Study design, materials and methods
Methods:
This was a retrospective review of KPIs of the Gynaecology ERAS Protocol, use of regular as well as rescue analgesics and antiemetics in patients’ records.
The KPIs looked at were
• Provision of information regarding ERAS pre-operatively
• Drinking fluids within 4 hours after surgery
• Mobilisation within 8 hours of surgery
• IV fluids having been stopped 12 hours post operatively
• Timing of removing the catheter
Results
Results:
64 patients were included overall with 41 in Group 1 and 23 in Group 2.
Overall, 83% (53/64) were given ERAS information pre-operatively.
Postoperatively, 91% (58/64) started drinking as per protocol, time to mobilise was recorded and was satisfactory in 22% (14/64) only, 70% (45/64) had IV fluids discontinued with 12 hours and 61% (28/46) had catheter removed as per protocol. Most KPIs were comparable between both groups except for achieving the mobilisation KPI (15%:Group 1 ; 35%:Group 2) (Table 1).
A higher percent of women in group 2 compared to group 1 had intrathecal morphine and regular opioid analgesia postoperatively. Subarachnoid block with Intrathecal morphine was administered in 59% (38/64) overall (56%: Group 1; 65%:Group 2). 70% (45/64) were prescribed regular opioid analgesia overall (68%:Group 1 ; 74%:Group 2).
Overall, of those who received regular analgesia, 89% (40/45) also required rescue analgesia. This was similar to those women who did not receive regular analgesia and needed rescue pain relief (84%;16/19). Use of rescue analgesia was not statistically significantly between both groups (85% in Group 1 versus 78% in Group 2; p = 0.47152).
The prescription of regular antiemetics was only 22% (14/64) overall and was different between both groups (17%:Group 1; 30% : Group 2). 82% (41/50) required rescue antiemetics when not prescribed regular antiemetics. However similar percentage of (80%) women who were prescribed regular antiemetics also required rescue antiemetics.
Interpretation of results
Interpretation of Results
Satisfactory compliance with ERAS protocol was noted with regards to most KPI parameters apart from that of mobilisation. It is known that this protocol cannot always be followed for all women due to differences in clinical characteristics and nature of surgery.
More patient in group 2 received intrathecal morphine and postop regular analgesia and regular antiemetics but in regard to rescue analgesia, there was no significant difference in the requirement of rescue dosages between group 1 and group 2. This can be due to different number of patients in two groups.
Despite regular antiemetics patients still required >80% rescue antiemetics – showing that these groups of patients are at very high risk for post-operative nausea and vomiting due to factors such as pre-existing anxiety, having a general anaesthetic and opiate analgesia, being female, having pelvic surgery despite attempts at reducing this.
Concluding message
Conclusion
ERAS (Enhanced Recovery After Surgery) protocols are a multifactorial, evidence-based protocols developed by multidisciplinary teams in order to minimise the effect of surgical stress on patients in order to speed up their recovery and reduce the length of their stay in hospital.
Early mobilisation is an important aspect of ERAS to improve patient outcomes. This was particularly poorly documented in this study.
We found that there was a high incidence of PONV whether antiemetics were prescribed or not which is expected as this group of patients is at very high risk for post operative nausea and vomiting. Since PONV is multifactorial one should tackle PONV reduction at every opportunity-
1. In the pre-operative care setting (reduce fasting,times and reduce anxiety) ,
2. Intra-operatively (administering prophylactic antiemetics, considering TIVA with propofol vs volatile anaesthetic and considering regional anaesthesia to reduce opioid requirement).
3. Post operatively ( early feeding, regular and as required antiemetics prescribed) situations.
The number of patients in group 2 is small with two having significant post-operative pain issues. We recommend that a larger mesh patient group be looked at in future to look for outliers with pain issues to guide development of an ERAS analgesic pathway for patients with pre-operative analgesic requirements as optimising pain relief in this group of women can improve outcomes post-operatively and enable an easier recovery.