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Senn L, Anand S. Integrative Review of Opioid Use and Protocol Adherence in Hospitals After Implementing Enhanced Recovery After Surgery Protocols for Cesarean Birth. Nurs Womens Health 2024:S1751-4851(24)00199-5. [PMID: 39370120 DOI: 10.1016/j.nwh.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 05/15/2024] [Accepted: 09/09/2024] [Indexed: 10/08/2024]
Abstract
OBJECTIVE To evaluate the enhanced recovery after surgery (ERAS) protocols used and amount of opioids administered during hospitalization for cesarean birth after the ERAS protocols were implemented. DATA SOURCES A search was conducted in CINAHL Complete, Scopus, and PubMed for sources published in English between January 2018 and December 2023. Search terms were cesarean AND opioid∗ AND eras OR erac OR enhanced recovery. STUDY SELECTION Eligible studies were conducted in the United States, used key pain management components from the ERAS guidelines, and reported results for in-patient postsurgical opioid use. DATA EXTRACTION Data obtained were for post-ERAS implementation only and included authors, date, sample size, study location, participant inclusion and exclusion criteria, methods, interventions used (ERAS guideline components), and morphine milligram equivalents used during the hospital stay. DATA SYNTHESIS Weighted averages were calculated for results reported as means and percentages. Descriptive summaries were used for the remainder of the results. RESULTS Twenty-six studies were found, accounting for 19,961 individuals' experiences after ERAS implementation. Although 30% of participants experienced only scheduled cesarean births, 70% experienced all types of cesarean births, including scheduled, urgent, or emergent. There was substantial heterogeneity of the data reported, especially for opioid use and time frames. In 11 studies that reported means, the weighted average for opioid use was 54 morphine milligram equivalents per stay. In 17 studies, researchers reported the number of women who experienced an opioid-free recovery, which averaged 40% of the women. CONCLUSION Implementation of standardized orders built on the ERAS guidelines in U.S. hospitals is associated with reduced opioid exposure for women experiencing scheduled and nonscheduled cesarean births while maintaining adequate pain relief. This review offers evidence that can support perinatal teams who are considering ERAS for cesarean birth or those looking for further improvements.
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Bär AK, Werkmeister R, Dort JC, Al-Nawas B. Perioperative care in orthognathic surgery - A systematic review and meta-analysis for enhanced recovery after surgery. J Craniomaxillofac Surg 2024:S1010-5182(24)00242-7. [PMID: 39183122 DOI: 10.1016/j.jcms.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 05/30/2024] [Accepted: 08/19/2024] [Indexed: 08/27/2024] Open
Abstract
The aim of this study was to determine whether implementing ERAS (Enhanced Recovery After Surgery) elements/protocols improves outcomes in orthognathic surgery (OGS) compared to conventional care. To achieve this, ERAS-specific perioperative elements were identified and literature on ERAS for OGS was systematically reviewed. Using PRISMA methodology and GRADE approach, 44 studies with 49 perioperative care elements (13 pre-, 15 intra-, 21 postoperative) were analyzed. While 39 studies focused on single elements, only five presented multimodal protocols, with three related to ERAS. Preoperative elements included antimicrobial and steroid prophylaxis and prevention of postoperative nausea and vomiting. Intraoperative aspects, especially anesthesiological, showed high evidence. Outcome parameters were heterogeneous: complications and postoperative pain were well-investigated with high evidence, while length of stay (LOS) and patient satisfaction received low to medium evidence. ICU LOS, healthcare costs, and readmission rates were underreported. The meta-analysis revealed significant results for pain reduction and trends towards fewer complications and shorter LOS in the ERAS group. Overall, ERAS protocols are not established in OMFS, particularly OGS. Further research is needed in pre- and postoperative care and standardized multimodal analgesia. The next step should be developing a comprehensive OGS protocol through a consensus conference and implementing it in clinical practice.
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Affiliation(s)
- Anne-Kathrin Bär
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacher Str. 170, 56072, Koblenz, Germany; Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany.
| | - Richard Werkmeister
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacher Str. 170, 56072, Koblenz, Germany
| | - Joseph C Dort
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Departments of Community Health Sciences and Oncology, Ohlson Research Initiative, Arnie Charbonneau Cancer Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
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Mundhra R, Gupta DK, Bahadur A, Kumar A, Kumar R. Effect of Enhanced Recovery after Surgery (ERAS) protocol on maternal outcomes following emergency caesarean delivery: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100295. [PMID: 38496380 PMCID: PMC10944090 DOI: 10.1016/j.eurox.2024.100295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/19/2024] [Accepted: 02/28/2024] [Indexed: 03/19/2024] Open
Abstract
Background With ever increasing rates of emergency caesarean deliveries (CD),incorporating the ERAS protocol might provide a perfect window of opportunity to increase maternal comfort during the postsurgical period, but also improve outcomes and facilitate optimal return of physiological function. Objective To determine whether an ERAS pathway at emergency caesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction. Material & methods Patients undergoing emergent caesarean delivery at ≥ 34 weeks of gestation were randomized to ERAS or conventional care. The primary outcome was to compare postoperative length of hospital stay. Secondary outcome variables included first oral intake, passage of flatus/defecation, first ambulation, first urination after catheter removal and postoperative pain scores in both groups. Results We randomized 142 women (71 each in ERAS versus Conventional arm) undergoing emergency cesarean delivery. Incorporation of ERAS protocol resulted in shorter length of hospital stay (73.92 ± 8.96 in conventional arm vs 53.87 ± 15.02 in ERAS arm; p value <.0001). Significant difference was seen in visual analogue scoring during initial ambulation and rest on day 0 and day 1 between ERAS and conventional arms with mean scores being lower in ERAS arm compared to Conventional arm (p value <.05). In terms of quality of life, ERAS arm had better quality of life compared to conventional arm. Conclusion Incorporation of ERAS protocol in emergency caesarean definitely improves patient outcome in terms of early resumption of activities with better quality of life.
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Affiliation(s)
- Rajlaxmi Mundhra
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Dipesh Kumar Gupta
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Anupama Bahadur
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Ajit Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Rakesh Kumar
- Department of Paediatrics, Himalayan Institute of Medical Sciences (HIMS), Dehradun, India
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Entezami P, Rock AK, Topp GP, Heydari ES, Field NC, Boulos AS, Dalfino JC, Yamamoto J, Pilitsis JG, Cherukupalli D, McCallum SE, Paul AR. Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques. Interv Neuroradiol 2024; 30:163-169. [PMID: 35648585 PMCID: PMC11095345 DOI: 10.1177/15910199221104616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/15/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION As we emerge from the current pandemic, hospitals, staff, and resources will need to continue to adjust to meet ongoing healthcare demands. Lessons learned during past shortages can be used to optimize peri-procedural protocols to safely improve the utilization of hospital resources. METHODS Retrospective review of patients who underwent elective endovascular intracranial aneurysm treatment was performed. Multivariable logistic regression was used to identify factors associated with patients who were able to be discharged within 24 h of elective procedures. Rates of complications (particularly readmission) were determined. RESULTS 330 patients underwent elective endovascular aneurysm treatment with 86 (26.1%) discharged within 24 h. Factors associated with earlier discharge included procedure years (2019-2021) and male sex. Patients were more likely to be discharged later (after 24 h) if they underwent stent-coil embolization or flow-diversion. There was no association between discharge timing and likelihood of readmission. DISCUSSION Our review highlights the safety of earlier discharge and allowed us to prepare a fast-track protocol for same-day discharge in these patients. This protocol will be studied prospectively in the next phase of this study. As we gain more comfort with emerging, minimally invasive endovascular therapies, we hope to safely achieve same-day discharge on a protocolized and routine basis, reducing the demand of elective aneurysm treatments on our healthcare system. CONCLUSION We retrospectively demonstrate that early discharge following elective aneurysm treatment is safe in our cohort and provide a fast-track pathway based on these findings for other centers developing similar protocols.
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Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Andrew K. Rock
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Gregory P. Topp
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | | | | | - Alan S. Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - John C. Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Junichi Yamamoto
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
| | - Julie G. Pilitsis
- Department of Neuroscience, Florida Atlantic University, Boca Raton, FL, USA
| | | | - Sarah E. McCallum
- Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, NY, USA
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Jun MR, Kim JM, Kim JY, Lee JH, Kim CE, Lee MO. Evaluation of basal rate infusion in intravenous patient-controlled analgesia for post-cesarean section pain management: A randomized pilot study. Medicine (Baltimore) 2024; 103:e37122. [PMID: 38394544 PMCID: PMC11309604 DOI: 10.1097/md.0000000000037122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 01/09/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE Administering opioids via intravenous patient-controlled analgesia is a prevalent approach for managing postoperative pain. Nevertheless, due to concerns about opioid-related side effects and the potential for opioid tolerance, there is a growing emphasis on adopting opioid-sparing techniques for postoperative pain management. We aimed to investigate the effect of adding a basal rate infusion in fentanyl-based IVA following a cesarean section (CS). METHOD Forty-eight patients, who received pain management through IVA after CS, were assigned randomly into 3 groups based on the background rate setting: Group 0 (0 mcg/hour, n = 16), Group 1 (15 mcg/hour, n = 16), and Group 2 (30 mcg/hour, n = 16). We assessed the impact of the basal infusion rate on opioid consumption and the visual analog scale (VAS) scores during the first 48 hours post-CS and also investigated opioid-induced side effects and the requirement for rescue analgesics in the ward during the first 48 hours after CS. RESULTS In the initial 24 hours following CS, fentanyl consumption significantly increased in Group 2 compared with Group 0 and Group 1 (P = .037). At 24 hours, VAS scores both at rest and during movement, tended to decrease, as the basal rate increased; however, no significant differences were observed between the groups (P = .218 and 0.827, respectively). Between the first 24- and 48-hours post-CS, fentanyl consumption showed a marked increase in both Group 1 and Group 2 compared to Group 0 (P < .001). At 48 hours, the VAS scores at rest displayed a trend toward reduction; however, no significant differences between groups were evident (P = .165). Although the incidence of opioid-induced complications was noted, no statistically significant differences were recorded between groups during the initial 24 hours and subsequent 24 to 48 hours period (P = .556 and P = .345, respectively). CONCLUSION The inclusion of a basal fentanyl infusion in the IVA protocol did not provide any advantages over an IVA devoid of a basal rate infusion in managing acute pain following CS.
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Affiliation(s)
- Mi Roung Jun
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jae-Myung Kim
- Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jeong Yeon Kim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Ji Hoon Lee
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Chae Eun Kim
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Moon Ok Lee
- Department of Anesthesiology and Pain Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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Aleid A, Alyaseen EM, Alfurayji RS, Alanazi BS, Alquraish FA, Al Mutair A, Alessa M, Albinsaad L. Enhanced Recovery After Surgery (ERAS) in Saudi Arabian Surgical Practice: A Comprehensive Analysis of Surgical Outcomes, Patient Satisfaction, and Cost-Effectiveness. Cureus 2023; 15:e49448. [PMID: 38152784 PMCID: PMC10751604 DOI: 10.7759/cureus.49448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/29/2023] Open
Abstract
Introduction Surgical procedures present substantial healthcare costs, patient discomfort, and potential adverse outcomes. In response, enhanced recovery after surgery (ERAS) protocols have emerged as comprehensive, evidence-based preoperative care pathways designed to optimize preoperative, intra-operative, and postoperative management. These protocols incorporate various interventions, such as preoperative education, nutritional optimization, minimally invasive techniques, multimodal pain management, early mobilization, and patient engagement. Despite their global success and growing popularity, the adoption and influence of ERAS protocols in Saudi Arabia have not been extensively explored. This study aims to assess the ERAS effects on surgical outcomes and evaluate its relationship with patient satisfaction, considering factors such as cost-effectiveness and compliance in the Saudi context. Methods This cross-sectional study encompassed data collection from 1,452 patients who underwent surgical procedures such as bariatric surgery and cholecystectomy, employing systematic random sampling across multiple healthcare facilities in Saudi Arabia. Data were gathered through structured questionnaires, medical records, and cost-effectiveness analysis within the period spanning from January to August 2023. The relationship between ERAS protocol implementation, surgical outcomes, patient satisfaction, and cost-effectiveness was analyzed using statistical tests, including correlation, regression analysis, and chi-square tests. A statistical significance threshold was set at p < 0.05, and Statistical Product and Service Solutions (SPSS, version 28.0) (IBM SPSS Statistics for Windows, Armonk, NY) was used for data analysis. Results Among the 1,452 respondents, 1,152 (79.3%) reported the implementation of ERAS protocols during their surgical procedures. Those receiving ERAS protocols exhibited significantly lower rates of surgical complications, readmissions, and reduced dependency on pain medication (p < 0.001). Additionally, participants subjected to ERAS protocols reported significantly higher satisfaction levels based on the mean satisfaction scale score, with a p-value of less than 0.001. Conclusion The results highlight substantial improvements associated with the implementation of ERAS protocols, particularly in terms of reduced surgical site infections, shortened hospitalization periods, and decreased pain management-related complications. Moreover, ERAS protocol implementation demonstrated enhanced surgical outcomes, increased postoperative satisfaction, and overall improved recovery experiences. These findings underscore the potential benefits of integrating ERAS protocols into the surgical practices of Saudi Arabia. This research contributes to a better understanding of the advantages offered by ERAS protocols and their potential for enhancing healthcare delivery in the region.
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Affiliation(s)
| | - Eman M Alyaseen
- College of Medicine and Medical Science, Arabian Gulf University, Manama, BHR
| | | | - Bader S Alanazi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | | | - Mohammed Alessa
- Department of Surgery, College of Medicine, King Faisal University, Hofuf, SAU
| | - Loai Albinsaad
- Department of Surgery, King Faisal University, Hofuf, SAU
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Wu Y, Fu Y, He Y, Gong X, Han Z, Fan H, Zhu T, Li H. The application of enhanced recovery after surgery (ERAS) in chronic rhinosinusitis patients undergoing endoscopic sinus surgery: A systematic review and meta-analysis. PLoS One 2023; 18:e0291835. [PMID: 37733792 PMCID: PMC10513253 DOI: 10.1371/journal.pone.0291835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVES Enhanced recovery after surgery (ERAS) has become extensively practiced and has shown encouraging benefits. Within recent years, ERAS has also been increasingly performed in chronic rhinosinusitis (CRS) patients undergoing endoscopic sinus surgery (ESS). However, the actual efficacy of ERAS in CRS patients undergoing ESS is not completely clear, and the related evidence remains weak. This systematic review and meta-analysis aimed to evaluate the effectiveness and safety of ERAS in the perioperative management of CRS patients receiving ESS. METHODS We searched randomized controlled trials in PubMed, Web of Science, EMBASE, Cochrane CENTRAL, Ovid, China National Knowledge Infrastructure, Chinese BioMedical Literature Database, Wanfang, and VIP Database up to February 2023, to analyze the effectiveness and safety of ERAS in ESS perioperative management of CRS patients. We appraised the methodological quality in the included RCTs using the Cochrane Collaboration tool and assessed the quality of evidence with the Recommendations Assessment, Development and Evaluation (GRADE) tool. Meta-analysis, subgroup analysis, and sensitivity analysis were carried out with the the software Review Manager 5.3 and Stata 12.0. In addition, potential publication bias was detected by Begg's test, Egger's test, and funnel plot test. RESULTS Twenty-eight studies involving 2636 patients were included within this study. In comparison with the standard care (SC) group, the ERAS group had the advantages in the following aspects: length of stay (MD = -2.50, 95%CI: -3.04 to -1.97), pain scores (MD = -1.07, 95%CI: -1.46 to -0.67), anxiety score (SMD = -2.13, 95%CI: -2.83 to -1.44), depression score (SMD = -2.42, 95%CI: -3.13 to -1.71), hospitalization expenses, and quality of life. At the same time, the ERAS group presented a markedly lower incidence of adverse events in comparison to the SC group, such as overall complications (RR = 0.28, 95%CI:0.20 to 0.41), postoperative nausea and vomiting (RR = 0.33, 95%CI:0.21 to 0.50), facial edema (RR = 0.20, 95%CI:0.11 to 0.38), low back pain (RR = 0.28, 95%CI:0.16 to 0.49), urinary retention (RR = 0.12, 95%CI:0.05 to 0.30) and haemorrhage (RR = 0.19, 95%CI:0.07 to 0.55). CONCLUSIONS The results showed that the ERAS protocol is effective and safe in CRS patients who undergo ESS. However, Due to the limited overall methodological quality included studies, caution should be exercised in the interpretation of the results. More high-quality, multiple-centre, and large-sample studies are in demand in the future to further validate its clinical efficacy.
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Affiliation(s)
- Yuqi Wu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yijie Fu
- School of Preclinical Medicine, Chengdu University, Chengdu, China
| | - Yuanqiong He
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinru Gong
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhoutong Han
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hongli Fan
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Tianmin Zhu
- School of Rehabilitation and Health Preservation, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hui Li
- School of Preclinical Medicine, Chengdu University, Chengdu, China
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Sobot Novakovic S, Cuk S, Svraka D, Milosevic D. Patient Satisfaction With General Anesthesia Compared to Spinal Anesthesia for Cesarean Section: A Multicenter Observational Study. Cureus 2023; 15:e42666. [PMID: 37521592 PMCID: PMC10386895 DOI: 10.7759/cureus.42666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/01/2023] Open
Abstract
Background Satisfaction in patients undergoing cesarean section (CS) is of great importance in every hospital. There are big differences between spinal and general anesthesia for CS in terms of outcome, recovery times, and quality of service. Methods This multicenter observational study included 1443 patients who had elective (n=622) or emergency (n=821) CS in five medical centers over the period of 16 months. Bauer questionnaire was used for measuring patient satisfaction after CS. The questionnaire contained 15 questions about anesthesia-related discomfort and satisfaction with anesthesia care. Results During the study period, 1161 (80%) patients underwent CS under general anesthesia (GA) and 282 of them (20%) received spinal anesthesia (SA) for CS. The most frequently reported anesthesia-related discomfort was pain at the surgical site (>70%), drowsiness (68%), and thirst (60%). The data on patient satisfaction showed high satisfaction that exceeded 90%. Anesthesia side effects were less frequent and the general satisfaction rate was higher in the SA group compared to the GA group (P < .001). Conclusion SA for CS had less frequent side effects and a better satisfaction rate compared to GA for CS. Hospitals need to make room for improvement of postoperative acute pain control and introduction to Enhanced Recovery After Surgery (ERAS) protocols for elective CS.
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Affiliation(s)
- Suzana Sobot Novakovic
- Anesthesiology and Critical Care, University Clinical Center of Republic of Srpska, Banja Luka, BIH
| | - Sanja Cuk
- Anesthesiology and Critical Care, University Clinical Center of the Republic of Srpska, Banja Luka, BIH
| | - Dragan Svraka
- Anesthesiology and Critical Care, University Clinical Center of Republic of Srpska, Banja Luka, BIH
| | - Dragan Milosevic
- Anesthesiology and Critical Care, University Clinical Center of Republic of Srpska, Banja Luka, BIH
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Cao S, Zhang Y, Lin B, Chen J, Chen X, Zhuang C. Enhanced recovery after gynecological surgery: A meta-analysis of randomized controlled trials. Nurs Health Sci 2022; 25:30-43. [PMID: 36464803 DOI: 10.1111/nhs.13000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/10/2022]
Abstract
Enhanced recovery after surgery protocol is a multidisciplinary and multimodal approach designed to improve perioperative outcomes for patients. This meta-analysis aimed to identify and elaborate on the efficacy of this protocol in women undergoing gynecologic surgery. Four databases were searched for randomized controlled trials from inception to December 2021. A total of 14 studies met the inclusion criteria and were analyzed. There was a significant reduction in the length of stay, the time to first flatus and first defecation, complications, and readmission rates in patients undergoing enhanced recovery after surgery when compared to routine care. The rate of discharge on the first postoperative day significantly increased in patients from the enhanced recovery group. There was no significant difference in the surgery time and blood loss. In conclusion, the enhanced recovery after surgery protocol might have a positive effect on patients undergoing gynecologic surgery. However, there is still heterogeneity between the included studies, and we need more research to draw reliable conclusions that enhanced recovery after surgery is favorable.
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Affiliation(s)
- SuFen Cao
- Department of Obstetrics, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - YuQiang Zhang
- Department of Obstetrics, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - BaiLang Lin
- Department of Nursing, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - JiaCheng Chen
- Department of Liver and Gallbladder Surgery, Hainan Provincial People's Hospital, Haikou, China
| | - XiaoJing Chen
- Medical Department, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - ChunYu Zhuang
- Department of Nursing, Haikou Hospital of The Maternal And Child Health, Haikou, China
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Cao L, Yao L, He W, Hou L, Yin Z, Wang D, Li K. Methodological quality in guidelines for enhanced recovery after surgery was suboptimal. J Clin Epidemiol 2022; 152:151-163. [PMID: 36191652 DOI: 10.1016/j.jclinepi.2022.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We aimed to appraise the methodological quality of existing guidelines for Enhanced Recovery After Surgery (ERAS) using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and to identify the concordance of different recommendations. STUDY DESIGN AND SETTING PubMed, Embase, Google Scholar, Web of Science, and clinical practice guideline websites were systematically searched. Four reviewers independently assessed the guidelines using the AGREE II instrument. The mean score of each AGREE II item, number of recommendations, strength of recommendation, and level of evidence were calculated. Agreement among reviewers was assessed using the intraclass correlation coefficient. RESULTS We identified 23 guidelines from 7,127 records. The overall agreement among reviewers was considered good (intraclass correlation coefficient, 0.92; 95% confidence interval [CI], 0.86-0.96). The mean scores of the six AGREE domains were scope and purpose, 60.1% (95% CI, 55.9-64.1); stakeholder involvement, 40.7% (95% CI, 35.4-46.0); rigor of development, 44.7% (95% CI, 42.2-47.2); clarity and presentation, 69.8% (95% CI, 65.3-74.3); applicability, 37.2% (95% CI, 31.8-42.6); and editorial independence, 47.8% (95% CI, 39.0-56.7). Only 2/23 ERAS guidelines were considered applicable without modifications. CONCLUSIONS The methodological quality of the ERAS management guidelines varied and was generally low. Future guideline development should adhere to the use of the AGREE II instrument and the GRADE system to better guide clinical practice and improve individualized treatment strategies.
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Affiliation(s)
- Liujiao Cao
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Liang Yao
- Health Research Methodology I, Department of Health Research Methods, Evidence and impact, McMaster University, Canada
| | - Wenbo He
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, China; Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Liangying Hou
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, China
| | - Zhe Yin
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Dan Wang
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China.
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Cesarean delivery using an ERAS-CD process for nonopioid anesthesia and analgesia drug/medication management. Best Pract Res Clin Obstet Gynaecol 2022; 85:35-52. [PMID: 35995654 DOI: 10.1016/j.bpobgyn.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/13/2022] [Indexed: 12/14/2022]
Abstract
Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.
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Birchall CL, Maines JL, Kunselman AR, Stetter CM, Pauli JM. Enhanced recovery for cesarean delivery leads to no difference in length of stay, decreased opioid use and lower infection rates. J Matern Fetal Neonatal Med 2022; 35:10253-10261. [PMID: 36178153 DOI: 10.1080/14767058.2022.2113512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE The primary objective of this study was to report surgical outcomes for cesarean delivery (CD) patients following the implementation of an Enhanced Recovery after Surgery (ERAS) pathway based on the ERAS Society recommendations. The primary outcome for which the study was powered was the length of stay (LOS). METHODS This IRB-approved cohort study was conducted at a single tertiary-care labor and delivery unit and utilized a pre-post intervention design. Our ERAS for CD protocol was designed using the ERAS Society recommendations and implemented globally for every patient admitted to the labor and delivery unit including both scheduled and unscheduled cases. The study was designed to have at least 85% power to detect a 6-h difference in length of stay (LOS) between the pre-intervention and post-intervention cohorts, assuming a standard deviation of 18 h. A total of 339 records were included for data analysis, 170 in the pre-intervention cohort and 169 in the post-intervention cohort. To assess the difference between groups with respect to the primary outcome of LOS, linear regression was used with and without adjusting for covariates. Differences in dichotomous secondary outcomes were assessed using binary logistic regression. Differences in continuous secondary outcomes were assessed via a two-sample t-test or Wilcoxon rank sum test. Individual components of protocol adherence were compared using chi-square tests. RESULTS Mean LOS was 80.5 ± 22.9 h and 82.3 ± 28.0 h, pre- and post-intervention respectively. There was no difference in LOS between the 2 cohorts (difference of means = 1.8 h; 95% confidence interval (CI): (-3.7, 7.3); p = .51). Cesarean procedure infection decreased from 11.8% pre-intervention to 5.3% post-intervention, corresponding to a 58% decrease in odds of cesarean procedure infection (odds ratio (OR)=0.42; 95% CI: (0.19, 0.96); p = .04). Inpatient opioid use also significantly decreased in the post-intervention cohort with a median MME per 12 h-period of 5.1 (25th percentile = 2.2, 75th percentile = 7.8) pre-intervention and 3.3 (25th percentile = 1.0, 75th percentile = 7.6) post-intervention (p = .04). CONCLUSION The results of this study support the implementation of an ERAS for CD protocol based on ERAS Society recommendations as evidenced by the statistically significant decrease observed in both procedure-related infection rates and inpatient opioid use. We did not find a significant difference in LOS, which leaves room for further investigation into factors that impact LOS after CD.
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Affiliation(s)
- Courtney L Birchall
- Department of Obstetrics and Gynecology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jaimie L Maines
- Attending Physician Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Allen R Kunselman
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Christy M Stetter
- Department of Public Health Sciences, Division of Biostatistics and Bioinformatics, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jaimey M Pauli
- Attending Physician Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
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Sharma K, Gupta S, Gupta A, Baghel A, Choudhary S, Choudhary V. Enhanced recovery after cesarean protocol versus traditional protocol in elective cesarean section: A prospective observational study. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.4103/joacc.joacc_16_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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