Andres Zorrilla Vaca, MD Resident Physician Brigham and Women’s Hospital Boston, Massachusetts

Surgery: ERAS Protocol Reduced Need for Opioids After Discharge Interview with:

Andres Zorrilla Vaca, MD Resident Physician Brigham and Women’s Hospital Boston, Massachusetts

Dr. Zorrilla Vaca

Andres Zorrilla Vaca, MD
Resident Physician
Brigham and Women’s Hospital
Boston, Massachusetts What is the background for this study?

Response: The background for this study was Enhanced Recovery After Surgery, also known as ERAS protocols. They basically consisted of a bundle of interventions that are performed preoperatively, intraoperatively and postoperatively with the aim of enhancing patient recovery and reducing complications.

This protocol in our institution started with a thorough preoperative counseling which includes, smoking cessation, pain and analgesia education, ERAS program expectations, pulmonary rehabilitation based on pulmonary function tests and incentive spirometry. On the day of surgery, prolonged fasting is avoided and a carbohydrate loading is given orally 2 hours before surgery. Our protocol also included a standardized multimodal analgesic regimen consisting of tramadol ER 300mg p.o. and gabapentin 300mg p.o., intraoperative acetaminophen 1gm i.v., posterior intercostal nerve blockade with liposomal bupivacaine 266mg prior to incision, intraoperative 30mg ketorolac upon wound closure and scheduled postoperative acetaminophen 1g p.o. q 6hrs and ketorolac 15mg i.v. q 6 hrs, as well as additonal interventions recommended by ERAS Society Guidelines.

As a general rule, preoperative sedatives (midazolam) are avoided as premedication and prophylaxis against nausea and vomiting (ondansetron, dexamethasone and scopolamine) is administered. Patients are kept euvolemic by using validated goal-directed fluid therapy algorithms (stroke volume variation and cardiac output) and normothermia is maintained throughout the procedure. What are the main findings?

Response: There was a 50% reduction of opioid prescriptions since ERAS was implemented. Video-assisted and robotic thoracic surgery were associated with less morphine equivalents compared to open surgery (84mg and 139mg, respectively). Interestingly, there was an association between the amount of opioid patients received intraoperatively, and at the time of discharge (1.4 additional morphine equivalents at discharge per each unit of morphine equivalent received during surgery). What should readers take away from your report? 

Response: Our study findings provide further evidence about the role of ERAS in decreasing exposure both during hospitalization as well as at hospital discharge. ERAS is a multidisciplinary evidence-based perioperative care pathway that was originally designed to hasten recovery, but studies like ours give relevant insights to patients regarding the role of ERAS in reducing opioid prescriptions at hospital discharge. What recommendations do you have for future research as a result of this work?

Response: Based on our findings, we can confirm that both surgeons and anesthesiologists play an important role in reducing opioid exposure after discharge by implementing minimally invasive surgical techniques and by lowering opioid administration during surgery, respectively. We also think that other opioid-sparing strategies (such as shared-decision making or opioid prescribing guidelines) should eventually be adopted by ERAS protocols. This might lead to further improvements in prescribing practices at hospital discharge. Is there anything else you would like to add?

Response: There are multiple ways to tackle the opioid crisis. There is no doubt that ERAS is a great pathway of patient care that encompasses evidence-based opioid minimization strategies, which include multimodal analgesia, patient education, rapid rehabilitation, and standardization of opioid prescribing.  

Sustained Reduction of Discharge Opioid Prescriptions Within an Enhanced Recovery After Surgery Program for Thoracic Surgery: A Multilevel Generalized Linear Model
Andres Zorrilla-Vaca, MD, Boston, MA

Research presented at the 18th Annual Perioperative and Critical Care Conference from The Society of Thoracic Surgeons. 

Other authors of the study were D. Rice, MD, T. Woodward, RNP, C. Patel, RNP, J. Brown, MD, M. Antonoff, MD, B. Sepesi, MD, W. Hofstetter, MD, S. Swisher, MD, A. Vaporciyan, MD, R. Mehran, MD, and G. Mena, MD.



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Last Updated on September 21, 2021 by Marie Benz MD FAAD