Management of Postoperative Pain after Elective Craniotomy: A Prospective Randomized Controlled Trial of a Neurosurgical Enhanced Recovery after Surgery (ERAS) Program

Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis

The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. Secondary outcomes included postoperative pain visual analog pain scores, incidence of postoperative nausea and vomiting (PONV), postoperative complications, all-cause reoperation, readmission after discharge, and mortality. A literature search up to August 10, 2023, was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. Five studies, including 871 patients, were identified for inclusion in this review. Compared with conventional perioperative care, ERAS protocols reduced the length of postoperative hospital stay (difference of medians, -1.52 days; 95% CI: -2.55 to -0.49); there was high heterogeneity across studies ( I2 , 74%). ERAS protocols were also associated with a lower risk of PONV (relative risk, 0.79; 95% CI: 0.69-0.90; I2 , 99%) and postoperative pain with a visual analog scale score ≥4 at postoperative day 1 (relative risk, 0.37; 95% CI: 0.28-0.49; I2 , 14%). Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.

Opiate Use Patterns Following Surgery for High Grade Glioma

INTRODUCTION

Opiate drugs are commonly prescribed for postoperative pain relief following craniotomy. The aim of this study was to assess opiate use in patients undergoing craniotomy for high-grade glioma and to identify risk factors contributing to prolonged opiate use.

METHODS

A retrospective chart review was conducted on adult patients undergoing craniotomy for high-grade glioma between January 2016 and January 2020. Medical records were assessed for history of pain syndrome, and alcohol, nicotine, and other substance use. Opiate length of utilization and dose measured by morphine equivalent dose (MED) was collected. Statistical analyses were conducted using R Statistical Software (v4.1.2; R Core Team 2021).

RESULTS

A total of 295 patients met inclusion criteria, with 26.4% undergoing biopsy and 73.6% undergoing craniotomy for resection. The average immediate postoperative MED/day was 20.3 (SD 21.5) and average duration of outpatient opiate use was 15.1 days (SD 63.1 days). Male sex and history of tobacco use were associated with increased MED/day in the postoperative period. A stratified analysis showed that, for patients undergoing craniotomy, MED/day was significantly increased with male sex and history of tobacco use. For patients undergoing biopsy, MED/day was significantly increased with history of other substance use. History of pain syndrome significantly increased the odds of opiate prescription renewal. Age significantly reduced the odds of opiate prescription renewal.

CONCLUSIONS

Postoperative opiate use in this cohort is modest. Increased opiate use is associated with comorbidities known to modulate pain perception. Prospective studies should be conducted to provide more robust data.

Designing Enhanced Recovery After Surgery Protocols in Neurosurgery: A Contemporary Narrative Review

Enhanced Recovery After Surgery (ERAS) protocols have revolutionized the approach to perioperative care in various surgical specialties. They reduce complications, improve patient outcomes, and shorten hospital lengths of stay. Implementation of ERAS protocols for neurosurgical procedures has been relatively underexplored and underutilized due to the unique challenges and complexities of neurosurgery. This narrative review explores the barriers to, and pioneering strategies of, standardized procedure-specific ERAS protocols, and the importance of multidisciplinary collaboration in neurosurgery and neuroanesthsia, patient-centered approaches, and continuous quality improvement initiatives, to achieve better patient outcomes. It also discusses initiatives to guide future clinical practice, research, and guideline creation, to foster the development of tailored ERAS protocols in neurosurgery.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

Importance

A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed.

Objective

To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors.

Data Sources

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021.

Study Selection

Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes.

Data Extraction and Synthesis

Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome.

Main Outcome and Measures

The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality.

Results

Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant.

Conclusions and Relevance

In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.

Developing a fast-track discharge protocol for patients with cerebral aneurysms treated via neuroendovascular techniques

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.

A review on wound management strategies in enhanced recovery after craniotomy: An in-depth analysis of their influence on patient recovery and surgical outcomes

Craniotomy, an essential neurosurgical operation, poses distinct difficulties in the realm of post-operative care, specifically with regard to the management of wounds. Efficient wound management is critical in order to optimize the surgical outcomes, reduce complications and facilitate a speedier recovery. The purpose of this comprehensive review was to assess contemporary wound management approaches as they pertain to improved recovery following craniotomy. This was achieved by contrasting conventional methods with more recent and innovative techniques and analysing the effects of these approaches on patient recovery and surgical results. An exhaustive literature search was undertaken, comprising narrative reviews, clinical studies, peer-reviewed articles and expert opinions. The emphasis was on the evolution of wound management strategies and techniques utilized after cranial section, as well as their contributions to patient recovery. The analysis reveals that while conventional wound management methods, including suturing and antiseptics, continue to be essential, innovative strategies such as negative pressure wound therapy, skin adhesives and advanced pain management protocols are becoming increasingly recognized. It has been demonstrated that these novel approaches improve recovery by decreasing the incidence of infections, enhancing patient comfort and producing superior cosmetic results. Nevertheless, obstacles continue to endure, including patient-specific variables, technological and financial considerations and the enduring consequences of recovery. Thus the treatment of wounds during craniotomy recuperation necessitates an integrated strategy that incorporates conventional techniques alongside contemporary advancements. Progress in this domain necessitates the customization of approaches to suit the unique requirements of each patient, the resolution of identified obstacles and an emphasis on ongoing investigation and interdisciplinary cooperation. The ever-changing terrain of wound management approaches underscores the ever-changing character of neurosurgical treatment and the continuous endeavour to enhance patient results following cranial resection.

Enhanced recovery after surgery in patients undergoing craniotomy: A meta-analysis

BACKGROUND AND OBJECTIVE

Enhanced recovery after surgery (ERAS) is a multidisciplinary,and evidence-based perioperative care method. It is effective in shortening hospital stays and improving clinical outcomes. However, the application of ERAS in craniotomy lacks reliable evidence. The purpose of this study is to investigate the efficacy and safety of ERAS in craniotomy.

METHODS

Studies of ERAS in craniotomy were systematically searched in PubMed, Embase, Cochrane, and Web of Science. Primary outcomes (total hospital stay and postoperative hospital stay, hospitalization cost, percent of patients with moderate to severe pain) and secondary outcomes (readmission rate and incidence of complication) were compared between ERAS and traditional perioperative care.

RESULT

Of the 10 studies included in this meta-analysis, 6 were randomized-controlled trials (RCTs), 3 were cohort studies, and 1 was non-RCT. A total of 1275 patients were included, with 648 in the ERAS group and 627 in the control group. Compared with the control group, the ERAS group had a significantly shortened total length of stay (LOS) (MD = -2.437, 95% CI: -3.616, -1.077, P = 0.001) and postoperative LOS, reduced hospitalization cost (SMD = -0.631, 95% CI: -0.893, -0.369, P = 0.001), and lower percent of patients with moderate to severe pain. There was no significant difference in readmission rate between the two groups. Though, the ERAS group had a significantly lower risk of pneumonia than the control group.

CONCLUSION

ERAS is safe and effective for craniotomy as it shortens total and postoperative LOS, reduces hospitalization costs, decreases the percent of patients with moderate to severe pain.

Management of Post-craniotomy Pain in Elective Cases: A Randomized Controlled Trial

BACKGROUND

 Craniotomy is associated with significant postoperative discomfort. Standardized pain management and enhanced recovery after surgery (ERAS) protocol could improve patient-reported outcomes and lower medical expenses.

AIM

 The aim of this study is to prospectively assess the effectiveness of an ERAS protocol for neurosurgery in the treatment of postoperative pain following elective craniotomies.

METHODS AND MATERIALS

 A total of 128 patients were assigned to the ERAS group and received care in accordance with the neurosurgical ERAS regulations, while 130 other participants were assigned to the control group and received traditional postoperative assistance. The participants' postoperative pain ratings using the numerical rating scale (NRS) were this study's main outcome of interest. The verbal NRS uses the numbers 0 to 10, with 0 indicating no sensation of pain and 10 indicating the most severe pain. On postoperative day (POD) 1, the patients' postoperative pain level at the surgical site was evaluated using the NRS. This was repeated every day until the patient either reported feeling no sensation of pain or was discharged home.

RESULTS

 The mean value of pain on the day of surgery was 4.43 ± 0.43 and 4.72 ± 0.68 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. However, the difference was not statistically significant (p = 0.478). The mean value of pain on POD1 was 3.13 ± 0.21 and 4.45 ± 0.95 for patients in the ERAS and control groups, respectively. These pain values were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.011). The mean value of pain on POD2 was 2.86 ± 0.3 and 4.33 ± 0.37 for patients in the ERAS and control groups, respectively. The values of pain were higher in the control group compared to the ERAS group, and the difference was statistically significant (p = 0.003). The mean value of pain on POD3 was 2.33 ± 0.52 and 4.04 ± 0.15 for patients in the ERAS and control groups, respectively. The pain values were higher in the control group compared to the ERAS group. The difference was meaningful statistically (p < 0.001). The mean value of pain on POD4 was 2.26 ± 0.9 and 2.84 ± 0.13 for the ERAS and control groups, respectively. However, the difference was not statistically significant (p = 0.274). The ERAS group had a significantly higher proportion of participants rating their pain between 1 and 3 (68.9%) and a lower proportion rating their pain between 4 and 7 (28.2%), compared to the control group (p < 0.001). Differences in the highest pain ratings (8-10) between the groups were not statistically significant. The duration of hospital stay, beginning from surgery to discharge, was lesser among study participants in the ERAS group, and this finding was statistically significant (p < 0.001).

CONCLUSION

 The findings of this study imply that the ERAS protocol may aid pain management following elective craniotomies. Additionally, the ERAS protocol decreased the overall expense of medical care and the cumulative/postoperative length of hospital stay.

Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review

INTRODUCTION

Postoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application.

METHODS

A literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL).

RESULTS

Twelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n=8). Non-opioid analgesia in ERAS improved postoperative pain control (n=4) and decreased the duration of pain (n=1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL.

CONCLUSION

Implementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.

The influence of enhanced recovery after surgery protocol adherence in patients undergoing elective neuro-oncological craniotomies

Objectives

Enhanced recovery after surgery (ERAS) protocols have reduced the length of hospital stay (LOS) and healthcare costs without increasing adverse outcomes. We describe the impact of adherence to an ERAS protocol for elective craniotomy among neuro-oncology patients at a single institution.

Methods

This retrospective study enrolled adult patients who underwent elective craniotomy and the ERAS protocol at our institute between January 2020 and April 2021. The patients were divided into high- and low-adherence groups depending on their adherence to ≥9 or <9 of the 16 items, respectively. Inferential statistics were used to compare group outcomes, and multivariable logistic regression analysis was used to examine factors related to delayed discharge (LOS>7 days).

Results

Among the 100 patients assessed, median adherence was 8 items (range, 4-16), and 55 and 45 patients were classified into the high- and low-adherence groups, respectively. Age, sex, comorbidities, brain pathology, and operative profiles were comparable at baseline. The high-adherence group showed significantly better outcomes, including shorter median LOS (8 days vs. 11 days; p ​= ​0.002) and lower median hospital costs (131,657.5 baht vs. 152,974 baht; p ​= ​0.005). The groups showed no differences in 30-day postoperative complications or Karnofsky performance status. In the multivariable analysis, high adherence to the ERAS protocol (>50%) was the only significant factor preventing delayed discharge (OR ​= ​0.28; 95% CI ​= ​0.10 to 0.78; p ​= ​0.04).

Conclusions

High adherence to ERAS protocols showed a strong association with short hospital stays and cost reductions. Our ERAS protocol was feasible and safe for patients undergoing elective craniotomy for brain tumors.

Prevention of Post-Operative Pain after Elective Brain Surgery: A Meta-Analysis of Randomized Controlled Trials

Background and Objective: To analyze the effects of several drug for pain prevention in adults undergoing craniotomy for elective brain surgery. Material and Methods: A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The inclusion criteria were limited to randomized controlled trials (RCTs) that evaluated the effectiveness of pharmacological treatments for preventing post-operative pain in adults (aged 18 years or older) undergoing craniotomies. The main outcome measures were represented by the mean differences in validated pain intensity scales administered at 6 h, 12 h, 24 h and 48 h post-operatively. The pooled estimates were calculated using random forest models. The risk of bias was evaluated using the RoB2 revised tool, and the certainty of evidence was assessed according to the GRADE guidelines. Results: In total, 3359 records were identified through databases and registers' searching. After study selection, 29 studies and 2376 patients were included in the meta-analysis. The overall risk of bias was low in 78.5% of the studies included. The pooled estimates of the following drug classes were provided: NSAIDs, acetaminophen, local anesthetics and steroids for scalp infiltration and scalp block, gabapentinoids and agonists of adrenal receptors. Conclusions: High-certainty evidence suggests that NSAIDs and acetaminophen may have a moderate effect on reducing post-craniotomy pain 24 h after surgery compared to control and that ropivacaine scalp block may have a bigger impact on reducing post-craniotomy pain 6 h after surgery compared to control. Moderate-certainty evidence indicates that NSAIDs may have a more remarkable effect on reducing post-craniotomy pain 12 h after surgery compared to control. No moderate-to-high-certainty evidence indicates effective treatments for post-craniotomy pain prevention 48 h after surgery.

Postoperative general medical ward admission following Chiari malformation decompression

OBJECTIVE

Prior to 2019, the majority of patients at Children's Hospital Colorado were admitted to the pediatric intensive care unit (PICU) following Chiari malformation (CM) decompression surgery. This study sought to identify the safety and efficacy of postoperative general ward management for these patients.

METHODS

After a retrospective baseline assessment of 150 patients, a quality improvement (QI) initiative was implemented, admitting medically noncomplex patients to the general ward postoperatively following CM decompression. Twenty-one medically noncomplex patients were treated during the QI intervention period. All patients were assessed for length of stay, narcotic use, time to ambulation, and postoperative complications.

RESULTS

PICU admission rates postoperatively decreased from 92.6% to 9.5% after implementation of the QI initiative. The average hospital length of stay decreased from 3.4 to 2.6 days, total doses of narcotic administration decreased from 12.3 to 8.7, and time to ambulation decreased from 1.8 to 0.9 days. There were no major postoperative complications identified that were unsuitable for management on a conventional pediatric medical/surgical nursing unit.

CONCLUSIONS

Medically noncomplex patients were safely admitted to the general ward postoperatively at Children's Hospital Colorado after decompression of CM. This approach afforded decreased length of stay, decreased narcotic use, and decreased time to ambulation, with no major postoperative complications.

Mechanism of gene network in the treatment of intracerebral hemorrhage by natural plant drugs in Lutong granules

PURPOSE

To study the effects of Lu-tong Granules (LTG) in ICH etermine the underlying mechanism of molecular network.

METHODS

Modern bioinformatics and network pharmacology methods were used to predict molecular network mechanisms between ICH and LTG. Animal experiments were carried out to verify the effect of LTG for the treatment of ICH, combined with behavior test and morphologic detection.

RESULTS

Forty-three active components in LTG and involved 192 gene targets were identified successfully. Moreoner, they were intersected with 1132 genes of ICH,88 intersection targets were obtained. subsequently, Cytoscape was used to screen Hub genes, in which,6 core molecules, including AKT1, IL6, VEGFA, CASP3, JUN and MMP9 were recognized. Furthermore, we constructed Six core compounds by " disease-drug-active ingredient-target-KEGG " (D-D-A-T-K) network, showed including quercetin, luteolin, β sitosterol, stigmasterol, kaempferol and formononetin, and PPI protein network interaction showed that AKT1:OS3 and CNA2:DKN1A had the highest correlation. Whereas the enrichment of GO and KEGG indicated that LTG was most likely to play a therapeutic role in ICH through AGE-RAGE signaling pathway in diabetic complications. Integrated analysis also showed that the first 10 pathways of KEGG are integrated into 59 genes, among which 6 core genes are closely involved. Lastly, molecular docking showed that there was a good binding activity between the core components and the core genes, and animal experiments confirmed effect of LTG in the treatment of ICH, by using TTC staining and behavior test.

CONCLUSION

LTG are effective for the treatment of ICH, the underlying mechanism could be involved in gene network including anti-inflammatory response, nerve repair, analgesia, anti-epilepsy and other aspects.

Real-World Implementation of Neurosurgical Enhanced Recovery After Surgery Protocol for Gliomas in Patients Undergoing Elective Craniotomy

Objective

To design a multidisciplinary enhanced recovery after surgery (ERAS) protocol for glioma patients undergoing elective craniotomy and evaluate its clinical efficacy and safety after implementation in a tertiary neurosurgical center in China.

Methods

ERAS protocol for glioma patients was developed and modified based on the best available evidence. Patients undergoing elective craniotomy for treatment of glioma between September 2019 to May 2021 were enrolled in a randomized clinical trial comparing a conventional neurosurgical perioperative care (control group) to an ERAS protocol (ERAS group). The primary outcome was postoperative hospital length of stay (LOS). Secondary outcomes were 30-day readmission rate, postoperative complications, duration of the drainage tube, time to first oral fluid intake, time to ambulation and functional recovery status.

Results

A total of 151 patients were enrolled (ERAS group: n = 80; control group: n = 71). Compared with the control group, postoperative LOS was significantly shorter in the ERAS group (median: 5 days vs. 7 days, p<0.0001). No 30-day readmission or reoperation occurred in either group. The time of first oral intake, urinary catheter removal within 24 h and early ambulation on postoperative day (POD) 1 were earlier and shorter in the ERAS group compared with the control group (p<0.001). No statistical difference was observed between the two groups in terms of surgical- and nonsurgical-related complications. Functional recovery in terms of Karnofsky Performance Status (KPS) scores both at discharge and 30-day follow-up was similar in the two groups. Moreover, no significant difference was found between the two groups in the Hospital Anxiety and Depression Scale (HADS) scores.

Conclusion

The implementation of the ERAS protocol for glioma patients offers significant benefits over conventional neurosurgical perioperative management, as it is associated with enhancing postoperative recovery, without additional perioperative complications and risks.

Clinical Trial Registration

Chinese Clinical Trial Registry (http://www.chictr.org.cn/showproj.aspx?proj=42016), identifier ChiCTR1900025108

Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.

Patients Older Than 75 Years Undergoing Polysegmental Lumbar Fusion Surgery Can also Benefit from Enhanced Recovery After Surgery Program

Purpose

To compare pain scores (visual analog scale) on postoperative days 1–3 and length of stay after implementing enhanced recovery after surgery (ERAS) in elderly patients undergoing multi-segments lumbar fusion surgery.

Methods

We performed a retrospective analysis of prospectively collected data, patients older than 75 years were enrolled in the study. We selected two periods, before (Pre-ERAS, n =54 patients) and after (ERAS, n =46 patients) implementation of ERAS. Data were collected on patient demographics, operative and perioperative details, 30-day readmission. The primary outcome was the length of stay (LOS), and the secondary outcomes were postoperative mean pain scores on postoperative days (POD) 1–3 and 30-day readmission rates.

Results

A total of 100 patients (46 in ERAS and 54 in pre-ERAS) were enrolled in this study. There were no significant differences in age, sex, body mass index (BMI), smoking and comorbidities between the groups. However, there was a significant difference in pain on postoperative day (POD) 1 (5.31 ± 1.98 vs 4.37 ± 0.85, p = 0.002), while there was no difference in postoperative complications. The mean LOS was significantly shorter in the ERAS than in the pre-ERAS group, it reduced from 12.29 ± 3.93 to 9.45 ± 2.72 days (p < 0.001).

Conclusion

To our knowledge, this is the first ERAS protocol used in patients (older than 75 years) undergoing polysegmental lumbar fusion surgery. Pain scores on POD 1 and LOS were significantly lower without increased adverse events after implementation of ERAS. This finding suggests that elderly people (>75 years of age) undergoing polysegmental lumbar fusion surgery could also benefit from ERAS.

Better clinical benefits and potential cost saving of an enhanced recovery pathways for laparoscopic adrenalectomy

BACKGROUND

Enhanced recovery pathways (ERPs) have been demonstrated to be clinically and economically effective for colorectal surgery. However, data are lacking to support the cost-effectiveness of ERPs for laparoscopic adrenalectomy, as well as potential economic loss. This study aims to determine the cost-effectiveness of ERPs vs. conventional care (CC) for patients undergoing laparoscopic adrenalectomy.

METHODS

A single centered retrospective case-control study was performed. Patients undergoing laparoscopic adrenalectomy from January 2018 to June 2021 were enrolled. One inpatient ward used ERPs, whereas the other did not. Case control was used for matching (53 patients for each group). Postoperative outcomes were recorded up to 30 days after surgery. ERPs-specific costs were integrated into the model. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration, which were reported in Renminbi. A bootstrap independent t-test was used for comparison.

RESULTS

The two groups were matched in terms of demographics and surgical details. Hospital stay was significantly shorter in the ERPs group (2.54 days, P<0.001). The rate of complications was lower in the ERPs group (1 vs. 7 patients, P=0.031), there was no severe complications or morbidity. ERPs-specific costs were ¥656 per patient. The self-payment cost difference per patient between the two groups was ¥3,154.52 in favor of the ERPs group, but this was not statistically significant (P=0.113). The mean direct saving per patient in the ERPs group was ¥8,326.00, the total costs saving including indirect and potential overhead per patient was ¥18,247.60.

CONCLUSIONS

Enhanced recovery is cost-effective compared with conventional perioperative management for laparoscopic adrenalectomy. Savings were noted in disposable materials, medicine and medical services, radiology and laboratory costs, with no increase in morbidity or duration.

Ropivacaine instillation through subgaleal drain: A novel approach for acute post-craniotomy pain

Background and Aims:

Post-craniotomy pain has often been overlooked and undertreated. Various classes of analgesic drugs have been used, not without limitations. Therefore, we planned to study the novel technique of wound instillation of ropivacaine through the surgical drain in patients undergoing supratentorial craniotomy to study its effect on post-craniotomy pain, analgesic requirement in the post-operative period along with the recovery profile of the patient and the side effects.

Methods:

This prospective, randomised, placebo-controlled, double-blinded study enroled 50 patients of either gender, scheduled to undergo elective craniotomy, under general anaesthesia. They were randomly divided into two groups and received either 12 ml of 0.25% ropivacaine (group R) or 12 ml of normal saline (group NS), through the subgaleal drain, after the closure of the dura. Pain scores were assessed at 1, 2, 4, 8 and 24 hours post-operatively. Student’s t-test was used for comparison of continuous variables and the Chi-square test or Fisher’s exact test was used for comparing the nominal categorical data.

Results:

The visual analogue scale score was higher in group NS than in group R, and the difference was statistically significant (P = 0.012, 0.016, and 0.005 at 0, 1, and 2 post-operative hours, respectively). The difference in the mean emergence time in the two groups was 1.12 minutes (P = 0.024).

Conclusion:

Single-time wound instillation of ropivacaine (12 ml of 0.25%) through surgical (subgaleal) drain during wound closure is an effective and simple technique for reducing post-operative pain and analgesic consumption and early emergence in neurosurgical patients undergoing supratentorial craniotomy.

Retrospective Study on the Application of Enhanced Recovery After Surgery Measures to Promote Postoperative Rehabilitation in 50 Patients With Brain Tumor Undergoing Craniotomy

Objective

To investigate whether enhanced recovery after surgery (ERAS) can promote rehabilitation of patients after neurosurgical craniotomy.

Methods

The clinical data of 100 patients with brain tumor undergoing craniotomy in the Department of Neurosurgery, Xiangya Hospital, Central South University, from January 2018 to August 2020 were collected, including 50 patients in the ERAS group and 50 patients in the control group. t-Test, Wilcoxon’s rank sum test, and chi-square analysis were used to compare the clinical characteristics, prognosis, and hospitalization time between the two groups.

Results

There was no significant difference in gender, age, and other general clinical data between the two groups (p > 0.05). The days of antiemetic drugs applied in the ERAS group were less than those in the control group (1.00 vs. 2.00 days, p = 0.003), and the proportion of patients requiring analgesics was lower than that of the control group (30% vs. 52%, OR = 0.41, 95% CI 0.18–0.93, p = 0.031). The time of urinary catheter removal and that of patients starting ambulation in the ERAS group were shorter than those in the control group (16.00 vs. 24.00 h, and 1.00 vs. 2.00 days, p < 0.001, respectively); and the hospital length of stay (LOS) in the ERAS group was shorter than that in the control group (Total LOS, 13.00 vs. 15.50 days; Postoperative LOS, 7.00 vs. 10.00 days, p < 0.001). By analyzing the prognosis of patients in the ERAS group and control group, we found that there was no significant difference in postoperative complications and Karnofsky Performance Status (KPS) score 1 month after operation between the two groups.

Conclusion

The application of ERAS in craniotomy can accelerate the postoperative recovery of patients without increasing the perioperative risk, which is worthy of wide application. However, whether the ERAS measures can reduce the postoperative complications and improve the prognosis of patients still needs more large-scale case validation and multicenter collaborative study.

Systematic Review of Enhanced Recovery After Surgery in Patients Undergoing Cranial Surgery

BACKGROUND

Enhanced Recovery after Surgery (ERAS) pathways are increasingly being integrated in neurosurgical patient management. The full extent of ERAS in cranial surgery is not well studied. We performed a systematic review examining ERAS in cranial surgery patients to 1) identify the extent to which ERAS is integrated in cranial neurosurgical procedures and 2) assess effectiveness of ERAS interventions for patients undergoing these procedures.

METHODS

A systematic review of MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Scopus, PsychInfo, and Google Scholar was conducted according to PRISMA guidelines (CRD42020197187). Studies eligible for inclusion assessed patients undergoing any cranial surgical procedure using an ERAS or ERAS-like pathway, defined by ≥2 ERAS protocol elements per the ERAS Society's RECOvER Checklist and the recommendations of Hagan et al. 2016 (not including patient education, criteria for discharge, or tracking of postdischarge outcomes).

RESULTS

Nine studies were included in qualitative synthesis, 2 of which were randomized controlled trials. All studies showed a moderate risk of bias. The most common ERAS elements used were screening and/or optimization and formal discharge criteria. The least common ERAS elements used were fasting/carbohydrate loading and antithrombotic prophylaxis. Complication rates were similar in studies comparing ERAS with non-ERAS groups. ERAS interventions were associated with reduced length of stay, with comparable and/or improved patient satisfaction.

CONCLUSIONS

ERAS is a safe and potentially favorable perioperative pathway for select patients undergoing cranial surgery. Future studies of ERAS in cranial surgery patients should emphasize postoperative optimizations and patient-reported outcome measures as key features.

Same day discharge for craniotomy

PURPOSE OF REVIEW

Same-day protocols for craniotomy have been demonstrated to be feasible and safe. Its several benefits include decreased hospital costs, less nosocomial complications, fewer case cancellations, with a high degree of patient satisfaction. This paper reviews the most recent publications in the field of same-day discharge after craniotomy.

RECENT FINDINGS

Since 2019, several studies on same-day neurosurgical procedures were published. Ambulatory craniotomy protocols for brain tumor were successfully implemented in more centers around the world, and for the first time, in a developing country. Additional information emerged on predictors for successful early discharge, and the barriers and enablers of same-day craniotomy programs. Moreover, the cost benefits of same-day craniotomy were reaffirmed.

SUMMARY

Same- day discharge after craniotomy is feasible, safe and continues to expand to a wider variety of procedures, in new institutions and countries. There are several benefits to ambulatory surgery. Well-established protocols for perioperative management are essential to the success of early discharge programs. With continued research, these protocols can be refined and implemented in more institutions globally, ultimately to provide better, more efficient care for neurosurgical patients.

Role of anaesthesia in neurosurgical enhanced recovery programmes

The application of Enhanced Recovery After Surgery (ERAS) in neurosurgical practice is a relatively new concept. A limited number of studies involving ERAS protocols within neurosurgery, specifically for elective craniotomy, have been published, contrary to the ERAS spine surgery pathways that are now promoted by numerous national and international dedicated surgical societies and hospitals. In this review, we want to present the patient surgical journey from an anaesthesia perspective through the key components that can be included in the ERAS pathways for neurosurgical procedures, both craniotomies and major spine surgery.