Matched Pairs Comparison of an Enhanced Recovery Pathway Versus Conventional Management on Opioid Exposure and Pain Control in Patients Undergoing Lung Surgery.

OBJECTIVE: The aim of this study was to assess the effect of an enhanced recovery after surgery (ERAS) pathway on pain and opioid use following lung resection. SUMMARY BACKGROUND DATA: A major component ERAS pathways is opioid-sparing analgesia; however, the effect on postoperative pain and opioid use in patients undergoing lung resection is unknown. METHODS: Following implementation of an ERAS pathway for lung resection, 123 consecutive patients were identified. Patients were propensity-matched 1:1 with a group of consecutive patients (n = 907) undergoing lung resection before ERAS. Differences regarding in-hospital opioid consumption, discharge prescribing of opioids, and postoperative pain scores were examined. Morphine milligram equivalents were separately calculated including and excluding tramadol as an opioid medication. RESULTS: There were no significant differences between matched patients regarding age, sex, performance status, receipt of preoperative treatment, extent of lung resection, or operative approach. Epidural analgesia was used in 66% of controls and in none of the ERAS group (P < 0.001). The number of adjunct analgesics used postoperatively was greater in the ERAS group (median 3 vs 2, P < 0.001). There was a major reduction in morphine milligram equivalents in the ERAS group whether tramadol was included (median 14.2 vs 57.8, P < 0.001) or excluded (median 2.7 vs 57.8, P < 0.001) and regardless of surgical approach. Average daily pain scores were lower in the ERAS group (median 1.3 vs 1.8, P = 0.004); however, this difference was present only among patients undergoing thoracotomy. The proportion of patients who were prescribed discharge opioids varied whether tramadol was included (96% each group, P = 1.00) or excluded (39% vs 80%, P < 0.001) in the analysis. CONCLUSIONS: Implementation of an ERAS pathway was associated with effective post-operative analgesia, major reductions in in-hospital consumption of opioids, and reduced pain, compared to conventional management.

Roadmap to the Enhanced Thoracic Surgical Journey.

The Enhanced Recovery Program (ERP) is a comprehensive, multidisciplinary approach that directly impacts the functional recovery and quality of life of patients after surgery. Initiated in 2013 at The University of Texas MD Anderson Cancer Center by the Liver Surgery group and expanded to numerous specialties, the Thoracic and Cardiovascular Surgery Department developed a version of Enhanced Recovery After Thoracic Surgery in 2014. The benefits gained thus far include (1) decreased postoperative complications, (2) reduced hospital length of stay, (3) decreased opioid usage, (4) decreased healthcare costs, and (5) improved patient satisfaction. This article aims to provide a brief description of the history of the enhanced recovery approach and to identify the critical elements of the program necessary for improved patient care. It is intended to serve as a practical guide for program implementation in thoracic surgery departments at other institutions.