | - Rita Roy
- National Spine Health Foundation, Reston, VA, USA
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Ramirez MF, Kamdar BB, Cata JP. Optimizing Perioperative Use of Opioids: A Multimodal Approach. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:404-415. [PMID: 33281504 PMCID: PMC7709949 DOI: 10.1007/s40140-020-00413-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The main purpose of this article is to review recent literature regarding multimodal analgesia medications, citing their recommended doses, efficacy, and side effects. The second part of this report will provide a description of drugs in different stages of development which have novel mechanisms with less side effects such as tolerance and addiction. RECENT FINDINGS Multimodal analgesia is a technique that facilitates perioperative pain management by employing two or more systemic analgesics along with regional anesthesia, when possible. Even though opioids and non-opioid analgesics remain the most common medication used for acute pain management after surgery, they have many undesirable side effects including the potential for misuse. Newer analgesics including peripheral acting opioids, nitric oxide inhibitors, calcitonin gene-related peptide receptor antagonists, interleukin-6 receptor antagonists and gene therapy are under intensive investigation. SUMMARY A patient's first exposure to opioids is often in the perioperative setting, a vulnerable time when multimodal therapy can play a large role in decreasing opioid exposure. Additionally, the current shift towards faster recovery times, fewer post-operative complications and improved cost-effectiveness during the perioperative period has made multimodal analgesia a central pillar of Enhanced Recovery After Surgery (ERAS) protocols.
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Affiliation(s)
- Maria F. Ramirez
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Brinda B. Kamdar
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
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Schnabel A, Weibel S, Meißner M, Reichl SU, Kranke P, Meyer-Frießem CH, Zahn PK, Pogatzki-Zahn E. Erector spinae plane block for postoperative pain. Hippokratia 2020. [DOI: 10.1002/14651858.cd013763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Alexander Schnabel
- Department of Anesthesiology, Intensive Care and Pain Medicine; University Hospital Münster; Münster Germany
| | - Stephanie Weibel
- Department of Anesthesiology and Critical Care; University Hospital Wuerzburg; Wuerzburg Germany
| | - Michael Meißner
- Department of Anesthesiology, Intensive Care and Pain Medicine; University Hospital Münster; Münster Germany
| | - Sylvia U Reichl
- Department of Anesthesiology, Perioperative and Intensive Care Medicine; Paracelsus Medical University; Salzburg Austria
| | - Peter Kranke
- Department of Anesthesiology and Critical Care; University Hospital Wuerzburg; Wuerzburg Germany
| | - Christine H Meyer-Frießem
- Department of Anaesthesiology, Intensive Care Medicine and Pain Management; BG-Universitätsklinikum Bergmannsheil gGmbH; Bochum Germany
| | - Peter K Zahn
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management; BG-Universitätsklinikum Bergmannsheil gGmbH; Bochum Germany
| | - Esther Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine; University Hospital Münster; Münster Germany
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Enhanced Recovery After Surgery (ERAS): Protocols in Post-Mastectomy Breast Reconstruction. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00378-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Brenin DR, Dietz JR, Baima J, Cheng G, Froman J, Laronga C, Ma A, Manahan MA, Mariano ER, Rojas K, Schroen AT, Tiouririne NAD, Wiechmann LS, Rao R. Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Ann Surg Oncol 2020; 27:4588-4602. [PMID: 32783121 DOI: 10.1245/s10434-020-08892-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.
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Affiliation(s)
- David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Jill R Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jennifer Baima
- Department of Physical Medicine and Rehabilitation, UMass Memorial Medical Center, Worcester, MA, USA
| | - Gloria Cheng
- Department of Anesthesia, University of Texas Southwestern, Dallas, TX, USA
| | - Joshua Froman
- Department of Surgery, Mayo Clinic, Owatonna, MN, USA
| | | | - Ayemoethu Ma
- Surgery and Integrative Medicine, Scripps Health, La Jolla, CA, USA
| | - Michele A Manahan
- Department of Plastic Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Edward R Mariano
- Department of Anesthesia, Stanford University, Stanford, CA, USA
| | - Kristin Rojas
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Anneke T Schroen
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Lisa S Wiechmann
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Roshni Rao
- New York Presbyterian Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
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Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties. Am J Surg 2020; 219:530-534. [DOI: 10.1016/j.amjsurg.2019.11.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 01/15/2023]
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