NEW ORLEANS – The enhanced recovery after surgery (ERAS) protocol resulted in significantly less opioid use for pain management for radical cystectomy patients, compared with traditional postop approaches, according to Dr. Hooman Djaladat.
“The whole idea behind the ERAS protocol was to diminish hospital stay and send the patients home sooner, with no increase in complications or readmission rates,” said Dr. Djaladat, associate professor of clinical urology at the University of Southern California, Los Angeles.
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ERAS protocols are multimodal perioperative care pathways, the aim of which is early recovery after surgery by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimens, and early mobilization.
Opioids have traditionally been the standard for pain management after radical cystectomy (RC) for bladder cancer, but opioid use is often accompanied by side effects such as respiratory depression, nausea, vomiting, confusion, and ileus – the leading cause of prolonged hospital stay.
Dr. Djaladat and his colleagues at USC compared the amount of opioid use, pain score, and postoperative ileus in consecutive ERAS and traditional postop RC patients at USC, and presented their findings in a poster at the annual meeting of the American Urological Association.
Study Methods
Dr. Djaladat and his colleagues retrospectively evaluated 205 open-RC patients, 124 of whom underwent pain management as outlined by ERAS protocol (May 2012 to December 2013) and 81 who underwent traditional pain management with opioids (February 2010 to September 2013); the two groups were matched according to patient demographics, and those with a history of opioid use prior to surgery were not included in the study.
Traditional pain management protocol relied primarily on intravenous and epidural opioids, with acetaminophen and ketorolac as supplements as needed. Patient-controlled analgesia also was used if necessary.
The ERAS protocol utilized predominantly acetaminophen and ketorolac started intraoperatively, supplemented by consistent use of local anesthetic through subfascial catheters. Opioids were used only for breakthrough pain.
All opioids used (oxycodone, hydromorphone, tramadol, hydrocodone, morphine, and fentanyl) were converted to intravenous morphine equivalents. Opioid use and pain scores were examined and compared up to postoperative day 4.
“Bottom line, a traditional pathway has been mostly opioid controlled, but ERAS protocol is mostly focused on nonopioid control,” said Dr. Djaladat. “We believe that opioids cause a lot of problems.”
Results
Length of hospital stay in the ERAS cohort was half that in the traditional cohort (4 days vs. 8 days, P < .0001). Additionally, mean morphine equivalent use in the ERAS group was about one-quarter of that observed in the traditional patients (4.9 mg/day vs. 20.87 mg/day, P < .0001).
Postoperative ileus was higher in the traditional group, compared with the ERAS group (22.2% vs. 7.3%, P < .0028). “One of the most important contributing factors to decreased ileus is less narcotic,” he said.
ERAS patients reported higher mean visual analogous (VAS) pain scores per day than traditional patients (3.1 vs. 1.14 on a 4-point scale, P < .0001). VAS scores are the modality by which patients’ pain is measured subjectively. However, Dr. Djaladat suggested in an interview that the statistically significant difference in VAS scores did not necessarily reflect a substantial difference in pain from a clinical perspective.
Dr. Djaladat and his colleagues observed that patients on ERAS protocol used significantly fewer opioid analgesics, which may have potentially contributed to decreased postoperative ileus and shorter lengths of hospital stay, he suggested. They affirm, however, that multi-institutional studies would aid in externally validating these results.
“We find that ERAS is sufficient to manage pain immediately and at the time of discharge, with less narcotic use, in patients who have just undergone radical cystectomy,” Dr. Djaladat reported.
Dr. Djaladat disclosed no relevant financial relationships.