Enhanced recovery after surgery (ERAS) may reduce patient costs and help mitigate the opioid crisis, but it does require an institutional behavioral change, according to Saturday morning’s Flipped Classroom session “Minimizing Opioids through Multimodal Analgesia and Patient Education.”
Mikio A. Nihira, MD, MPH, clinical professor of obstetrics and gynecology, vice-chair and residency program director, University of California Riverside, reviewed the benefits of an ERAS approach and provided a framework to help build a pathway to ERAS.
Dr. Nihira noted that the path to effective ERAS requires actions in preoperative, intraoperative, and postoperative phases of surgery.
“Preoperatively, being really specific about the educational process and setting expectations for patients is one of the most powerful aspects of enhanced recovery—making sure patients are ready from a physical standpoint and being able to be more liberal in terms of fluids rather than typically dehydrating our patients before surgery,” he said.
He described available apps that patients can download that provide education about what to expect leading up to the surgery, how to prepare, and how to manage postoperatively, much like the pregnancy “What to Expect” books.
Multimodal analgesia and adjuvant pain management are the prescribed approach to limiting or eliminating opioids from the pain management protocol in an ERAS plan.
“A strategy to address the post-surgical opioid problem and improve patient care is to use techniques like multimodal to minimalize amount of opioids that we use to prevent opioid associated adverse events. And in terms of postoperatively, reducing the amount of opioids we prescribe so we can prevent diversion,” he said. Diversion refers to prescribed medications that are used by the patient, leaving them available to be used by other family members.
Dr. Nihira reviewed the multimodal approach using various forms of IV and oral acetaminophen and NSAIDs, COX-2 Selective NSAIDs, and single agent opioids. He also covered the various adjuvant analgesics currently in use, including corticosteroids, gabapentin, and pregabalin.
But, he warned, you need to be aware that there are many other drugs patients take at home that have acetaminophen, so educate patients to avoid use of other forms of acetaminophen if you use it in your multimodal approach.
With ERAS, there are multiple interventions going on throughout the preoperative, intraoperative, and postoperative stages that require time, effort, and behavior change among multiple team members, he noted.
“Doing this as a large-scale or systematic intervention requires a lot of data monitoring so people can confirm which of the interventions have been successful or have not been successful,” he said.
ERAS requires building a team approach for success. Surgeons, anesthesiologists, pain management specialists, pharmacists, nurses, PT/OT, case management specialists, and leadership all need to buy in.
“So when you’re going to try to change the culture in terms of enhanced recovery, who needs to know?” he asked. “It’s trying to build that understanding where some people may have to put out more of their resources.”
Identifying stakeholders, providing the evidence-based benefits, and establishing concrete metrics is necessary, as is support from leadership in understanding that the team approach is needed.
“It’s really this whole idea of saying, ‘This is a team. This is not a mandatory thing,'” he said. “As a surgeon, I can’t mandate that things are going to happen. I can advocate that for my patient and try to get things to work in incremental fashion, but understand that this is a systematic change.”