A fully integrated multidisciplinary enhanced recovery program for pancreaticoduodenectomy patients significantly reduced postoperative opioid use and facilitated the transition from parenteral to oral opioid use after the procedure.
Researchers from Cancer Treatment Centers of America (CTCA) said although the intraoperative part of their enhanced recovery program was already well established at their institution, preoperative and postoperative elements were added in January 2016, and the new integrated enhanced recovery program has since been applied to all major abdominopelvic surgeries.
Presenting findings from their retrospective review at the 2018 annual meeting of the American Society for Enhanced Recovery (abstract 16), Neil Seeley, MD, the chief of the Division of Anesthesia and medical director of anesthesiology at CTCA, said: “One of the major objectives in an enhanced recovery program is reduction in narcotic utilization, but these changes were not clearly defined for pancreaticoduodenectomy.”
| Table 1. Standard Care For Pancreaticoduodenectomy |
| The Control Group |
|---|
| 23 patients (5/2013-1/2016)a |
| Pre-op |
| Standard care, surgeon preference |
| Intra-op |
| First 4 of 23 patients (5/2014-9/2015) |
| standard anesthesia care, anesthesia preference |
| Intra-op |
| Remaining 19 patients (9/2015-1/2016) |
| Preoperative regional blocks |
| Minimal intraoperative narcotics |
| Intraoperative multimodal analgesics |
| Goal-directed fluid therapy |
| Aggressive nausea prophylaxis, glucose control and temperature management |
| Post-op |
| Standard care, surgeon preference |
|
a Intraoperative enhanced recovery program elements were added prior to full implementation of the integrated protocol.
|
| Table 2. Enhanced Recovery Program for Pancreaticoduodenectomy |
| The Treatment Group |
|---|
| 24 patients (1/2016-8/2017), fully integrated enhanced recovery protocol |
| Pre-op |
| Patient pathway: education |
| Nutrition consult: IMPACT Advanced Recovery (Nestlé HealthCare Nutrition) supplements given preoperatively; recommended for all patients |
| PT consult: evaluation, “pre-hab” exercises |
| Behavioral health/mind–body consult: assess and treat mood concerns, cognitive functioning and adherence issues |
| Pain consult: for those patients with history of pain |
| Naturopathic medical consult: assess and recommend nutraceuticals to assist with surgery and recovery |
| Preanesthesia consult: risk assessment and pathway education |
| Preoperative use of complex carbohydrate drinks |
| Preoperative oral multimodal medications |
| Intra-op |
| Preoperative regional blocks |
| Zero intraoperative IV narcotics |
| Intraoperative multimodal analgesics |
| Goal-directed fluid therapy |
| Aggressive nausea prophylaxis, glucose control and temperature management |
| Post-op |
| Post-op care on dedicated enhanced recovery program floor (with enhanced recovery protocol training for nurses and advanced practitioners) |
| Ambulate on day of surgery, PT visit |
| No use of nasogastric tubes |
| Advanced to regular diet starting the morning of POD 1 plus routine diet supplements |
| Chewing gum on day of surgery |
| Naturopathic medicines, including arnica and probiotics |
| Routine, around-the-clock postoperative multimodal analgesics: NSAIDs, acetaminophen, gabapentinoids, muscle relaxants |
| Nonmedicinal adjunctive techniques (maximizing pain control while minimizing side effects compared with opioid therapy): cold/hot packs, acupuncture, chiropractic care, behavioral health and mind–body medicine consults with therapies offered |
| Oral narcotics as needed for breakthrough pain after multimodal and nonmedicinals have been tried |
| IV narcotics only used for breakthrough pain after oral narcotics failed |
| NSAIDs, nonsteroidal anti-inflammatory drugs; POD, postoperative day; PT, physical therapy |
A total of 23 control and 24 treatment patients were identified. Patient charts were reviewed for overall opioid use and route of administration. Five patients were eliminated from the evaluation, as they were on chronic narcotics before the procedure. The researchers found a significant difference in total oral morphine equivalents used intraoperatively and to postoperative day 3 and beyond (Figure 1). “In terms of route of administration, there was a clear movement to early oral administration, which continued through the day prior to discharge,” Dr. Seeley said (Figure 2).
Dr. Seeley told Anesthesiology News that the protocol now is used for all their major intraabdominal and pelvic surgeries, and they continued to see similar results. “Before the protocol was completed, we were surprised that we did not see early improvement after all of the major changes we had made in our anesthesia management,” Dr. Seeley said. “As was mentioned in the abstract, the big improvements only came after the formal multidisciplinary protocol was instituted—which was months after the anesthesia changes were made. This reminds me of when desflurane came out and we were disappointed that our PACU stays were not significantly shorter. Our analysis discovered that PACU policy dictated a minimum length of stay, and until we changed that policy, we could not capitalize on the beneficial characteristics of the new drug. I believe our enhanced recovery protocol rediscovered this same phenomenon. The postoperative management had to change in order to capitalize on the improved condition of the patient coming out of the OR [operating room].”
—Kam Mander, BPharm