In order for an Enhanced Recovery After Surgery (ERAS) protocol to work as intended, you often need an extra something that could make some medical professionals a little uncomfortable. “Everybody involved in an ERAS initiative must be open to all ideas,” says Jill Hanisak, DNP, CRNA, anesthesia services education coordinator for Lehigh Valley Health Network (LVHN) in Allentown, Pa. “They need to try new approaches, show a willingness to change and apply the most current research.”
It’s this openness, as well as the results of such a strategy as it pertains to the facility’s ERAS program, that earned LVHN this year’s OR Excellence Award in Pain Control. Thanks to a comprehensive ERAS pathway, the facility was able to reduce patients’ opioid utilization by 61% (compared with historical controls), decrease pain scores and improve patient satisfaction scores.
The health system’s multipronged approach to managing pain was a significant departure from its previous strategy. The team at LVHN charged with overseeing the new ERAS pathway aims to preemptively attack the potential sources of pain and discomfort early on in the preoperative process by optimizing patients’ nutrition status and offering them a carbohydrate-rich drink and clear liquids up to two hours before surgery. “NPO doesn’t work,” says Dr. Hanisak. “The carb drink helps in a number of ways, including reducing insulin resistance that occurs after surgery.”
Preoperatively, patients also receive oral acetaminophen, pregabalin and tramadol, a combination that provides potent and preemptive opioid-sparing pain relief. “The goal is to mitigate the patient’s physiologic stress response to surgery,” says Dr. Hanisak.
In addition to regional anesthesia, patients are given a multimodal anesthetic regimen that includes propofol, dexmedetomidine and esmolol infusions as well as a bolus administration of both magnesium and ketamine (starting at .5 mg/kg). That course of action helps to reduce the patient’s pain after surgery and goes a long way toward preventing PONV, which many patients fear more than the discomfort of their procedures. “By using propofol infusions instead of inhalation gases, we’re able to greatly reduce rates of PONV,” says Dr. Hanisak.