NEW ORLEANS — In patients undergoing spinal or peripheral nerve surgery, postoperative opioid use was reduced when an “enhanced recovery after surgery” (ERAS) protocol was followed at the University of Pennsylvania in Philadelphia, researchers report
ERAS is a comprehensive perioperative surgical pathway protocol that involves multidisciplinary, collaborative management of patients. While ERAS protocols are gaining favor around the country, the report by this group of researchers here at the American Association of Neurological Surgeons (AANS) 2018 Annual Meeting, is among the first to show its benefit in elective spine and nerve surgery.
“The major goals of our ERAS pathway are to optimize the surgical experience for patients and to improve their clinical outcomes,” said Zarina S. Ali, MD, assistant professor of neurosurgery at the University of Pennsylvania, who has spearheaded this program and who presented the findings. “In particular, our ERAS pain management protocol has the potential to safely reduce opioid use in both the perioperative period as well as after surgery.”
Under ERAS, the use of patient-controlled analgesia (PCA) was almost completely eliminated, while more than half the patients treated via a standard postoperative approach relied on PCA, she said.
The paper’s discussant, Michael Y. Wang, MD, from the University of Miami in Florida, praised the benefits of ERAS and urged attendees to “go home and talk to your general surgeons about it.”
Wang and his colleagues have shown multiple benefits for ERAS, not only improvements in patient outcomes but reductions in the cost of care, in patients undergoing lumbar spinal fusion.
Stemming the Opioid Tide
The researchers say that ERAS has the potential to decrease inpatient and postoperative narcotic use in spinal surgery — procedures that have recently been linked to increased risk for long-term opioid use in the postoperative period. This would be a welcome outcome, she said, because research suggests that “three quarters of our institution’s spine and neurological surgery population are opioid-naive…and 3% to 7% of opioid-naive patients undergoing surgery continue to take opioids 1 year later.”.
The University of Pennsylvania researchers hypothesized that a “360-degree care approach,” with its focus on multimodal opioid-sparing pain management, would have the potential to decrease overall opioid use.
Their ERAS pathway includes 16 domains of care with multiple interventions. This paradigm relies on the multidisciplinary and collaborative care for all patients across their surgical “journey” in a relatively standardized fashion, she said.
Briefly, the preoperative component includes surgical education and text message reminders, nutrition optimization, discharge planning, and, where appropriate, diabetes management, smoking cession counseling, screening for long-term opioid use and relevant referrals, obstructive sleep apnea screening, and subsequent referrals to sleep medicine specialists.
Perioperative components include metabolism management, multimodal analgesia, early mobilization, wound care management, and a “safe spinal surgery checklist” designed to assure the completion of the protocol by all operating room staff. Postoperative nursing instructions include aggressive early postoperative mobilization. Foley catheters outside of the operating room are used only in select patients, and standard wound care regimens are implemented.
“Most importantly, postoperative pain management is achieved by a robust opioid-sparing multimodality regimen,” she said. This includes epidural analgesia and short-acting anesthetics along with implementation of nonopioid medications: standing orders for acetaminophen, gabapentin, and local anesthetics. PCA is generally not used.
The postoperative care pathway stresses clinical team communication and includes a post–acute-care neurosurgical triage pathway.
Investigators enrolled 201 consecutive patients undergoing elective spinal or peripheral nerve surgery into the ERAS protocol from April to June 2017. The control group was a historical cohort of 74 patients treated from September to December 2016 under a traditional surgical care regimen that included routine pain management with PCA from postoperative day 1.
The two groups were similar in overall demographic characteristics, including prior spinal surgery, use of preoperative narcotics, and type of surgical procedure.
The researchers analyzed opioid and nonopioid medication use in the preoperative, perioperative, and postoperative periods, along with several secondary outcomes.
At 1 month, patients undergoing spinal and peripheral nerve surgery who were managed under the ERAS protocol had less need for opioids but achieved pain relief that was as good as that provided by opioids in the control group, the study showed.
Table 1. Opioid and Nonopioid Use in ERAS vs Control Patients
| Medications | Control Group (n = 74) (%) | ERAS Group (n = 201) (%) | P Value |
|---|---|---|---|
| Opioid medications | |||
| PCA use | 54.1 | 0.5 | <.001 |
| Narcotic use 1 month after surgery | 53.0 | 39.0 | .041 |
| Nonopioid medications | |||
| Acetaminophen | 83.8 | 90.5 | .13 |
| Dexamethasone | 16.2 | 13.4 | .56 |
| Tramadol | 2.7 | 13.4 | .008 |
| Ketorolac | 10.8 | 23.9 | .018 |
| Cyclobenzaprine | 44.6 | 52.2 | .280 |
| Diazepam | 60.8 | 59.2 | .89 |
| Gabapentin | 23.0 | 80.6 | <.001 |
| 3+ nonopioid agents | 41.9 | 74.1 | <.001 |
| 4+ nonopioid agents | 20.3 | 48.8 | <.001 |
“PCA was nearly eliminated in the ERAS group. Despite this, overall pain scores at admission and discharge, as well as inpatient highest pain scores between ERAS and control groups, were not different,” Ali reported.
Pain scores were similar for control and ERAS patients: at baseline, 6.3 vs. 6.6 (P = .45); on the first postoperative day, 7.6 vs 7.5 (P = .79); and on the third postoperative day, 6.5 vs 6.9 (P = .42), respectively. While the exact consumption of opioids via PCA in the control group could not be determined, the researchers did observe a trend for reduced total morphine equivalent dosages.
“When we looked at maximum pain scores, we found no increases associated with the near-elimination of PCA and the adoption of the multimodal opioid-sparing regimen,” Ali emphasized. “Importantly, at the 1-month postop time point, without any changes to discharge prescriptions of opioids, we found a reduction in opioid use in our patients, as compared to the control group.”
Proportion of patients not using narcotics at 1 month was 61% in the ERAS group compared with 47% in the control group (P = .041).
Some numeric trends in secondary outcomes favored the ERAS group, including shorter hospital length of stay, fewer intensive care unit admissions, lower complication rates, greater discharge to home, and lower readmission rates. In this small cohort, however, these did not reach statistical significance.
“Iterative Process”
Ali acknowledged some limitations of the study, such as modest sample size, lack of randomization, use of a historical control group, lack of blinding, and short follow-up, but maintained that “Despite these, the study demonstrated safety and efficacy of our University of Pennsylvania neurosurgery ERAS protocol.
“We continue to iterate on our pathway and to monitor outcomes,” she said. “We believe ERAS pathways similar to ours can be safely incorporated at other centers performing spinal and peripheral nerve surgery…with the potential to improve outcomes.”
Wang, who started designing ERAS protocols 7 years ago, called ERAS “a massive movement” that is improving surgical recovery and, in this “real-world” cohort of patients, for example, appears to make a difference in the use of narcotics.
“The bottom line is the group from Penn was really able to document a significant decrease in PCA usage and total narcotic consumption by instituting some very basic and simple things,” he observed. “They reduced narcotics significantly, and patients were much less likely to use narcotics 1 month after surgery, so there’s a lasting benefit.”
Exactly how the protocol resulted in these changes is not clear. “Lots of it is process improvement, which is important to any ERAS program,” he continued. “ERAS is an iterative process where you change your practice, measure again, and see what works and what doesn’t…I am sure these investigators are going to continue to improve upon this [their protocol], such as with local analgesia, fluid management, modification of surgical techniques, and rehabilitation.”
“I congratulate the group at Penn for being the first to publish on ERAS in this set of patients,” Wang commented in closing.
Ali and Wang have disclosed no relevant financial relationships.
2018 Annual Meeting of the American Association of Neurological Surgeons (AANS). Abstract 500. Presented April 30, 2018.
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