Variables impacting prolonged post-anesthesia care unit length of stay in gynecologic cancer patients in the era of same day minimally invasive hysterectomy.

OBJECTIVES: Minimally invasive surgery for treatment of gynecologic malignancies is associated with decreased pain, fewer complications, earlier return to activity, lower cost, and shorter hospital stays. Patients are often discharged the day of surgery, but occasionally stay overnight due to prolonged post-anesthesia care unit (PACU) stays. The objective of this study was to identify risk factors for prolonged PACU length of stay (LOS). METHODS: This is a single institution retrospective review of patients who underwent minimally invasive hysterectomy for gynecologic cancer from 2019 to 2022 and had a hospital stay <24-h. The primary outcome was PACU LOS. Demographics, pre-operative diagnoses, and surgical characteristics were recorded. After Box-Cox transformation, linear regression was used to determine significant predictors of PACU LOS. RESULTS: For the 661 patients identified, median PACU LOS was 5.04 h (range 2.16-23.76 h). On univariate analysis, longer PACU LOS was associated with increased age (ρ = 0.106, p = 0.006), non-partnered status [mean difference (MD) = 0.019, p = 0.099], increased alcohol use (MD = 0.018, p = 0.102), increased Charlson Comorbidity Index (CCI) score (ρ = 0.065, p = 0.097), and ASA class ≥3 (MD = 0.033, p = 0.002). Using multivariate linear regression, increased age (R2 = 0.0011, p = 0.043), non-partnered status (R2 = 0.0389, p < 0.001), and ASA class ≥3 (R2 = 0.0250, p = 0.023) were associated with increased PACU LOS. CONCLUSIONS: Identifying patients at risk for prolonged PACU LOS, including patients who are older, non-partnered, and have an ASA class ≥3, may allow for interventions to improve patient experience, better utilize hospital resources, decrease PACU overcrowding, and limit postoperative admissions and complications. The relationship between non-partnered status and PACU LOS is the most novel relationship identified in this study.

Use of Perioperative Intravenous Lidocaine as Part of an Abdominal Surgery Enhanced Recovery Pathway Does Not Significantly Impact Postoperative Pain.

BACKGROUND: The utility of perioperative intravenous lidocaine in improving postoperative pain control remains unclear. We aimed to compare postoperative pain outcomes in ERP abdominal surgery patients who did vs did not receive intravenous lidocaine. We hypothesized that patients receiving lidocaine would have lower postoperative pain scores and consume fewer opioids. METHODS: We performed a retrospective cohort study of patients undergoing elective abdominal surgery at a single institution via an ERP from 2017 to 2018. Patients who received lidocaine in the 6 months prior to a lidocaine shortage were compared to those who did not receive lidocaine for 6 months following the shortage. The primary outcome measures were pain scores as measured on the visual analogue scale and opioid consumption as measured by oral morphine equivalents (OME). RESULTS: We identified 1227 consecutive ERP abdominal surgery patients for inclusion (519 patients receiving lidocaine and 708 patients not receiving lidocaine). Demographics between the two cohorts were similar, with the following exceptions: more females, and more patients with a history of psychiatric diagnoses in the group that did not receive lidocaine. Adjusted, mixed linear models for both OME (P = .23) and pain scores (P = .51) found no difference between the lidocaine and no lidocaine groups. DISCUSSION: In our study of ERP abdominal surgery patients, perioperative intravenous lidocaine did not offer improvement in postoperative pain scores or OME consumed. We therefore do not recommend the use of intravenous lidocaine as part of an ERP multimodal pain management strategy in abdominal surgery patients.

REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system.

INTRODUCTION: Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future. METHODS AND ANALYSIS: In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping. ETHICS AND DISSEMINATION: The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol. TRIAL REGISTRATION NUMBER: NCT04606264.

Enhanced Recovery Protocols Reduce Mortality Across Eight Surgical Specialties at Academic and University-affiliated Community Hospitals.

OBJECTIVE: To determine if implementation of a simplified ERP across multiple surgical specialties in different hospitals is associated with improved short and long-term mortality. Secondary aims were to examine ERP effect on length of stay, 30-day readmission, discharge disposition, and complications. SUMMARY BACKGROUND DATA: Enhanced recovery after surgery and various derivative ERPs have been successfully implemented. These protocols typically include elaborate sets of multimodal and multidisciplinary approaches, which can make implementation challenging or are variable across different specialties. Few studies have shown if a simplified version of ERP implemented across multiple surgical specialties can improve clinical outcomes. METHODS: A simplified ERP with 7 key domains (minimally invasive surgical approach when feasible, pre-/intra-operative multimodal analgesia, postoperative multimodal analgesia, postoperative nausea and vomiting prophylaxis, early diet advancement, early ambulation, and early removal of urinary catheter) was implemented in 5 academic and community hospitals within a single health system. Patients who underwent nonemergent, major orthopedic or abdominal surgery including hip/knee replacement, hepatobiliary, colorectal, gynecology oncology, bariatric, general, and urological surgery were included. Propensity-matched, retrospective case-control analysis was performed on all eligible surgical patients between 2014 and 2017 after ERP implementation or in the 12 months preceding ERP implementation (control population). RESULTS: A total of 9492 patients (5185 ERP and 4307 controls) underwent ERP eligible surgery during the study period. Three thousand three hundred sixty-seven ERP patients were matched by surgical specialty and hospital site to control non-ERP patients. Short and long-term mortality was improved in ERP patients: 30 day: ERP 0.2% versus control 0.6% ( P = 0.002); 1-year: ERP 3.9% versus control 5.1% ( P < 0.0001); 2-year: ERP 6.2% versus control 9.0% ( P < 0.0001). Length of stay was significantly lower in ERP patients (ERP: 3.9 ± 3.8 days; control: 4.8 ± 5.0 days, P < 0.0001). ERP patients were also less likely to be discharged to a facility (ERP: 11.3%; control: 14.8%, P < 0.0001). There was no significant difference for 30-day readmission. All complications except venous thromboembolism were significantly reduced in the ERP population (P < 0.02). CONCLUSIONS: A simplified ERP can uniformly be implemented across multiple surgical specialties and hospital types. ERPs improve short and long-term mortality, clinical outcomes, length of stay, and discharge disposition to home.

Bivalirudin Versus Unfractionated Heparin in Patients With Cardiogenic Shock Requiring Venoarterial Extracorporeal Membrane Oxygenation.

This study evaluated differences in efficacy and safety outcomes with bivalirudin compared with unfractionated heparin (UFH) in patients with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO). We performed a retrospective study at an academic medical center that included patients greater than 18 years of age supported with VA ECMO due to cardiogenic shock from January 2009 to February 2021. The primary endpoint was ECMO-associated thrombotic events normalized to duration of ECMO support. Secondary safety endpoints included major bleeding (per ELSO criteria) and blood product administration. Overall, 143 patients were included in our analysis with 54 having received bivalirudin and 89 having received UFH. Median duration of ECMO support was 92 (interquartile range, 56-172) hours. ECMO-associated thrombotic events per ECMO day were significantly less among those that received bivalirudin ( P < 0.001). In adjusted regression, bivalirudin was independently associated with an increased time to thrombosis when compared with UFH (Exp[B] -3.8; 95% confidence interval, 1.7-8.8; P = 0.002). Patients receiving bivalirudin experienced less major bleeding events ( P = 0.02) with less total red blood cell and fresh frozen plasma administration ( P = 0.04 and P = 0.03, respectively). Bivalirudin is a safe and efficacious alternative to UFH in patients requiring VA ECMO for cardiogenic shock.

Same-day Hospital Discharge after Minimally Invasive Hysterectomy in a Gynecologic Oncology Practice: Feasibility, Safety, Predictors of Admission, and Adverse Outcomes.

STUDY OBJECTIVES: (1) Determine the feasibility and safety of same-day hospital discharge (SDHD) after minimally invasive hysterectomy (MIH) in a gynecologic oncology practice and (2) detail predictors of immediate postoperative hospital admission and multiple 30-day adverse outcomes. DESIGN: Retrospective cohort study. SETTING: University of Pittsburgh Medical Center Magee-Womens Hospital. PATIENTS: MIH by a gynecologic oncologist between January 2017 and July 2019. INTERVENTIONS: Clinicopathologic, operative, and medical characteristics, as well as 30-day postoperative complications, emergency department (ED) encounters, and hospital readmissions were extracted. Admitted and SDHD patients were compared using descriptive, chi-square, Fisher's exact, t test, and logistic regression analyses. Univariate and multivariable analyses (MVA) revealed predictors of postoperative hospital admission, 30-day readmission, and a 30-day composite adverse event variable (all-reported postoperative complications, ED encounter, and/or readmission). MEASUREMENTS AND MAIN RESULTS: A total of 1124 patients were identified, of which 77.3% had cancer or precancer; 775 patients (69.0%) underwent SDHD. On MVA, predictors of postoperative admission included older age, distance from hospital, longer procedure length, operative complications, start time after 2 PM, radical hysterectomy, minilaparotomy, adhesiolysis, cardiac disease, cerebrovascular disease, venous thromboembolism, diabetes, and neurologic disorders (p <.05). Moreover, 30-day adverse outcomes were rare (complication 8.7% National Surgical Quality Improvement Program/11.9% all-reported; ED encounter 5.0%; readmission 3.6%). SDHD patients had fewer all-reported complications (10.3% vs 15.5%, p = .01), no difference in ED encounters (4.6% vs 5.7%, p = .44), and fewer observed readmissions (2.8% vs 5.2%, p = .05). Predictors of readmission were identified on univariate; MVA was not feasible given the low number of events. Longer procedure length and cardiac and obstructive pulmonary disease were predictors of the composite adverse event variable (p <.05). CONCLUSION: SDHD is feasible and safe after MIH within a representative gynecologic oncology practice. Clinicopathologic, medical, and surgical predictors of multiple adverse outcomes were comprehensively described. By identifying patients at high risk of postoperative adverse events, we can direct SDHD selection in the absence of standardized institutional and/or national consensus guidelines and identify patients for prehabilitation and increased perioperative support.

The Effect of Scheduled Intravenous Acetaminophen in an Enhanced Recovery Protocol Pathway in Patients Undergoing Major Abdominal Procedures: A Prospective, Randomized, and Placebo-Controlled Clinical Trial.

OBJECTIVE: Enhanced recovery protocols (ERPs) utilize multi-modal analgesia regimens. Individual regimen components should be evaluated for their analgesic efficacy. We evaluated the effect of scheduled intravenous (IV) acetaminophen within an ERP on analgesia and recovery after a major abdominal surgery. DESIGN: This study is a prospective, randomized, double-blinded clinical trial. SETTING: The study setting was a tertiary care, academic medical center. SUBJECTS: Adult patients scheduled for elective major abdominal surgical procedures. METHODS: Patients in group A received 1 g IV acetaminophen, while patients in group P received IV placebo every six hours for 48 hours postoperatively within an ERP. Pain scores, opioid requirements, nausea and vomiting, time to oral intake and mobilization, length of stay, and patient satisfaction scores were measured and compared. RESULTS: From 412 patients screened, 154 patients completed the study (Group A: 76, Group P: 78). Primary outcome was the number of patients with unsatisfactory pain relief, defined as a composite of average Numeric Rating Scale (NRS) scores above 5 and requirement of IV patient-controlled analgesia for pain relief during the first 48 hours postoperatively, and was not significantly different between the two groups (33 (43.4%) in group A versus 42 (53.8%) patients in group P, P = .20). Opioid consumption was comparable between two groups. Group A utilized significantly less postoperative rescue antiemetics compared to group P (41% vs. 58%, P = .02). CONCLUSIONS: Scheduled administration of IV acetaminophen did not improve postoperative analgesia or characteristics of postoperative recovery in patients undergoing major abdominal surgery within an ERP pathway.

Probable Delirium as a Risk Factor for Adverse Surgical Outcomes in Geriatric Patients With Acute Hip Fracture: Preoperative Assessment Using a Short Screening Tool.

Hip fractures in geriatric patients are associated with substantial morbidity and mortality including postoperative delirium. Few data are available regarding preoperative identification of patients at risk of postoperative delirium before surgical repair of hip fracture. We used the Ultrabrief Two-Item Bedside Test, a proxy for delirium, to identify patients who are likely to have adverse outcomes postoperatively. This prospective pilot study included patients 65 years and older with an acute hip fracture. The questionnaire was administered preoperatively, and patients were followed up for 30 days postoperatively. We enrolled 30 patients, with a mean age of 78 years. The 12 patients with an abnormal test result had a significantly lower body mass index, a trend in descriptive statistics for pulmonary disease, and a higher ASA physical status. In addition, hospital stay following fracture repair was longer for patients with an abnormal test result, although not significantly (mean [SD]=8.8 [4.2] days vs 6.4 [2.0] days, median=8 vs 6 days, log-rank P=.052). A 2-item questionnaire could help identify patients who have sustained hip fracture who are likely to have a longer hospitalization. Future studies are needed to confirm these findings and determine whether interventions can reduce risk.

Anesthesiologists' Role in Value-based Perioperative Care and Healthcare Transformation.

Health care is undergoing major transformation with a shift from fee-for-service care to fee-for-value. The advent of new care delivery and payment models is serving as a driver for value-based care. Hospitals, payors, and patients increasingly expect physicians and healthcare systems to improve outcomes and manage costs. The impact of the coronavirus disease 2019 (COVID-19) pandemic on surgical and procedural practices further highlights the urgency and need for anesthesiologists to expand their roles in perioperative care, and to impact system improvement. While there have been substantial advances in anesthesia care, perioperative complications and mortality after surgery remain a key concern. Anesthesiologists are in a unique position to impact perioperative health care through their multitude of interactions and influences on various aspects of the perioperative domain, by using the surgical experience as the first touchpoint to reengage the patient in their own health care. Among the key interventions that are being effectively instituted by anesthesiologists include proactive engagement in preoperative optimization of patients' health; personalization and standardization of care delivery by segmenting patients based upon their complexity and risk; and implementation of best practices that are data-driven and evidence-based and provide structure that allow the patient to return to their optimal state of functional, cognitive, and psychologic health. Through collaborative relationships with other perioperative stakeholders, anesthesiologists can consolidate their role as clinical leaders driving value-based care and healthcare transformation in the best interests of patients.

Perioperative stroke-related mortality after non-cardiovascular, non-neurological procedures: A retrospective risk factor evaluation of common surgical comorbidities.

BACKGROUND: Perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population is an uncommon, yet devastating outcome. A combination of emboli and hypoperfusion may cause large vessel occlusions leading to perioperative strokes and mortality. Identifying independent risk factors for perioperative stroke-related mortality may enhance risk-stratification algorithms and preventative therapies. OBJECTIVES: This study utilised cause-of-death data to determine independent risk scores for common surgical comorbidities that may lead to perioperative stroke-related mortality, including atrial fibrillation and asymptomatic carotid stenosis. METHODS: This retrospective, IRB-exempt, case-control study evaluated non-cardiovascular, non-neurological surgical patients in a claims-based database. ICD-10-CM and ICD-9-CM codes identified cause of death and comorbidity incidences, respectively. A multivariate regression analysis then established adjusted independent risk scores of each comorbidity in relation to perioperative stroke-related mortality. RESULTS: Patients with atrial fibrillation were more likely (1.7 aOR, 95% CI (1.1, 2.8) p = 0.02) to die from perioperative stroke-related mortality than from other causes. No association was found with asymptomatic carotid stenosis. Further, in-hospital strokes (25.9 aOR, 95% CI (16.0, 41.8) p < 0.001) or diabetes (1.8 aOR, 95% CI (1.1, 2.9) p = 0.02) may increase perioperative stroke-related mortality risk. CONCLUSIONS: Atrial fibrillation, diabetes and in-hospital strokes may be independent risk factors for perioperative stroke-related mortality in the non-cardiovascular, non-neurological surgery population.

Perioperative Transthoracic Echocardiography Practice By Cardiac Anesthesiologists-Report of a "Start-Up" Experience.

OBJECTIVE: In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management. DESIGN: Retrospective case series. SETTING: Single institution, tertiary university hospital. PARTICIPANTS: A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series. INTERVENTIONS: All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team. MEASUREMENTS: Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions). MAIN RESULTS: Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique). CONCLUSION: Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults.

Platelet transfusion is associated with 90-day and 1-year mortality for adult patients requiring veno-arterial extracorporeal membrane oxygenation.

BACKGROUND: Studies examining one-year mortality respecting component blood transfusion are sparse. We hypothesize that component blood product transfusions are negatively associated with 90-day and 1-year survival for all patients requiring veno-arterial (VA) or veno-venous (VV) ECMO. STUDY DESIGN AND METHODS: This was an IRB-approved retrospective cohort analysis of 676 consecutive patients requiring ECMO at the University of Pittsburgh between 2005 and 2016. Patients were analysed both as an entire cohort and as two subsets with respect to ECMO modality (VA vs. VV). Additional data collected and analysed included patient characteristics, laboratory values and blood product transfusion. RESULTS: Multivariable analysis revealed that platelet transfusion was associated with 90-day mortality (OR: 1·05, P = 0·037) and one-year mortality for the entire cohort (OR = 1·05, P = 0·046,). Platelet transfusion volume was also associated with mortality in the VA-ECMO subset of patients at both 90 days (OR = 1·08, P = 0·03) and one year (OR: 1·11, P = 0·014). Age, peak International Normalized Raton ECMO, nadir haemoglobin (on ECMO) and final haemoglobin (after ECMO) were significantly associated with mortality for patients requiring VA-ECMO. For VV-ECMO patients, age, INR and peak creatinine on ECMO were associated with mortality. No individual component blood product was associated with one-year mortality for patients requiring VV-ECMO. CONCLUSION: Platelet transfusion was associated with increased 90-day and 1-year mortality for patients requiring VA-ECMO.

Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol.

BACKGROUND: Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets. METHODS: We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression. RESULTS: Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05). DISCUSSION: Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.

A specific enhanced recovery protocol decreases opioid use after thyroid and parathyroid surgery.

BACKGROUND: Enhanced recovery protocols have not been investigated previously for cervical endocrine surgery. The study aim was to determine whether systematic implementation of an enhanced recovery protocol specific for thyroid/parathyroid surgery can improve postoperative outcomes. METHODS: A customized enhanced recovery protocol for thyroid/parathyroid surgery was designed and utilized systematically for all patients who underwent parathyroidectomy, thyroid lobectomy, or total thyroidectomy. Outcomes were assessed 12 months before enhanced recovery protocol implementation (n = 464 patients) and after enhanced recovery protocol implementation (n = 654 patients). RESULTS: Enhanced recovery protocol implementation was associated with a 72% decrease in mean oral morphine equivalents utilized in-house (before 82 ± 64 versus after 23 ± 28; P < .0001) and many enhanced recovery protocol patients were entirely opioid-free (0.2% vs 21%, P < .0001). When used, the enhanced recovery protocol was associated with a lesser mean amount of ondansetron to treat postoperative nausea and vomiting (5.5 mg ± 3 vs 4.5 ± 2: P < .0001). Duration of stay was short before implementation of the enhanced recovery protocol and did not change substantially after implementation (1.1 days ± 0.7 vs 1.1 ± 0.7; P = .26). CONCLUSION: The systematic use of a simple, cervical, endocrine surgery-specific enhanced recovery protocol decreased perioperative opioid use by ~70%, with significantly less postoperative nausea and vomiting. Implementation of a multidisciplinary enhanced recovery protocol may be an important initial step toward limiting opioid overuse during common operative procedures.

Post-operative Nausea and Analgesia Following Total Mastectomy is Improved After Implementation of an Enhanced Recovery Protocol.

BACKGROUND: Enhanced Recovery Protocols (ERPs) provide a multimodal approach to perioperative care, with the aims of improving patient outcomes while decreasing perioperative antiemetic and narcotic requirements. With high rates of post-operative nausea or vomiting (PONV) following total mastectomy (TM), we hypothesized that our institutional designed ERP would reduce PONV while improving pain control and decrease opioid use. METHODS: An ERP was implemented at a single institution for patients undergoing TM with or without implant-based reconstruction. Patients from the first two months of implementation (ERP group, N = 72) were compared with a retrospective usual-care cohort from a three-month period before implementation (UC group, N = 83). Outcomes included PONV incidence, measured with antiemetic use; patient-reported pain scores; perioperative opioid consumption, measured by oral morphine equivalents (OME); and length of stay (LOS). RESULTS: The characteristics of the two groups were similar. PONV incidence and perioperative opioid consumption were lower in the ERP than the UC group (21% vs. 40%, p 0.011 and mean 44.1 OME vs. 104.3 OME, p < 0.001), respectively. These differences in opioid consumption were observed in the operating room and post-anesthesia care unit (PACU); opioid consumption on the floor was similar between the two groups. Patient-reported pain scores were lower in the ERP than the UC group (mean highest pain score 6.4 vs. 7.4, p 0.003). PACU and hospital LOS were similar between the two groups. CONCLUSION: ERP implementation was successful in decreasing PONV following TM with and without reconstruction, while simultaneously decreasing overall opioid consumption without compromising patient comfort.