Clinical Benefits of ERAS
Patient education. The first item in most ERAS protocols is patient education. It is generally thought that the more information a patient has about what to expect before, during, and after surgery, the better the clinical outcomes.
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February 2019UC Davis is convinced that patient education is effective in moving the needle on surgical recovery, so they have incorporated a team approach to filling key knowledge gaps. “Our nurse practitioner is more involved in the preoperative communication with the patient and family. We are more aggressive in outlining the expectations for the entire process—from the procedure through recovery—to do an even better job of patient education and preparation,” Dr. Farwell said.
We are noticing that patients are recovering faster [and] spending much less time in the intensive care units and on ventilators, reinforcing what we have learned about admitting patients straight to the floor, early mobilization, and changing our approach to postoperative care. —D. Gregory Farwell, MD
For ambulatory sinus procedures, Satish Govindaraj, MD, associate professor of otolaryngology at the Icahn School of Medicine at Mount Sinai, and colleague Alfred Iloreta, MD, assistant professor of otolaryngology at Icahn, have implemented educational videos that patients can watch from the comfort of their home as they prepare for sinus surgery. In a pilot study, they found that patients who watched the four educational videos and received automated reminders to take medications reported that the videos helped them “better understand their condition and treatment” than patients who received a sham platform (95.7% vs 74.1%, respectively)
(Int Forum Allergy Rhinol [published online ahead of print December 13, 2018; doi: 10.1002/alr.22233].
Preoperative nutrition. ERAS protocols are specifically designed to pre-habilitate patients who are undergoing a major procedure. “They address the functional and biologic benefits of preoperative nutrition and hydration—even mild dehydration impairs mood and neurologic function—and studies have shown that postoperative nausea and vomiting is less in patients who have not fasted prior to surgery,” said Gerald M. Haase, clinical professor of surgery at the University of Colorado School of Medicine in Aurora. (Br J Surg. 2005;92:415–421).
In addition, “preoperative carbohydrate loading has been shown to reduce insulin insensitivity and decrease hyperglycemic risks. Adequate nutrition and preoperative carbohydrate loading reduce hospital stay, infectious complications, and patients’ distress from hunger and anxiety,” Dr. Haase wrote in an editorial in American Journal of Otolaryngology, Head and Neck Medicine and Surgery. In the editorial, he urged otolaryngologist–head and neck surgeons to join the ERAS parade (Am J. Otoalaryngol. 2018;39:652–653).
Pain management. In the era of the opioid abuse epidemic, many institutions are revising their pain management protocols. In the ERAS recommendations, the authors suggest that clinicians rely on a “multimodal approach [to pain management] combining strong opioids, nonopioid analgesics, and peripheral and neuroaxial local anesthetics acting on different sites of the pain pathway.”
However, in a survey of 1,770 members of the American Rhinologic Society, Dr. Govindaraj and colleagues found that the most commonly prescribed pain medications after functional endoscopic sinus surgery were opioids/non-opioid combinations (average of 27 pills) (Int Forum Allergy Rhinol. 2018;8:1199–1203). “What this study demonstrated is that many physicians prescribe a blanket number of opioids based on how they were taught, and do not think about alternative [non-opioid] methods of pain management, such as extra-strength Tylenol or gabapentin, as often as they should.”
In the division of rhinology at Mount Sinai, “we have incorporated a standardized pain management sheet that the surgeon has to fill out about what type of pain medication we want, how many pills we expect to use, and whether we want to incorporate extra-strength Tylenol into that pain regimen,” Dr. Govindaraj said. “We have to better educate patients when they should use stronger opioid medication.”
Dr. Farwell echoed the need to push for safer opioid use. “We’re all well aware of the [risk of misuse and abuse] of opioids, so we’ve become far more aggressive [in using] non-opioid management,” he said. “We’re also conducting research into novel pain regimens, including gabapentin. I think [the opioid crisis has] encouraged a lot of us to look at alternatives to opioids.”
But Dr. Levine worries that in the push to spare opioids, ERAS protocols introduce medications that may not be safe for older patients. As an anesthesiologist at Mt. Sinai, Dr. Levine treats a lot of geriatric patients who are at risk for cognitive decline and delirium. “We really should have ERAS protocols for specific patient populations, as well as for surgical techniques, that account for such risks.