Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients - Benefits of an enhanced recovery pathway

The implementation of a pectus bar insertion enhanced recovery after surgery pathway: A quality improvement initiative

BACKGROUND

Pectus excavatum repair is associated with significant discomfort, and pain is a primary contributor to postoperative hospital length of stay. Recent advances in postoperative pain control include the use of intercostal cryoablation techniques that may now make it possible to discharge patients on the day of surgery. Unnecessary variation in patient care and noncompliance with care bundles may be a factor in extended length of stay. The global aim of this quality improvement initiative was to successfully implement an enhanced recovery after surgery (ERAS) pathway on patients undergoing pectus excavatum repair. The SMART aim was to have a greater than 70% compliance for the perioperative bundle elements within 1 year of the pathway implementation.

METHODS

Multiple Plan-Do-Study-Act (PDSA) cycles were designed to create and implement an ERAS pathway for patients undergoing a pectus bar insertion procedure. This multidisciplinary pathway was designed, managed, and implemented with key stakeholders from the Departments of Evidence Based Practice, Surgery, Anesthesiology, and Perioperative Nursing. Patient characteristics, outcomes, and compliance with elements of the pathway were measured for analysis for both the baseline and post-intervention groups with monthly automated reports.

RESULTS

After implementation of the ERAS pathway, data on the first 50 patients showed a 90% compliance with the perioperative bundle elements. Mean length of stay was significantly decreased from 33 h (95% CI [28.76, 37.31]) to 18 h (95% CI [14.54, 21.70]). There were zero readmissions within 24 hours for patients who were discharged on the day of surgery.

CONCLUSION

Employing a multidisciplinary approach in both planning and execution that standardized clinician practices and minimized unnecessary variation in patient care, an ERAS pathway for pectus bar insertion has been successfully established at our institution.

Development of a five point enhanced recovery protocol for pectus excavatum surgery

PURPOSE

We implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation.

METHODS

A 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test.

RESULTS

A total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P = 0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p = 0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience.

CONCLUSION

Our results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics.

LEVEL OF EVIDENCE

III - Retrospective comparative study.

Pain Quality After Pediatric Pectus Excavatum Repair

BACKGROUND

Neuropathic pain medications are included in multimodal postoperative analgesic strategies, but quality of perioperative pain is rarely assessed.

AIMS

The purpose of this study was to describe adolescents' pain experiences after thoracoscopic pectus excavatum repair (Nuss procedure) using the Adolescent Pediatric Pain Tool.

DESIGN

This prospective descriptive longitudinal study was designed to test the hypothesis that pain quality descriptors reported are consistent with neuropathic pain.

METHODS

A convenience sample of 23 adolescents aged 12 to 17 years from a single urban, university affiliated, nonprofit children's hospital consented to self-report pain using the Adolescent Pediatric Pain Tool before and during hospitalization, and up to 14 months after Nuss procedure. Visual analytic techniques were used to analyze reported pain intensity, location, and affective, evaluative, sensory, and temporal qualities.

RESULTS

Postoperative pain quality, intensity, number of sites, and surface area decreased over time. Word clouds illustrated that neuropathic sensory and temporal pain quality descriptors increased in frequency 2 to 6 weeks after surgery and were the predominant descriptors 2 to 4 months after surgery. Dot matrix charts illustrated an inconsistent relationship of pain quality and intensity with pain surface area.

CONCLUSIONS

Pain quality should be assessed with valid, reliable, and developmentally appropriate tools. Visual analytics help illustrate pain quality at single points in time and longitudinally and may be helpful in guiding postoperative pain treatment.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Postoperative management of pediatric patients undergoing minimally invasive repair of pectus excavatum: Where are we now?

PURPOSE

Minimally invasive repair of pectus excavatum (MIRPE) often leads to a painful and challenging recovery period. This study aims to describe the postoperative management of pediatric patients undergoing MIRPE and compare postoperative outcomes between patients using different routes of postoperative analgesia.

METHODS

Retrospective chart review of pediatric patients who underwent MIRPE from July 2003 to September 2019 at a single pediatric tertiary care center. Data on pain management and course of hospital stay were ascertained. Descriptive statistics, Mann-Whitney U and Pearson Chi-Square tests were used to analyze data. A p-value <0.05 was considered significant.

RESULTS

Of the 115 patients identified, 58 (50.4%) managed pain postoperatively using thoracic epidural and 57 (49.6%) used intravenous patient-controlled analgesia (IVPCA). The transition from the predominant use of epidural to IVPCA for MIRPE occurred between 2012 and 2013. Higher pain scores were reported by the IVPCA group at 6 h (p<0.001) and 12 h (p<0.001) postoperative. Patients using IVPCA had lower postoperative opioid consumption (p<0.001) and switched to oral opioids sooner than the epidural group (p<0.001). Fewer patients in the IVPCA group required urinary catheterization (p<0.001). Patients using IVPCA had a shorter hospital stay (4 days [IQR 4-5]) compared to the epidural group (5.5 [IQR 5-6]; p<0.001). Readmission was comparable at 3.48% in the total sample.

CONCLUSION

Patients using intravenous patient-controlled analgesia reported higher pain scores however, this route of analgesia was associated with shorter hospital stay. Prospective studies designed to address moderator variables are required to confirm findings and develop standardized recovery protocols.

A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure

Background

A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control.

Methods

All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort.

Results

Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002).

Conclusions

Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.

Implementation and outcomes of enhanced recovery protocols in pediatric surgery: a systematic review and meta-analysis

BACKGROUND

This systematic review examines the feasibility and safety of implementing Enhanced recovery after Surgery (ERAS) protocols in children.

STUDY DESIGN

A systematic search of Medline, PubMed, and the Cochrane library for papers describing ERAS implementation in children between January 2000 and January 2021. The systematic review was performed according to the PRISMA statement. The meta-analysis was done using R Software (Ver 4.0.2). p value of < 0.05 was considered statistically significant.

RESULTS

Sixteen studies, describing a total of 1723 patients, were included in the meta-analysis. An average of 15 (range 11-16) relevant components were implemented with an overall compliance close to 84%. The time to initiate feeds and reach full enteral nutrition was reduced in ERAS group with mean difference (MD) of - 21.20 h (95% CI - 22.80, - 19.59, p < 0.01), and - 2.20 days (95% CI - 2.72, - 1.71, p < 0.01), respectively. The use of opioids for postoperative analgesia was reduced with MD of -0.86 morphine equivalents mg/kg (95% CI - 1.40, - 0.32, p < 0.01). The length of hospital stay showed a significant reduction with MD of -2.54 days (95% CI - 2.94, - 2.13, p < 0.01). There was no difference in the complication and readmission rates between the groups.

CONCLUSION

ERP implementation in pediatric perioperative care is a viable option in a variety of surgical settings. There is clear evidence of a decrease in hospital stay duration with no increase in complication or readmission rates. The length of hospital stay reduced in inverse proportion to the number of ERAS elements implemented. Parental satisfaction is increased by initiating enteral feeding early, minimizing catheter and drain use, and reducing opioid use.

Variability in discharge opioid prescribing practices for children: a historical cohort study

PURPOSE

Legitimate opioid prescriptions can increase the risk of misuse, addiction, and overdose of opioids in children and adolescents. This study aimed to describe the prescribing patterns of discharge opioid analgesics following inpatient visits and to determine patient and prescriber characteristics that are associated with prolonged opioid prescription.

METHODS

In a historical cohort study, we identified patients discharged from hospital with an opioid analgesic prescription in a tertiary pediatric hospital from 1 January 2016 to 30 June 2017. The primary outcome was the duration of opioid prescription in number of days. We assessed the association between patient and prescriber characteristics and an opioid prescription duration > five days using a generalized estimating equation to account for clustering due to repeated admissions of the same patient.

RESULTS

During the 18-month study period, 15.4% of all admitted patients (3,787/24,571) were given a total of 3,870 opioid prescriptions at discharge. The median [interquartile range] prescribed duration of outpatient opioid therapy was 3.75 [3.00-5.00] days. Seventy-seven percent of the opioid prescriptions were for five days or less. Generalized estimating equation analysis revealed that hospital stay > four days, oxycodone prescription, and prescription by clinical fellows and the orthopedics service were all independently associated with a discharge opioid prescription of > five days.

CONCLUSIONS

Most discharge opioids for children were prescribed for less than five days, consistent with current guidelines for adults. Nevertheless, the dosage and duration of opioids prescribed at discharge varied widely.

Thoracic paravertebral nerve catheter reduces postoperative opioid use for vertebral body tethering patients

PURPOSE

Vertebral body tethering is increasingly being performed, yet postoperative pain management has not yet been optimized. We sought to determine whether the addition of a thoracic paravertebral block in addition to a standard multimodal postoperative pain management program could provide greater pain relief, reduced analgesic requirement, and reduced length of stay.

METHODS

Patients who underwent VBT at a single tertiary referral center were retrospectively reviewed. All patients received a single-shot intrathecal (IT) injection at the completion of the procedure in addition to a standardized multimodal pain management program. 45 patients received a thoracic paravertebral catheter with lidocaine infusion (TPVB) which was left in place for 4-6 days, whereas 24 control patients did not have a TPVB. Length of stay, maximum postoperative Numeric Pain Intensity Scale (NPIS), and total dose of opioids, ibuprofen, ketorolac and acetaminophen administered during hospitalization were evaluated.

RESULTS

69 patients met inclusion criteria. The mean cumulative dose of opioids administered during hospitalization was 148 oral morphine milligram equivalent (MME) in the control group vs. 47 MME in the TPVB group (p < 0.0001). Severe postoperative NPIS of ≥ 7 was reported in 9 out of the 24 control patients (38%) and in 13 out of the 45 patients (29%) who received a TPVB in addition to the standardized care (p = 0.46). There was no significant difference in the mean cumulative dose of NSAIDs (ibuprofen, ketorolac) consumed by the control group compared to the TPVB group (2632 mg vs. 1630 mg, p = 0.77). Mean length of stay in the control group was 3.8 vs. 3.0 days in the TPVB group (p < 0.001). There were no major complications associated with use of the TPVB.

CONCLUSION

In this series compared to controls, patients treated with a TPVB had reduced postoperative requirement of opioids and decreased length of hospital stay.

Thoracic epidural-based Enhanced Recovery After Surgery (ERAS) pathway for Nuss repair of pectus excavatum shortened length of stay and decreased rescue intravenous opiate use

BACKGROUND

PCA- and block-based enhanced recovery after surgery (ERAS) pathways have been shown to decrease hospital length of stay (HLOS) and opiate use following Nuss Repair for Pectus Excavatum (NRPE). No thoracic epidural-based ERAS pathway has demonstrated similar benefits.

METHODS

In this pre-post single-center study, data were retrospectively collected for patients ≤ 21 years undergoing NRPE from May 2015 to August 2019. Univariate and multivariate methods were used to evaluate whether implementation of a thoracic epidural-based ERAS in April 2017 was associated with HLOS, opiate use, or pain scores.

RESULTS

There were 110 patients: 35 pre- and 75 post-ERAS. HLOS decreased from median 4.8 (1.1) to 3.3 (0.6) days with ERAS (p < 0.001). Use of rescue intravenous opiates decreased from 35.3% pre- to 9.3% with ERAS (p = 0.013). When adjusted for baseline characteristics, ERAS was associated with a 1.3 ± 0.2 day decrease in HLOS and 0.188 times the odds of rescue intravenous opiate use (p = 0.011).

CONCLUSIONS

Pain scores, ED visits, and readmissions did not change with ERAS (p > 0.05). Implementation of a thoracic epidural-based ERAS following NRPE was associated with decreased HLOS and need for any rescue intravenous opiates without a change in pain scores, ED visits, or readmission.

Opioid stewardship in pediatric surgery: Approaching zero

INTRODUCTION

In response to the opioid epidemic, we hypothesized that adequate pain control can be achieved with few, if any, opioid prescriptions at discharge following pediatric surgical procedures.

METHODS

All records for patients 0-15 years old who underwent pediatric surgical operations from December 2017 through May 2018 were reviewed. Opioids prescriptions, emergency department (ED) visits, and hospital readmissions were recorded. Postoperative pain was assessed on a scale from 0 to 10 via phone call within three days of discharge.

RESULTS

352 patients underwent 394 surgical procedures. Three patients were prescribed opioids at discharge. There were no pain-related readmissions. One patient returned to the ED owing to pain. 116 unique pain scores were obtained from 114 patients: score 0 (n = 69, 59%), 1-3 (n = 31, 27%), 4-5 (n = 11, 9%), 6-8 (n = 5, 4%), and 9-10 (n = 0, 0%). There was a positive association between pain and increasing age (r = 0.26, p = 0.005). No patients who underwent hernia repair reported a pain score greater than 3.

CONCLUSIONS

Adequate pain control at discharge after pediatric general surgical procedures can be achieved for most children with scheduled nonopioid medications only. A limited supply of opioids for analgesia after discharge may benefit small subset of patients. This strategy would help reduce opioid prevalence in the community.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

Level III.

The impact of an enhanced recovery perioperative pathway for pediatric pectus deformity repair

PURPOSE

Pediatric repair of chest wall deformities is associated with significant pain, morbidity, and resource utilization. We sought to determine outcomes of a perioperative enhanced recovery after surgery (ERAS) pathway for patients undergoing minimally invasive (Nuss) and traditional (Ravitch) corrective procedures.

METHODS

Our ERAS protocol was implemented in 2015. We performed a retrospective review of patients for Nuss or Ravitch procedures before and after ERAS implementation. Combined and procedure segregated bivariate analyses were conducted on postoperative outcomes and resource utilization.

RESULTS

There are 17 patients in the pre-intervention group (Nuss = 13 and Ravitch = 4) compared to 38 patients in the post-intervention group (Nuss = 28 and Ravitch = 10). Protocol implementation increased utilization of pre-operative non-narcotic medication. The combined and Nuss post-intervention groups had a significant decrease in epidural duration and time to enteral medications, but had increased total postoperative opioid usage. The Ravitch post-intervention group had a significant decrease in intra-operative narcotics and discharge pain scores. There were no differences in length of stay or complications.

CONCLUSION

Implementation of our ERAS protocol standardized pectus perioperative care, but did not improve postoperative opioid usage, complications, or resource utilization. Alterations in the protocol may lead to achieving desired goals of better pain management and decreased resource utilization.

Successful use of an enhanced recovery after surgery (ERAS) pathway to improve outcomes following the Nuss procedure for pectus excavatum

PURPOSE

Pectus excavatum is a common chest wall deformity amenable to surgical correction, most commonly by a technique known as the Nuss Procedure. The surgery is associated with significant postoperative pain and lengthy hospital stays. We hypothesized that a standardized enhanced recovery after surgery (ERAS) pathway would result in significantly reduced length of stay (LOS) and reduced levels of postoperative pain without an increase in readmissions or emergency department (ED) visits.

METHODS

We instituted a pectus excavatum ERAS program at a high-volume academic center. Our ERAS protocol standardized perioperative exercise and pharmacologic regimens, pre- and post-operative education, and early return to activity. We conducted a retrospective review of all patients undergoing the Nuss procedure from 2015 to 2018. ERAS was implemented at the mid-point of the study period, and pre- and post-protocol patients were compared in our analysis. The primary outcome measure was LOS. The secondary outcomes included pain scores, incidence of urinary retention, and readmissions or ED visits.

RESULTS

One hundred nine patients were included in this study (51 patients pre-ERAS and 58 post-ERAS). The average length of hospitalization prior to implementation of ERAS was 3.49 and after the implementation 2.90 (p = 0.0007). The implementation of ERAS showed a trend of decreasing readmissions and emergency department visits, but this did not reach statistical significance. There was a statistically significant decrease in both requirement for urinary catheter placement and pain scores on postoperative day 0.

CONCLUSIONS

Implementation of ERAS for the Nuss procedure leads to a significant reduction in LOS, early pain scores, and urinary catheter usage, without an increase in post-operative ED visits and hospital readmissions. An ERAS protocol should be utilized in this patient population.

TYPE OF STUDY

Retrospective comparative study.

TYPE OF EVIDENCE

Level III.