E. K. Hunt1, 2, C. A. Zatorski1, 2, P. T. Liu1, 2, C. W. Du1, 2, S. J. Eckhart1, 2, A. Crisafio3, M. J. Moritz1, 2 1Lehigh Valley Health Network, Department Of Surgery, Allentown, PA, USA 2University Of South Florida College Of Medicine, SELECT Program, Allentown, PA, USA 3St. George’s University School Of Medicine, St. George’s, St. George’s, Grenada
Introduction:
Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary, peri-operative pathway designed to minimize the stress response, optimize recovery, and limit narcotic usage via multimodal analgesia. Use of ERAS in major abdominal surgeries has been reported to increase patient satisfaction and decrease pain, time to diet, length of stay, and cost. Implementation of an ERAS pathway for laparoscopic living donor nephrectomies (LLDN) has been slow as it is a major paradigm shift from the traditional over-hydration with forced diuresis to goal directed fluid therapy.
Methods:
A retrospective, cross-sectional analysis of a quality improvement project that studied the ERAS implementation for LLDN was performed. Historical controls were compared to those ERAS participants. Key components of the ERAS protocol included 4-quadrant transversus abdominal block, intravenous anesthesia, multimodal pain therapy utilizing non-narcotic analgesia throughout the perioperative period, goal directed fluid therapy, and early nutrition and mobility. Fisher’s exact and Mann Whitney tests evaluated the differences in pain metrics and functional status. Significance was estimated at p<0.05.
Results:
85 patients underwent LLDN from January 2017 to March 2021. 50 historical controls were compared to 35 ERAS participants. There were no differences in demographic characteristics. Total post-operative mean morphine equivalents (MMEs) were significantly lower in the ERAS group. Additionally, ERAS patients had lower mean pain scores and were more likely to report a pain score ≤ 7. ERAS patients on postoperative day 1 were more likely to ambulate and tolerate a regular diet (14% v. 54.2%, p < 0.000). Length of stay was longer in the control group compared to the ERAS group. Despite less intraoperative crystalloid (4.4 L ± 1.3 v. 2.1 L ± 0.85, p = 0.000) and longer intraoperative times (304.6 min ± 64.3 v. 378 min ± 80.9, p = 0.000), there was no difference in the peak creatinine.
Conclusion:
The implementation of a standardized ERAS LLDN pathway was successful in lowering postoperative narcotic use, improving subjective pain control, improving early ambulation, and shortening length of stay. Despite longer OR times (due to block administration) and a decline in intraoperative crystalloid administration, there was no difference observed in kidney function.
