Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol |
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| Authors: | Syed S Razi Joy A Stephens-McDonnough Safi Haq Michael Fabbro Aliercy Nunez Sanchez Richard H Epstein Nestor R Villamizar Dao M Nguyen |
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| Institution: | 1. Section of Thoracic Surgery, Department of Surgery, University of Miami, Miami, Fla;2. Department of Anesthesia, University of Miami, Miami, Fla;3. Department of Clinical Pharmacy, University of Miami, Miami, Fla;1. Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa;2. Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pa;1. Section of General Thoracic Surgery, UC Davis Health, Sacramento, California;2. Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan;3. Department of Design, University of California, Davis, Davis, California;4. Center for Design in the Public Interest, University of California, Davis, Davis, California;5. Center for Healthcare Policy and Research, UC Davis Health, Sacramento, California;6. Department of Pediatrics, UC Davis Health, Sacramento, California;7. Department of Anesthesiology, Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor, Michigan;8. Burn Surgery Division, Department of Surgery, UC Davis Health, Sacramento, California;1. Department of Thoracic and Cardiovascular Surgery, University of Texas M.D. Anderson Cancer Center, Houston, Texas;2. Department of Anesthesia and Perioperative Medicine, University of Texas M.D. Anderson Cancer Center, Houston, Texas;1. Department of Anesthesiology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado;2. Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, Maine;3. Department of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, Colorado;4. Department of Pharmacy Practice, College of Pharmacy, University of New England, Portland, Maine;5. Department of Family Medicine, University of Michigan, Ann Arbor, Michigan;6. Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, Colorado;7. St. Vincent Hospital, Heart Center of Indiana, Indianapolis, Indiana |
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| Abstract: | ObjectiveTo evaluate differences in postoperative pain control and opioids requirement in thoracic surgical patients following implementation of an Enhanced Recovery after Thoracic Surgery protocol with a comprehensive postoperative pain management strategy.Material and MethodsA retrospective analysis of a prospectively maintained database of patients undergoing pulmonary resections by robotic thoracoscopy or thoracotomy from January 1, 2017, to January 31, 2019, was conducted. Multimodal pain management strategy (opioid-sparing analgesics, infiltration of liposomal bupivacaine to intercostal spaces and surgical sites, and elimination of thoracic epidural analgesia use in thoracotomy patients) was implemented as part of Enhanced Recovery after Thoracic Surgery on February 1, 2018. Outcome metrics including patient-reported pain levels, in-hospital and postdischarge opioids use, postoperative complications, and length of stay were compared before and after protocol implementation.ResultsIn total, 310 robotic thoracoscopy and 62 thoracotomy patients met the inclusion criteria. This pain management strategy was associated with significant reduction of postoperative pain in both groups with an overall reduction of postoperative opioids requirement. Median in-hospital opioids use (morphine milligram equivalent per day) was reduced from 30 to 18.36 (P = .009) for the robotic thoracoscopy group and slightly increased from 15.48 to 21.0 (P = .27) in the thoracotomy group. More importantly, median postdischarge opioids prescribed (total morphine milligram equivalent) was significantly reduced from 480.0 to 150.0 (P < .001) and 887.5 to 150.0 (P < .001) for the thoracoscopy and thoracotomy groups, respectively. Similar short-term perioperative outcomes were observed in both groups before and following protocol implementation.ConclusionsImplementation of Enhanced Recovery after Thoracic Surgery allows safe elimination of epidural use, better pain control, and less postoperative opioids use, especially a drastic reduction of postdischarge opioid need, without adversely affecting outcomes. |
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| Keywords: | ERATS postoperative pain management ERAS"} {"#name":"keyword" "$":{"id":"kwrd0025"} "$$":[{"#name":"text" "_":"Enhanced Recovery After Surgery ERATS"} {"#name":"keyword" "$":{"id":"kwrd0035"} "$$":[{"#name":"text" "_":"Enhanced Recovery After Thoracic Surgery LipoB"} {"#name":"keyword" "$":{"id":"kwrd0045"} "$$":[{"#name":"text" "_":"liposomal bupivacaine LOS"} {"#name":"keyword" "$":{"id":"kwrd0055"} "$$":[{"#name":"text" "_":"length of stay MME"} {"#name":"keyword" "$":{"id":"kwrd0065"} "$$":[{"#name":"text" "_":"morphine milligram equivalent R-VATS"} {"#name":"keyword" "$":{"id":"kwrd0075"} "$$":[{"#name":"text" "_":"robotic video-assisted thoracoscopic surgery TEA"} {"#name":"keyword" "$":{"id":"kwrd0085"} "$$":[{"#name":"text" "_":"thoracic epidural analgesia |
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