So I found this in an article for breast reconstruction patients who have a big free flap and are in the hospital for days. They said an interdisciplinary approach has been shown to help in other fields, to improve healing, decrease pain medication requirements, etc. I am already doing a bunch of things for my patients pre surgery- stop smoking or vaping, eat high protein diets, take probiotics, lose weight, mammograms and EKGs and clearances as needed.
But I am always trying to improve, so I had to see what was their protocol?
ERAS. Enhance. Recovery. After. Surgery.
There are 4 stages: Planning and “optimization,” preop, intraop, and postop.
Planning and Optimization:
- stop smoking at least one month ahead
- stop drinking alcohol for one month ahead
- CBC (your blood level)
- Metabolic panel
- Referral to endocrine, your primary care doctor, or a cardiologist when needed
- Patient education about anesthesia
Preop
- Antibiotic within 1 hour of incision time
- Acetaminophen 1000 mg po
- Gabapentin 600g po
- Celecoxib 400mg po
- Scopolamine patch or oral antinausea med
- NPO of solids after midnight, clear liquids ok until 2 hours before surgery
- 12 oz of sports drink the morning of surgery
Intraop
- Induction with lidocaine, propofol, and vecuronium
- Dexamethasone 4-8 mg IV
- Maintenance with flurane or Propofol, titrated
- Lidocaine infusion 1-2 mg/kg/hr stopped 30 minutes before Exparel
- Ketamine .5mg/kg bolus at induction followed by .2mg/kg/hr infusion
- acetaminophen 1000mg IV every 8 hours following preop dose
- Balanced electrolyte solution 1-4ml/kg/hr
- Avoid use of vasopressors
- Maintain neuromuscular blockade with vecuronium infusion
- Zofran infusion 4mg IV 30 minutes before waking up
- Reversal of neuromuscular blockade
- Aspirin 300mg per rectum
Postop
- Flap monitoring
- Gabapentin 500 mg po bid
- Acetaminophen 1000 mg po
- hydromorphone .4 mg IV every 3 hours PRN for rescue
- Early ambulation
- Early feeding
- Thromboprophylaxis
My thoughts?
Their preop optimization I think is great. I am big on making sure you are as healthy and ready for surgery as you can be ahead of surgery. If you are vegetarian or have heavy periods or a history of anemia, check your blood level. You simply need blood to heal. Protein loading before surgery has been shown to statistically significantly lower infection rates and improve scarring. If you are 60 and older, you should have a recent EKG, and if you have any other issues (diabetes, high blood pressure, smoker) you should have a good exercise tolerance (not walking the dog- something where you really sweat), and if you don’t consider a stress test. For patients having breast surgery, do a mammogram. If you want to lose weight, do it first. The more you are near your ideal weight the better I can tuck and lift you, and the lower your surgical risk (higher BMI = higher surgery risks across the board.) Smoking anything- vaping, pot, cigarettes- is bad. Period. You need to stop and not cheat.
Their use of Acetaminophen is one I need to look at. It seems like a good addition to my protocol. Celecoxib as well. You can read all my blogs on that subject. Gabapentin has been disproven in the anesthesia literature (yes, my anesthesia colleagues and I discuss these things in the OR, and that is one which they do not favor from the studies they have seen.)
Exparel, also called “liposomal bupivicaine” is awesome, and I use it in all my tummy tucks. I for sure have seen decreased use of pain medications (less constipation, less opioid), and patients are up and about faster, which lowers risk of blood clots, is more comfortable, and helps your bowels move faster.
I don’t know about the sports drink the morning of surgery. Or liquids that close to surgery. We worry about aspiration during anesthesia, so we like your tummy empty. Will have to chat with anesthesia about that.
So overall, I don’t know that this will change what I do much. But good to see that I am doing a lot of this already, and this may encourage me to start using Acetaminophen on all my patients as protocol.