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Perioperative Management and Implementation of Enhanced Recovery Programs in Gynecologic Surgery for Benign Indications

Carey, Erin T., MD, MSCR; Moulder, Janelle K., MD, MSCR

doi: 10.1097/AOG.0000000000002696
Contents: Gynecology: Clinical Expert Series
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Enhanced recovery after surgery (ERAS) programs are a multimodal approach to optimize the surgical experience. Intraoperative and postoperative pain management is essential because the stress of surgery results in significant neurohormonal and metabolic shifts that can influence patient analgesia. Enhanced recovery after surgery programs address the physiologic and psychological factors that contribute to pain outcomes and overall satisfaction scores. A multimodal approach to recovery throughout the perioperative surgical experience is representative of successful pathways. Enhanced recovery after surgery programs begin in the outpatient and preadmission setting by targeting behavioral changes and modifiable risk factors for pain in addition to cultivating patient expectations. Preoperatively, ERAS allows for patients to enter surgery without a fluid deficit that was previously seen with prolonged fasting and mechanical bowel preparations. Opioid-sparing analgesic agents are provided preemptively and many have synergistic effects when administered together, resulting in fewer opioids administered in the postoperative setting. Intraoperatively, euvolemia and normothermia are essential in reducing the adverse metabolic effects of surgery. Postoperatively, pain management, reduction in postoperative nausea and vomiting, proactive mobilization, and early enteral feeing minimize patient discomfort and decrease the duration until return to baseline. Although incorporation of all phases of the ERAS pathway will maximize patient benefit, stepwise incorporation of the phases of the pathway can still improve the surgical experience at minimal cost.

Enhanced recovery pathways are multimodal, modifying preoperative, intraoperative, and postoperative practices to optimize acute pain management and improve postoperative outcomes.

Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina; and the Department of Obstetrics and Gynecology, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee.

Corresponding author: Erin T. Carey, MD, MSCR, 101 Manning Drive, CB7570, Chapel Hill, NC 27599; email: erin_carey@med.unc.edu.

Financial Disclosure Dr. Carey has been a consultant for Teleflex Medical and served as a medical expert in litigation within the last 3 years. Dr. Moulder has been a consultant for Teleflex Medical within the last 3 years.

Continuing medical education for this article is available at http://links.lww.com/AOG/B107.

Each author has indicated that she has met the journal's requirements for authorship.

Received November 2, 2017. Received in revised form January 1, 2018. Accepted January 19, 2018.

Enhanced recovery after surgery (ERAS) programs began in the late 1990s as a multidisciplinary approach to address known causes of delays and complications in postoperative recovery.1 At the time, the paradigm for perioperative care did not address two key elements associated with surgical morbidity: the degree of surgical injury and decreasing the body's stress response to that injury.2 The surgical stress response results in metabolic and endocrinologic changes that increase catabolism, immunosuppression, and decrease organ function with subsequent delays in recovery.3 Targeted multimodal interventions were proposed as a solution to the unfavorable outcomes induced by the surgical stress response to maintain anabolic homeostasis.2

In gynecologic surgery, minimally invasive procedures afford patients shorter hospital stays, improved perioperative pain control, decreased blood loss, fewer infections, and a faster recovery than an abdominal approach. Minimally invasive surgery is merely one component of ERAS, reducing intraoperative surgical stress. However, ERAS extends beyond the incision and can be applied to a comprehensive perioperative care protocol. Enhanced recovery after surgery begins in the outpatient setting and continues through the perioperative and postoperative periods, the culmination of patient-centered and value-based care. We describe the application of ERAS in gynecology, including specific recommendations for implementation and expected benefits for our patients, health care providers, and key stakeholders.

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ORIGIN AND APPLICATION OF ENHANCED RECOVERY AFTER SURGERY

Early findings demonstrated that outcomes were a product of perioperative, not solely intraoperative, care. The modern ERAS paradigm flows through the patient surgical experience and is comprised of the four essential stages: preadmission, preoperative, intraoperative, and postoperative (Fig. 1). Each stage has specific enhanced recovery components to decrease surgical stress or mitigate the negative effects of the surgical stress response.1 The success of any ERAS program depends on organization of a multidisciplinary group, involving anesthesiologists, surgeons, perioperative nurses and therapists, and, most importantly, patients who are well-informed about postoperative recovery and expectations.2,4

Fig. 1

Fig. 1

Although the first ERAS Society guidelines were published for colonic resection, by 2015 guidelines for major gynecologic surgery became available.5 Enhanced recovery after surgery had rapid uptake in colorectal surgery, and more than a decade of data is available supporting a reduction in hospital stay, no change in readmission rate, and earlier return to baseline function.4 Similar to colorectal surgery, many of the pharmacologic and nonpharmacologic interventions have demonstrated improved postoperative outcomes, including improved pain management and decreased length of stay, when integrated into gynecologic surgeries, namely hysterectomy.6 In 2014, a formal, standardized protocol was proposed to optimize gynecologic oncology patient outcomes and monitor compliance and the ERAS Society gynecologic oncology guidelines are now available for preoperative, intraoperative, and postoperative care.5,7

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THE FOUR ESSENTIAL STAGES

The four essential stages of ERAS include preadmission, preoperative, intraoperative, and postoperative. Although each stage remains multidisciplinary, the common theme is that the patient and the health care providers in the pathway have shared expectations. The goal of the patient–health care provider team is to improve the perioperative experience through evidence-based pharmacologic and nonpharmacologic protocols to safely expedite routine surgical advance.

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Preadmission

Major surgery is both physically and psychologically stressful for patients. The preoperative preparation, dubbed “prehabilitation,” has been identified as an underutilized opportunity to improve the surgical experience, set expectations, and potentially optimize postoperative outcomes. Needs-based preoperative education, including goal setting of postoperative pain expectations, has been associated with a significant reduction in preoperative anxiety.8 Prehabilitation through physical training and inspiratory muscle conditioning has been associated with fewer intraoperative and postoperative complications and may decrease length of stay; however, most studies have only identified significant findings in patients with poor baseline physical capacity.9

Patients at increased risk of higher than expected postoperative pain should be identified. Women with poor pain-coping skills or high presurgical anxiety are more likely to have higher acute and chronic pain after hysterectomy.10 When available, a preoperative referral to a pain psychologist specializing in cognitive behavior therapy can create a pain management plan effective in highly anxious patients and those more likely to catastrophize. Online self-management programs have also been shown to be effective in chronic pain reduction in the outpatient setting and may be beneficial when a pain psychologist is not readily available.11

Other modifiable risk factors that affect acute postoperative pain perception should be addressed at the preoperative visit. Nicotine, a central nervous system stimulant, harbors analgesic properties. In nicotine-dependent patients, withdrawal during the perioperative surgical window results in lower pain thresholds and secondary higher opioid consumption than nonsmokers with current tobacco use resulting in higher amounts of opioid consumption in the first 72 hours postoperatively when compared with nonsmokers or past smokers.12 Smoking cessation 4 weeks before surgery has been associated with fewer postoperative complications including wound infections.13 Aggressive smoking cessation preoperatively has been associated with decreased tobacco abuse at 12 months postoperatively; supplemental nicotine can improve compliance without compromising wound healing or postoperative complications.13 In parallel, excessive alcohol consumption can be associated with surgical stress response malfunction, increased bleeding time, and prolonged hospitalization14 and should be addressed in the preoperative period.

Preoperative fasting, cultivated from the historic adage of “nothing to eat or drink after midnight,” was initially instituted to prevent aspiration of gastric contents during anesthesia. However, the effects of prolonged fasting (greater than 12 hours) are associated with metabolic changes that may affect perioperative outcomes through diminishing liver glycogen, thus impairing glucose metabolism and increasing insulin resistance. Surgery alone results in a significant reduction of insulin sensitivity and the amount of insulin resistance is related to route and length of surgery.2

The American Society of Anesthesiology recommends fasting from intake of a light meal at least 6 hours (8 hours if fried foods or high fat content) and fasting for 2 hours from the modest intake of clear liquids (including carbohydrate-loading drinks) before elective procedures requiring sedation or regional or general anesthesia.15 The reduction in recommended fasting times, particularly of clear liquids, has improved surgical outcomes and patient comfort with no increased risk of aspiration. Gastric volumes are actually lower in patients who are able to drink small amounts of water preoperatively.15

Iatrogenic preoperative hypovolemia through mechanical bowel preparation has also been reconsidered. Bowel preparations can lead to patient discomfort, dehydration, and electrolyte disturbances. A recent meta-analysis of five randomized controlled trials suggests neither oral nor rectal bowel cleansing is supported in gynecologic surgery and can be discontinued as a recommendation.6

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Preoperative Analgesia

The primary goal of preoperative analgesia is to optimize perioperative pain management with minimal opioid exposure. Opioids, although extremely effective for acute pain, directly contribute to perioperative complications such as nausea and vomiting, delay in bowel function, and respiratory suppression.

The initial approach begins in the preoperative arena where a medication cocktail harboring different mechanisms of action is applied to reduce the overall pain response. The most commonly used preoperative medications are acetaminophen or paracetamol, nonsteroidal antiinflammatory drugs (NSAIDs), and gabapentinoids. Independently, these medications have been associated with decreased opioid use and reduced pain postoperatively.

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Acetaminophen

The mechanism of action of acetaminophen is unknown; however, it is an effective analgesic for mild-to-moderate pain. It does not possess antiinflammatory properties, although it may weakly inhibit cyclooxygenase transcription. Acetaminophen should be considered the ultimate drug companion, more effective when used in conjunction with NSAIDs and opioids, and may reduce opioid requirements overall. Intravenous (IV) acetaminophen has been shown to reduce acute pain, total opioid consumption, and opioid-related side effects in abdominal hysterectomy.16 There have been no prospective trials comparing IV with oral acetaminophen in gynecologic surgery; therefore, in our practice, we use a single dose of 975 mg acetaminophen orally given the comparable efficacy and decreased cost.

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Nonsteroidal Antiinflammatory Drugs

Although there is insufficient evidence to recommend nonselective NSAIDs preoperatively, there is moderate evidence for selective cyclooxygenase inhibitors (eg, celecoxib). Although no preemptive analgesia studies evaluate celecoxib in gynecologic surgery, cyclooxygenase inhibitors appear to be an important adjunct multimodal preemptive analgesia with the most commonly studied doses 200–400 mg orally administered 30–60 minutes preoperatively.17 These should be used with caution in patients with a history of coronary artery disease as a result of an increased risk of cardiovascular events; however, there does not appear to be a measurable effect on coagulation with perioperative use compared with nonselective NSAIDS.17

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Gabapentinoids

The gabapentinoids, gabapentin and pregabalin, are analogs of γ-amino butyric acid, and function on the α-2δ subunit of voltage-dependent calcium channels. This is likely the source of the analgesic effect of this drug class. Perioperatively, the analgesic effect of the gabapentinoids is twofold: decrease in movement-related pain, improving functional recovery, and prevention of tissue injury, thus reducing the risk of central sensitization.18 Studies have also demonstrated continued dosing in the days to weeks after surgery can prevent chronic postsurgical pain. Both gabapentin and pregabalin have opioid-sparing effects in the postsurgical state.18 Preoperatively, a single dose of 600 or 1,200 mg gabapentin, or 150 or 300 mg pregabalin, administered 1–2 hours before surgery, appears to be effective.19

Compared with other medications used for preemptive analgesia, perioperative gabapentinoid use is well supported in the gynecologic literature. A recent meta-analysis included randomized controlled trials of women who underwent total abdominal hysterectomy under general anesthesia with a preoperative dose of gabapentin.20 In the women who received preoperative gabapentin, there was an overall reduction in pain scores and opioid consumption as well as decreased nausea and vomiting (likely secondary to less opioid exposure20). Similarly, preoperative pregabalin reduces total acute pain, narcotic use, and nausea and vomiting in hysterectomy.19 The amount of postoperative pain relief may be dose-dependent with the higher doses associated with greater reduction in pain. Higher doses may also be paired with more side effects such as sedation and high doses should be used with caution in a somnolent or elderly patient.

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Antidepressants

Antidepressants, specifically tricyclic antidepressants and serotonin nonselective reuptake inhibitors, have been extensively studied in pain disorders. Although traditionally indicated for anxiety and depression, the increased norepinephrine may also be effective in managing a multitude of neuropathic and musculoskeletal chronic pain disorders. Despite success in animal models, tricyclic antidepressants have failed to show consistent reduction in pain in the postoperative setting with preoperative or perioperative administration, although they have never been studied in gynecologic surgery.21 Specific to serotonin nonselective reuptake inhibitors, one randomized controlled trial evaluated the perioperative effects of women who received 60 mg duloxetine before abdominal hysterectomy with a repeat dose at 24 hours. In addition to improved acute pain and reduced opioid use, the overall quality of recovery was higher when compared with placebo, specific to measurements of physical comfort, independence, emotional status, and pain.22 There are no data on longer recovery quality measurements.

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Intraoperative

Intraoperative medications also play an important role in postoperative pain management, including drug infusions, incision infiltration, and neuraxial anesthesia.

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N-Methyl-D-Aspartate Antagonists

Ketamine, a phencyclidine derivative, acts as an antagonist on the N-methyl-D-aspartate receptor. It noncompetitively inhibits glutamate activation of the channel, resulting in positive analgesic effects. In women undergoing laparoscopic surgery, a small dose of intraoperative ketamine was shown to reduce pain score and opioid use in the postoperative setting when compared with an infusion postoperatively or placebo.23 Low preoperative dosing such as in this study may avoid the known risk of hallucinations, nightmares, and psychomimetic reactions with systemic use.23

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Local Anesthetics

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Incisional Infiltration

Preincisional and postincisional wound infiltration with local anesthetics have been used to reduce acute postoperative pain in gynecologic surgery.24 Anesthetic relief is achieved by blockade of the voltage-gated Na channels, preventing activation of sensory pain pathways; however, the short duration of action limits the length of relief achieved. The development of longer lasting local anesthetics such as liposomal subtypes may play an important role in postoperative pain management.

Liposomal bupivacaine differs from bupivacaine hydrochloride in that it is encapsulated in multiple lipid layers allowing for sustained release with a half-life of 24–34 hours compared with a half-life of 3.5 hours for bupivacaine hydrochloride. Although this formulation has demonstrated a decrease in postoperative opioid use, it may not be superior to bupivacaine hydrochloride in reducing postoperative pain at the surgical site.25

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Regional and Neuraxial Anesthesia

Despite smaller incision size and postoperative pain with the emergence of minimally invasive surgery in gynecologic surgery, a role may still exist for regional anesthesia. Paracervical blocks at the time of vaginal hysterectomy are associated with a significant reduction in postoperative pain.26 Rather than infiltrating the tissue immediately around the wound, transversus abdominis plane blocks direct the local anesthetic regionally to the T6–L1 nerve root for abdominal approaches. This technique, performed using anatomic landmarks or under ultrasound guidance preoperatively or postoperatively, has been effectively used for pain control in abdominal procedures including hysterectomy. However, a meta-analyses of transversus abdominis plane block used in a variety of surgeries under general or neuraxial anesthesia identified limited evidence for it reducing pain and opioid consumption.27

Epidural and spinal analgesia are neuraxial regional blocks used extensively in abdominopelvic surgery. Neuraxial anesthesia may help improve coronary and tissue perfusion, diminish insulin resistance, reduce the metabolic stress response to surgery, reduce inflammatory markers, diminish postoperative nausea and vomiting, improve gut motility as well as decrease opioid consumption. Specific to pain management, epidurals with local anesthetic and opioid may decrease pain after abdominal surgery, and epidurals containing local anesthetic accelerate return of bowel function and allow for earlier feeding. As a result of the effect on patient outcomes, neuraxial anesthesia is among the recommendations from the ERAS Society for gynecologic oncology for abdominal surgery.7 Systemic anesthetics such as IV perioperative lidocaine have not shown consistent reduction in early postoperative pain scores, and there are few data to support a decrease in pain beyond the first 24 hours of surgery.28 Although neuraxial anesthesia is recommended for abdominal surgery, its role in outpatient minimally invasive surgery for benign indications is limited as a result of its potential to delay time to ambulation, catheter removal, and prolonging time to discharge.

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Fluid Administration

Fluid management is a mainstay of ERAS. Whereas fluid overload can lead to peripheral and visceral edema as well as electrolyte abnormalities, hypovolemia can affect cardiac output and tissue oxygenation.6 Euvolemia results in fewer postoperative complications, earlier return of bowel function, and shorter hospital stay. Euvolemia is achieved with a zero-sum fluid balance, a strategy of decreased crystalloid and increased colloid for net-neutral weight gain from surgical fluid administration.3,6

Achieving euvolemia requires a three-pronged approach, with preoperative, intraoperative, and postoperative fluid management. As discussed earlier, patients should ingest clear fluids or a carbohydrate drink 2 hours before induction of anesthesia and avoid mechanical bowel preparation.

Intraoperatively, euvolemia is the goal. Although maintenance fluid should be used to replace insensible losses, total loss is less than previously known, and excess fluid administration can lead to delayed recovery of gastrointestinal function.29 In high-risk patients undergoing major surgery with increased surgical risk and greater fluid shifts, goal-directed fluid therapy based on stroke volume optimization may be considered.29

Postoperatively, the rapid transition to oral intake is encouraged and IV fluids should be discontinued. If patients require IV fluids, low-sodium and low-volume fluids should be administered to maintain zero fluid balance.

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Body Temperature

Intraoperative thermoregulation is driven by environmental heat loss and decreased metabolic energy production. Commonly used anesthetic agents can impair thermoregulatory control, primarily affecting normal cold-response thresholds.30 Even mild hypothermia can induce perioperative complications. Coagulopathy may occur as a result of impairment in platelet aggregation and reduced clot formation. Hypothermia, even less than 1°C, can significantly increase blood loss and subsequent need for transfusion. Persistent hypothermia triggers vasoconstriction postoperatively, resulting in decreased perfusion of tissue and decreased oxygen delivery. In addition, hypothermia reduces wound healing and can diminish immune activation, part of the wound healing process.30 Maintaining normothermia is an important part of mitigating the negative effects of the physiologic stress of surgery. Preoperative warming devices provide both insulation and active warming, although insulation alone will not prevent hypothermia.30 Intraoperatively, it is essential to monitor core body temperature and respond to hypothermia through managing room temperature, fluid warming system, and forced-air infusion blankets.

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Postoperative

The culmination of the pathway is the postoperative ERAS experience. Here, multiple nonmedication interventions are initiated to reduce patient discomfort and safely expedite routine surgical advances.

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Line Removal

Prompt discontinuation of movement-limiting structures (eg, catheters, drains, IV tubing) is directly related to mobility and pain control. Prolonged use of urinary catheters is unwarranted in most settings, and removal can occur as early as in the operating room. A systematic review compared immediate and delayed urinary catheter removal after hysterectomy for benign indications.31 Although immediate removal increases risk of repeat catheterization, delayed removal increases the risk of urinary tract infections and bacteriuria31 and should be minimized and immediately removed when appropriate.

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Mobilization

Early mobilization is a key component in all postoperative care protocols. Pain control is necessary to achieve early ambulation, and minimally invasive surgery allows for less incisional pain and opioid consumption and thus may increase compliance of a mobility program. The importance of postoperative mobilization is well-established—movement improves pulmonary function, promotes bowel function, and decreases atelectasis, muscle wasting, and insulin resistance. Our protocol includes a minimum of 2 hours out of bed on the day of surgery and then at least 6 hours daily until discharge. Although movement practices vary by institution, “early and often” is a common mantra.

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Dietary Recommendations

More recently, early enteral feeding and the elimination of postoperative fasting have been associated with decreased length of stay and risk of postoperative ileus.7 As with preoperative fasting, postoperative fasting should be avoided when possible, because similar metabolic changes occur with each prolonged fasting episode. We recommend resuming a regular diet within 24 hours of surgery.

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Nausea and Vomiting

Postoperative nausea and vomiting is one of the most common and debilitating side effects of general anesthesia and opioid use, lasting hours to days after exposure. In addition to patient discomfort, it has been associated with prolonged hospital stay.32 The majority of ERAS programs include aggressive prophylaxis and treatment through preoperative medications and minimizing opioid exposure. Using the established risk factors of female gender, nonsmoker status, a personal history of postoperative nausea and vomiting, and postoperative use of opioids, health care providers may be able to predict patients more likely to experience postoperative nausea and vomiting. Regardless of the risk profile, a prophylactic, multimodal approach is offered to most patients with the most effective factor being opioid-sparing analgesia. The application of a transdermal scopolamine patch alone or combined with other preventative measures is effective in the prevention of postoperative nausea and vomiting, particularly later symptom presentation as a result of steady drug delivery over 72 hours.32

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Pain Management

The American Society of Anesthesiologists have published practice guidelines for acute pain management in the perioperative setting.19 The postoperative goals of mobilization, dietary advancement, and timely discharge home are dependent on appropriate pain management.

Ketorolac tromethamine, a NSAID with extensive use in the postoperative setting as a result of ease of IV administration, has been used with variable results in acute pain management after gynecologic surgery. Once tolerating orals, alternating acetaminophen and NSAID therapy is traditional teaching in postoperative pain management. A systematic review analyzed 21 studies that compared paracetamol and acetaminophen alone or in combination with NSAID therapy and found increased analgesia with the combination of two drugs than with either alone.33

Opioid analgesia remains the most effective drug for acute postoperative pain, but the side effect profile limits use. The opioid mechanism of action is broad, binding to the μ-opioid receptor in many places along the pain pathway and inhibiting pain perception peripherally and centrally. Postoperatively, the most significant side effect is respiratory depression with the potential for hypoxia and respiratory arrest. Other side effects include nausea and vomiting, pruritus, drowsiness, and decreased bowel function. When appropriate, initiating oral opioid therapy in the fast-track patient is recommended over IV patient-controlled analgesia. The transition to minimally invasive surgery and ERAS often allows for bypassing a stepdown analgesic such as patient-controlled analgesia and the ability to initiate oral therapy with adequate pain control. During the hospitalization, we recommend using the same opioid as will be used on discharge to address any side effect concerns before discharge. An example of a gynecology ERAS protocol is shown in Box 1.

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Perioperative Enhanced Recovery Pathway Cited Here...

Preoperative

  • Elimination of mechanical bowel preparation and rectal enema for most procedures for benign indications
  • 8-oz carbohydrate beverage 2–4 h before surgery
  • No solids after midnight; clear liquid diet 2–4 h before surgery

Intraoperative

Analgesia immediately before operating room

  • Acetaminophen 1,000 mg PO
  • Gabapentin 600–1,200 mg PO once or pregabalin 100–300 mg PO once
  • Celecoxib 200–400 mg PO once

Nausea and vomiting prophylaxis

  • Scopolamine transdermal patch 2 h preoperatively
  • Dexamethasone 4 mg IV once at induction

Analgesia, intraoperative

  • Regional anesthesia if appropriate
  • Acetaminophen 1,000 mg IV once (if no oral)
  • Opioids as needed
  • Ketamine 0.5 mg/kg (10 mg/mL) bolus on induction and closure and an infusion of 10 micrograms/kg/min
  • Ketorolac 15–30 mg IV once at end of case if appropriate
  • Local wound infiltration: preincisional or postincisional bupivacaine hydrochloride or postincision liposomal bupivacaine

Fluid balance

  • Goal-directed fluid therapy with a net zero balance at the end of the surgical case
  • Lactated Ringer's over normal saline for electrolyte balance (reduced sodium)
  • Colloid over crystalloid replacement when appropriate

Postoperative

Diet

  • Advance diet as tolerated without restrictions
  • Avoid nasogastric tube
  • Initiate bowel regimen with osmotic agents (senna or docusate sodium)

Line management

  • Foley catheter removed in operating room or morning of postoperative day 1
  • Removal of nasogastric tube in operating room if placed
  • Limit drains
  • IV fluids decreased to 40 mL/h until 600 mL of oral intake, then peripheral lock IV until discharge

Activity

  • Limit drains
  • Day of surgery out of bed 2 h (chair sitting and walking)
  • Postoperative day 1 and beyond, 6–8 h out of bed

Analgesia

  • No IV pain medication after release from PACU if possible
  • Scheduled acetaminophen 1,000 mg PO every 6–8 h (3,000–4,000 mg/24 h)
  • Scheduled NSAIDs:
  • Ketorolac 15–30 mg IV every 6 h for 4 doses
  • or
  • Ibuprofen 600–800 mg PO every 6 h, 6 h after last ketorolac dose
  • Oral opioids:
  • Tramadol 100 mg PO every 6 h PRN pain
  • Oxycodone 5 mg PO every 4 h PRN pain rated 4–6/10 or 10 mg orally for pain rated 7–10/10
  • or
  • Hydromorphone 2 mg PO every 4 h PRN pain rated 4–6/10 or 4 mg orally for pain rated 7–10/10
  • Breakthrough IV opioids if no relief with oral opioids in 30 min:
  • Hydromorphone 0.4 mg IV once; repeat in 20 min once if no response
  • or
  • Morphine 2 mg IV once; repeat in 20 min once if no response
  • Consider patient-controlled analgesia if unable to obtain pain relief with above regimen

Nausea and vomiting management

  • Opioid-sparing analgesia
  • Ondansetron 4 mg PO every 6 h prn nausea and vomiting
  • or
  • Prochlorperazine 10 mg IV every 6 h prn nausea and vomiting

PO, oral administration; IV, intravenous; PACU, postanesthesia care unit; NSAIDs, nonsteroidal antiinflammatory drugs; prn, as needed.

Opioid prescriptions are provided to patients for acute pain management at home after minor and major surgery, although little is known about use of opioids after hospital discharge. A recent survey evaluated opioid use and storage after discharge after surgery with the majority of patients using less than half of the pills they took home. Concerning patterns of excess opioids saved and stored in unsecure locations were revealed.34 Interventions to reduce this problem include either decreasing the number of opioids prescribed on discharge or providing an avenue for opioid return and destruction to reduce the morbidity and mortality risks of overprescribing. We recommend using a shared decision-making model when dismissing patients home with opioids. It is our practice to discharge patients home with no more than 20 tablets of opioids for a minimally invasive hysterectomy and fewer for minor surgery.

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ENHANCED RECOVERY AFTER SURGERY FOR THE OPIOID-DEPENDENT PATIENT

Patients who use chronic opioids for pain management are at risk for inadequate postoperative pain relief.35 Opioid-tolerant patients may experience greater pain during the first 24 hours postoperatively and require an increase in opioids when compared with opioid-naive patients.35 Active perioperative management of these patients will improve postoperative pain outcomes. Preoperatively, the patient should take their maintenance opioids the morning of surgery. Although there is no way to consistently determine the amount of intraoperative opioid use, regional anesthesia, ketamine infusion, and local anesthetic infiltration may reduce postoperative pain in opioid-dependent patients.35

The real challenge lies in the postoperative pain management of the opioid-dependent patient—they require higher doses of opioids for longer than opioid-naive patients and are at constant risk of being undermedicated for their pain. Here, it may be reasonable to incorporate patient-controlled analgesia. In addition to rapid onset, benefits of a patient-controlled analgesia include decreased patient anxiety and prevention of acute opioid withdrawal symptoms. If the patient cannot tolerate orals, a baseline dose can be programmed. Patients should be discharged on their preoperative regimen as well as provided supplemental opioids for postsurgical pain control. In patients with high opioid intake (greater than 50 morphine milligram equivalents daily), history of substance abuse, or current treatment with methadone, buprenorphine, or naltrexone, a preoperative referral to a pain medicine physician may be considered. Opioid weans should be avoided in the immediate postoperative period. In our practice, we encourage short-interval follow-up postoperatively to assess opioid use and postsurgical pain control.

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IMPLEMENTATION OF ENHANCED RECOVERY AFTER SURGERY

Culture change is difficult because it is just that: a change in current practice. Successful implementation of ERAS lies in the education of the staff, patient, and families. The ERAS team is multidisciplinary, including surgeons, anesthesiologists, nurses, dieticians, physiotherapists, and psychotherapists. Identification of a champion in each discipline may allow for dissemination of key ERAS concepts and improve compliance. In addition, an ERAS coordinator serves the critical role of facilitating communication and collaboration among teams.

Potential barriers to ERAS include lack of coordination, communication, compromise, and standardization of care.1 Although implementation is enabled by the agreement of key stakeholders of the patient–health care provider unit, sustainability is only possible with support from hospital administration and continuous evaluation of compliance for ongoing assessment of quality improvement.1 In the era of value-based care, it should be noted that implementation of many of the elements of ERAS can be done with minimal cost and improved patient comfort and satisfaction.36

Indeed, the decreased length of stay and decreased complication rate are thought to be the drivers of reduced overall health care costs.37 Estimated cost-savings after ERAS implementation range from $153 to $697 per patient for gynecologic procedures for benign indications, with conservative estimates accounting for the cost of ERAS-specific patient education.6

A recent systematic review evaluated the health economics of ERAS and found that ERAS protocols are generally cost-effective across surgical specialties.38 However, the authors state that the data reported tended to relate to in-hospital costs rather than the indirect costs that may be associated with ERAS protocols. For example, earlier discharge may simply shift the recovery process to the outpatient setting, resulting in a cost transfer from the hospital to the community caregiver. However, patients receiving ERAS for surgery had faster return to work, decreased caregiver burden, and fewer visits to community health centers compared with patients receiving conventional care.39 As such, the theoretical cost transfer for ERAS may actually be unfounded, given the cost savings from a societal perspective.

Enhanced recovery after surgery should be the standard of care in gynecologic surgery. By optimizing nonpharmacologic interventions and multimodal analgesia, ERAS affords patients earlier return to function with good pain control despite a significant reduction opioid requirements and high patient satisfaction with reduced hospital fees.40 Although implementation of the entire ERAS pathway may be challenging at first, stepwise incorporation of the phases of the pathway can still improve the patient experience at minimal cost and maximum clinical benefit.

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REFERENCES

1. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017;152:292–8.
2. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606–17.
3. Barber EL, Van Le L. Enhanced recovery pathways in gynecology and gynecologic oncology. Obstet Gynecol Surv 2015;70:780–92.
4. Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008;248:189–98.
5. Nelson G, Altman AD, Nick A, Meyer L, Ramirez PT, Achtari C, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS®) Society recommendations—part I. Gynecol Oncol 2016;140:313–22.
6. Kalogera E, Dowdy SC. Enhanced recovery pathway in gynecologic surgery: improving outcomes through evidence-based medicine. Obstet Gynecol Clin North Am 2016;43:551–73.
7. Nelson G, Altman AD, Nick A, Meyer L, Ramirez PT, Achtari C, et al. Guidelines for postoperative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS®) Society recommendations—part II. Gynecol Oncol 2016;140:323–32.
8. Aydin D, Klit J, Jacobsen S, Troelsen A, Husted H. No major effects of preoperative education in patients undergoing hip or knee replacement–a systematic review. Dan Med J 2015;62. pii: A5106.
9. Minnella EM, Awasthi R, Gillis C, Fiore JF Jr, Liberman AS, Charlebois P, et al. Patients with poor baseline walking capacity are most likely to improve their functional status with multimodal prehabilitation. Surgery 2016;160:1070–9.
10. Pinto PR, McIntyre T, Nogueira-Silva C, Almeida A, Araújo-Soares V, et al. Risk factors for persistent postsurgical pain in women undergoing hysterectomy due to benign causes: a prospective predictive study. J Pain 2012;13:1045–57.
11. Williams DA, Kuper D, Segar M, Mohan N, Sheth M, Clauw DJ. Internet-enhanced management of fibromyalgia: a randomized controlled trial. Pain 2010;151:694–702.
12. Chiang HL, Chia YY, Lin HS, Chen CH. The implications of tobacco smoking on acute postoperative pain: a prospective observational study. Pain Res Manag 2016;2016:9432493.
13. Mastracci TM, Carli F, Finley RJ, Muccio S, Warner DO; Members of the Evidence-Based Reviews in Surgery Group. Effect of preoperative smoking cessation interventions on postoperative complications. J Am Coll Surg 2011;212:1094–6.
14. Tonnesen H, Petersen KR, Hojgaard L, Stokholm KH, Nielsen HJ, Knigge U, et al. Postoperative morbidity among symptom-free alcohol misusers. Lancet 1992;340:334–7.
15. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology 2017;126:376–93.
16. Moon YE, Lee YK, Lee J, Moon DE. The effects of preoperative intravenous acetaminophen in patients undergoing abdominal hysterectomy. Arch Gynecol Obstet 2011;284:1455–60.
17. McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1—from the preoperative period to PACU. Perioper Med (Lond) 2017;6:8.
18. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J, et al. The prevention of chronic postsurgical pain using gabapentin and pregabalin: a combined systematic review and meta-analysis. Anesth Analg 2012;115:428–42.
19. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012;116:248–73.
20. Alayed N, Alghanaim N, Tan X, Tulandi T. Preemptive use of gabapentin in abdominal hysterectomy: a systematic review and meta-analysis. Obstet Gynecol 2014;123:1221–9.
21. Wong K, Phelan R, Kalso E, Galvin I, Goldstein D, Raja S, et al. Antidepressant drugs for prevention of acute and chronic postsurgical pain: early evidence and recommended future directions. Anesthesiology 2014;121:591–608.
22. Castro-Alves LJ, Oliveira de Medeiros AC, Neves SP, Carneiro de Albuquerque CL, Modolo NS, De Azevedo VL, et al. Perioperative duloxetine to improve postoperative recovery after abdominal hysterectomy: a prospective, randomized, double-blinded, placebo-controlled study. Anesth Analg 2016;122:98–104.
23. Kwok RF, Lim J, Chan MT, Gin T, Chiu WK. Preoperative ketamine improves postoperative analgesia after gynecologic laparoscopic surgery. Anesth Analg 2004;98:1044–9.
24. Leung CC, Chan YM, Ngai SW, Ng KF, Tsui SL. Effect of pre-incision skin infiltration on post-hysterectomy pain—a double-blind randomized controlled trial. Anaesth Intensive Care 2000;28:510–6.
25. Hamilton TW, Athanassoglou V, Mellon S, Strickland LH, Trivella M, Murray D, et al. Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. The Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD011419. DOI: .
26. Blanton E, Lamvu G, Patanwala I, Barron KI, Witzeman K, Tu FF, et al. Non-opioid pain management in benign minimally invasive hysterectomy: a systematic review. Am J Obstet Gynecol 2017;216:557–67.
27. Charlton S, Cyna AM, Middleton P, Griffiths JD. Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery. The Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD007705. DOI: .
28. Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. The Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD009642. DOI:
29. Miller TE, Roche AM, Mythen M. Fluid management and goal-directed therapy as an adjunct to enhanced recovery after surgery (ERAS). Can J Anaesth 2015;62:158–68.
30. Sessler DI. Perioperative thermoregulation and heat balance. Lancet 2016;387:2655–64.
31. Zhang P, Hu WL, Cheng B, Cheng L, Xiong XK, Zeng YJ. A systematic review and meta-analysis comparing immediate and delayed catheter removal following uncomplicated hysterectomy. Int Urogynecol J 2015;26:665–74.
32. Antor MA, Uribe AA, Erminy-Falcon N, Werner JG, Candiotti KA, Pergolizzi JV, et al. The effect of transdermal scopolamine for the prevention of postoperative nausea and vomiting. Front Pharmacol 2014;5:55.
33. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110:1170–9.
34. Bartels K, Mayes LM, Dingmann C, Bullard KJ, Hopfer CJ, Binswanger IA. Opioid use and storage patterns by patients after hospital discharge following surgery. PLoS One 2016;11:e0147972.
35. Mitra S, Sinatra RS. Perioperative management of acute pain in the opioid-dependent patient. Anesthesiology 2004;101:212–27.
36. Nelson G, Kalogera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol 2014;135:586–94.
37. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002;183:630–41.
38. Stowers MD, Lemanu DP, Hill AG. Health economics in enhanced recovery after surgery programs. Can J Anaesth 2015;62:219–30.
39. Lee L, Mata J, Ghitulescu GA, Boutros M, Charlesbois P, Stein B, et al. Cost-effectiveness of enhanced recovery versus conventional perioperative management for colorectal surgery. Ann Surg 2015;262:1026–33.
40. Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH, et al. Enhanced recovery implementation in major gynecologic surgeries: effect of care standardization. Obstet Gynecol 2016;128:457–66.
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