Efficacy of Enhanced Recovery After Surgery Protocols in Pain

EFFICACY OF ENHANCED RECOVERY AFTER SURGERY PROTOCOLS IN PAIN CONTROL FOR PATIENTS UNDERGOING VIDEO ASSISTED THORACOSCOPIC SURGERY

Running Head: ERAS in VATS

Mackenzie Steen, PA-C, DMSc1; Sowmyanarayanan Thuppal MD, PhD1,2 ; Bridget McClain1; Allison Sweeney1; Stephen Markwell, MA1; Stephen Hazelrigg, MD1; Traves Crabtree, MD1

1Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois

2Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois

Corresponding author: Mackenzie Steen, PA-C, DMSc, Division of Cardiothoracic Surgery, Department of Surgery, 701 N First Street, PO Box 19638, Springfield, IL 62794-9638, Phone: 217 -545-8994, Fax: 217-545-7053, E-mail: msteen56@siumed.edu

ABSTRACT

Background: Enhanced Recovery After Surgery (ERAS) protocols are an increasingly utilized method of improving post-surgical outcomes, including outcomes related to pain control. One focus of ERAS is decreasing reliance on opioid-based medication.

Objective: The primary objective of this study was to evaluate the impact of ERAS protocols on patient pain scores and opioid usage after video-assisted thoracoscopic surgery (VATS).

Methods: A retrospective analysis was performed, comparing patients undergoing pulmonary resection via a VATS approach since the implementation of ERAS protocols vs. resection prior to ERAS. Outcomes including average daily pain scores, total daily usage of opioid medications as measured by IV morphine milligram equivalents (MME), rates of opioid prescription after discharge, complication rates, length of stay, 30-day readmission rates, and 30-day mortality rates were reported.

Results: A total of 287 (pre-ERAS, n = 108; ERAS, n = 55) patients from over a 2-year period were reviewed. ERAS was associated with a similar average daily self-reported pain scores compared to pre-ERAS (POD0 [6.5 vs 5.9], POD1 [6.0 vs 5.4], POD2 [4.8 vs 4.4] POD3 [3.0 vs 4.9], POD4 [6.6 vs 4.5], POD5 [6.6 vs 4.8]. ERAS was associated with similar total daily opioid administration, except for post-operative day 0 (19.0 vs 26.0, p = 0.002). Usage of ERAS had no significant effect on any other post-operative outcomes assessed during this study.

Conclusion: Usage of scheduled, non-opioid medications as part of an ERAS protocol resulted in similar pain scores and opioid usage after minimally invasive pulmonary resection.

Keywords: ERAS, Enhanced Recovery After Surgery, VATS, opioid,

METHODS

Study Design

The study was approved by the Committee for Research Involving Human Subjects. A retrospective analysis was conducted between January 1, 2019 and January 3, 2021. Data was collected from all adult patients (>18 years old) undergoing VATS for resection of benign or malignant pulmonary disease including lobectomy, segmentectomy, sublobar and wedge resection, bullectomy and bleb resection, and lung biopsy. Data from patients undergoing VATS for pleural or mediastinal disease, elective thoracotomy, intra-operative conversion to thoracotomy, emergent procedures, lung-volume reduction surgery, and those undergoing robotic-assisted thoracoscopic surgery were excluded. Patients with a history of chronic opioid usage defined as the usage of opioids on all or most days for at least 3 months prior to the date of surgery were also excluded. Information regarding previous opioid usage was obtained via review of the state Prescription Monitoring Program (PMP).

Pre-ERAS Protocol

Prior to implementation of ERAS, standard postoperative pain management consisted of a primarily opioid based regimen utilizing intravenous morphine, hydromorphone, or fentanyl as well as oral opioids such as tramadol and hydrocodone-acetaminophen on an as needed basis. Acetaminophen was routinely utilized but was not given on a scheduled basis as protocol. Nonsteroidal anti-inflammatory medications and gabapentinoids were administered on a case by case basis. Intraoperative multilevel intercostal nerve blocks utilizing 0.25% bupivacaine were already part of standard practice. Thoracic epidural catheters and patient controlled analgesia pumps were not part of standard practice for VATS. Pre-ERAS standard of care did not include pre-operative administration of acetaminophen, gabapentin, or anti-inflammatories.

ERAS Protocol

In September 2021, our division of cardiothoracic surgery implemented the ERAS protocols for patients undergoing VATS. These protocols include perioperative measures to reduce pain such as scheduled preoperative administration of non-opioid oral analgesics the morning of surgery, decreasing intraoperative narcotic usage, emphasizing usage of intraoperative multilevel intercostal nerve blocks, and postoperatively increasing utilization of scheduled non-opioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, lidocaine patches, and gabapentinoids. A comprehensive list of ERAS measures are listed in Table 1.

Operative Details

All surgeries were performed by one of the thoracic surgeons at our institution using a two or three incision technique. After induction with general anesthesia, a double-lumen endotracheal tube was placed for lung protective single-lung ventilation. Patients were placed in lateral decubitus positions. All patients received antibiotic prophylaxis within 1 hour of incision and had sequential compression devices placed. Prior to incision, local anesthetic was injected into the incision site and a pre-emptive nerve block was performed posterior to the incision in the corresponding intercostal space. At the conclusion of the case, a 20F or 24F chest tube was inserted to the apex of the thoracic cavity, a multilevel intercostal nerve block was performed between the 3rd and 9th intercostal spaces using 20-30 mL of 0.25% bupivacaine without epinephrine, and the lung was re-inflated under direct visualization. All patients were in stable condition and extubated prior to leaving the operating room. Chest tubes were removed upon radiographic confirmation of lung expansion and resolution of air leak

Data Collection

Pre-operative data on patient demographics, co-morbidities, pulmonary function testing, American Society of Anesthesiologists (ASA) classification, surgical procedure, and indication for surgery were collected for both cohorts. Post-operative data collected on each subject included average daily numeric pain rating, total daily in-hospital opioid usage as measured by morphine milligram equivalents (MME), in-hospital length of stay, 30-day readmission, 30-day mortality, opioid prescription rates, postoperative complications and associated Clavien-Dindo classification.19 Pain scores were evaluated on a 10-point scale; 0 = no pain, 1-3 = mild, 4-6 = moderate; 7-10 = severe pain. In-hospital opioid usage was evaluated by totaling the subject’s daily opioid administration as measured by intravenous morphine milligram equivalents (MME). Record was also kept of whether opioids were prescribed upon discharge. Prescribed opioids included hydrocodoneacetaminophen, tramadol, acetaminophen with codeine, and oxycodone.

Data Analysis

Descriptive statistics were computed for all study variables. Continuous variables were described with measures of central tendency (mean, median) and dispersion (inter-quartile range [IQR], standard deviation). Categorical variables were summarized as frequencies and percentages. Wilcoxon rank-sum tests or independent groups’ t-tests, as appropriate, were used to compare the groups on continuous variables. Differences between the two groups on categorical variables were compared with Chi-square tests of independence. Effect size measures were also calculated and reported to describe the differences between the groups.

RESULTS

A total of 287 patients over a 2-year period were obtained for review. Of this group, 163 met inclusion criteria and were included for analysis. Information on patient demographics and operative details are presented in Table 2. There was no significant difference between the two cohorts with regards to all measures assessed except for pre-operative FEV1. Patients who underwent the ERAS protocol had a lower average pre-operative FEV1 compared to the pre-ERAS cohort (84% [67% - 94%] predicted vs 70% [60% - 80%] predicted, p = 0.0021).

General postoperative outcomes for each cohort are presented in Table 3. The outcomes assessed included average length of stay, 30-day readmission rate, 30-day mortality, complication rate, and opioid utilization on discharge. Each of these outcomes were similar between groups. With regards to opioid utilization, the percentage of patients in each cohort with an opioid prescription that was written (74.8% vs 72.7%) and subsequently filled after discharge (64.5% vs 72.2%) was similar. The findings on daily self-reported pain scores are displayed in Figure 1. Daily pain scores were similar between each cohort on postoperative days 1 through 3, (POD1 [6.5 vs 5.9], POD 2 [6.0 vs 5.4], and POD3 [4.8 vs 4.4]). Pain scores in the ERAS group were slightly higher than the pre-ERAS group on POD 4 (6.6 vs 4.5) and POD 5 (6.6 vs 4.8). However, this difference was not statistically significant. This study found no significant difference overall in daily selfreported pain scores between the two groups. Data on median daily in-hospital opioid usage is presented in Figure 2. ERAS protocol was associated with a lower utilization of opioids on post-operative day 0 (26.0 MME vs 19.0 MME, P = 0.002). Opioid utilization was similar between each group on post-operative days 1 through 5.

DISCUSSION

Opioids have long been used as the primary method of pain control after surgery. Between growing concerns about the potential adverse effects of opioids and problems with dependency and addiction providers are continually looking for safer alternatives. This study did not find a significant difference in average daily opioid usage after pulmonary resection via VATS approach, except for on post-operative day 0. It did not find a difference in the number of opioid prescriptions written after surgery. It also did not find a significant difference in average daily pain scores between the two groups. There was no difference between the two groups with regards to length of stay, re-admission rates, mortality rates, or postoperative complications. This study provides a unique perspective on the usage of multimodal non-opioid medications in a center which is already accustomed to utilizing many features of ERAS-centered care. Furthermore, this study is unique in its focus on minimally-invasive VATS surgeries over robotic or thoracotomy-based procedures. A previous retrospective analysis by Razi et al evaluating pain control using ERAS after thoracic surgery found a significant decrease in in-hospital opioid usage and opioid prescriptions upon discharge.18 This study focused on ERAS following thoracotomy and robotic thoracic surgery, rather than VATS. Martin et al, also found significant reductions in in-hospital morphine usage after VATS (86 vs 22, p < 0.0001) and thoracotomy (130 vs 54, p < 0.0001).21 However, similar to this institution’s study Martin did not find a significant difference in average daily pain scores in patients who underwent VATS or thoracotomy.21 A possible explanation for the lack of improvement in opioid-related outcomes after ERAS is that this institution adhered to many elements of ERAS prior to the initiation of this study. The ERAS Society and ESTS, as mentioned previously, released a set of guidelines in 2019. This department already adhered to measures including smoking cessation, usage of regional anesthesia with intercostal nerve blocks, and performing nearly all pulmonary resections through a minimally invasive approach. It has been suggested that VATS in and of itself is a form of ERAS.22 Centers which already have an aggressive commitment to VATS are likely to already implement many features of ERAS, and thus do not see a significant difference in their outcomes compared to centers with higher volumes of thoracotomy.22 It has not been the practice of this institution to use epidural anesthesia or patient-controlled analgesia for the majority of cases, with the exception of elective thoracotomy. Usage of ERAS at this institution was not associated with an increase in postoperative complications, 30-day re-admissions, or 30-day mortality. In a review of 600 patients who underwent VATS lobectomy or segmentectomy Brunelli et al, found ERAS protocols to not be associated with a significant change in 30-day or 90-day mortality, re-admission rates, or cardiopulmonary complications.16 Similarly, Forster et al found no significant difference in cardiopulmonary complications or readmission rates after adoption of ERAS protocols for patients undergoing VATS after resection of NSCLC.14 Forster did find a decrease in average length of stay (5 vs 7 days, P = 0.004).14 The findings of this study are consistent with other studies, although there was no decrease in average length of stay.

Study Limitations

This study focused on a specific subset of patients undergoing minimally invasive thoracic surgery, those undergoing pulmonary resection for primarily malignancy. This study does not evaluate the efficacy of ERAS on pain control for minimally-invasive infectious, diaphragmatic, pleural, or esophageal procedures. It also does not compare the efficacy of the protocol on post-surgical outcomes for patients undergoing robotic or thoracotomy-based procedures. However, previous studies looking at the efficacy of ERAS protocols for both of these approaches have found a decrease in in-hospital opioid usage for robotic patients and in opioid prescriptions after surgery.18 For patients undergoing thoracotomy, ERAS is associated

with a significant decrease in cardiopulmonary complications and decreased usage of thoracic epidural.20 The results obtained by this institution could likely be extended to these populations, as well as other patients who have undergone VATS for other indications. The sample size of this study is smaller compared to similar studies evaluating ERAS protocols for pain control and other quality improvement measures.18 A larger sample size, and one in which the post-ERAS cohort was closer in volume to the pre-ERAS cohort, may have yielded different findings. Additionally, after the initial implementation of ERAS protocols there was a several-week adjustment period in which medication compliance faltered. Certain medications used as part of the protocol, such as the anti-inflammatories and gabapentinoids, were not given as routinely. This required additional education and collaboration with our administration and pharmacy to ensure each qualifying patient received the full protocol. This delay to achieve a higher rate of compliance may negatively impact the early efficacy of the protocol and subsequent analysis.

CONCLUSION

Addition of ERAS protocols at this institution did not significantly improve postoperative outcomes or opioid utilization after VATS. This institution had implemented many features of ERAS as standard practice prior to the implementation of a formal multimodal pain management protocol. ERAS may prove beneficial to programs looking to transition from conventional pain management strategies. However, additional studies are needed to evaluate ERAS in the setting of minimally invasive thoracic surgery.

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ALL OR NOTHING SAPHENOUS VEIN GRAFT HARVESTING

Sean Storey DMSc, MS, PA-C South Shore University Hospital, Northwell Health

ABSTRACT:

Coronary artery bypass graft surgery remains the optimal revascularization strategy in patients with complex, ischemic, multivessel coronary artery disease. Long-term benefits of this surgical procedure are highly dependent on preserved graft patency, serving as a major factor in clinical prognosis and long-term survival. The saphenous vein remains the most utilized conduit for all non-left anterior descending territories. Employing optimal harvesting techniques to minimize saphenous vein injury during harvesting remains an important determinant in preserving graft patency. Open-vein and no-touch harvesting techniques have been shown to confer superior long-term graft patency individually as compared to traditional endoscopic techniques. Combining these practices could synergistically provide multifactorial benefits in preserving and extending graft patency beyond other harvesting techniques. In the search to improve the most common surgical procedure in adult cardiac surgery, utilization of both open-vein and no-touch harvesting in ideal candidates could prove to be essential in positively impacting both long-term clinical outcomes and post-operative mortality.

Key Points

Describe optimal surgical interventions for patients with complex, ischemic, multi-vessel coronary artery disease.

List and describe conduit selection and efficacy (Venous vs. Arterial).

Describe pathophysiology of vascular injury secondary to harvesting technique.

Review and debate practices optimizing saphenous vein harvesting and graft patency.

Significance of Conduit Harvesting

Cardiovascular disease remains the leading cause of death globally, taking an estimated 17.9 million lives each year.1 Ischemic heart disease falls under this umbrella and is expected to account for 14.2% of all deaths by 2030.1,2 Coronary artery bypass graft (CABG) surgery remains the optimal revascularization strategy in patients with complex, ischemic, multivessel coronary artery disease (CAD).2-4 The continuous refinement of surgical techniques and conduit harvesting has significantly contributed to the reduction in both morbidity and mortality.5 The long-term benefits of CABG surgery are highly dependent on the preservation of continuous graft patency.6 This serves as a major determinant in the patients' clinical prognosis and long-term survival.2 Techniques to optimize saphenous vein graft (SVG) performance and improve long-term graft patency are therefore a major priority in CABG surgery.

The most common utilized conduit to supplement the left internal mammary artery (LIMA) in CABG surgery is the SVG.7,8 Although extensive medical literature has demonstrated the benefits (i.e., greater longer-term patency and long-term survival benefits) associated with arterial grafts (i.e., radial artery, right internal mammary artery), complications of ischemia, graft spams, sternal healing (bilateral internal mammary harvesting in diabetics), anatomical limitations (i.e., insufficient collateral compensation) offsets the advantages provided by this conduit selection.2,6,9