March 25, 2019

The Role of ERAS Protocols in the Current Opioid Crisis

By: Lisa A. Coleman, DO, FACS, FASCRS

As the opioid crisis continues to worsen, medical practitioners are searching for ways to combat the spread and devastating effects. A surgical protocol now available locally is working to not only fight the epidemic but drive improved patient satisfaction outcomes following surgical procedures.

The name of the protocol, Enhanced Recovery After Surgery (ERAS), also known as Enhanced Recovery Protocols (ERPs), is somewhat of a misnomer, in that the protocol encompasses not only the recovery period, but also the pre-operative, operative, and post-operative stages.

ERAS protocols have been mostly used by colorectal surgeons to return patients to normal function faster following a surgical procedure; however, the protocol can be adapted to suit other specialty surgeries.

Developed based on the latest recommendations and best practices, the goals of the protocol are to manage a patient’s expectation of pain following surgery, decrease the length of stay in the hospital, and return the patient to function faster.

A key aspect and crucial component to the protocol’s potential to combat the current opioid epidemic is the minimal use of narcotics to manage post-operative pain. In many cases, surgeons are able to forgo the use of opioids in favor of non-narcotic medications to manage pain.

To demonstrate the protocol’s effectiveness in reducing a patient’s time in the hospital, the current average stay following open abdominal surgery is 5-7 days, and when an ERAS protocol is in place, the average length of stay is reduced by 1-3 days.

Protocol benefits extend into areas related to increasing patient satisfaction and encouraging greater communication between the various disciplines involved in a patient’s hospital stay.

As an inherently interdisciplinary approach, ERAS protocols rely heavily on the collaboration of the surgeons, anesthesiologists, pre-operative and post-operative recovery nurses, the patient and the patient’s family.

In the specific cases of colorectal and bowel procedures, the following protocols are set into effect.

As the patient is being prepped for surgery, pain medication is started to get ahead of, and more effectively manage, post-operative pain, followed in many cases by a Transversus Abdominis Plane (TAP) block as opposed to the traditional anesthetic epidural block. This approach has proven favorable as it is targeted rather than widespread, decreasing the impact on bowel and bladder function, and providing prolonged pain relief for up to 72 hours following surgery.

Further, the protocol also focuses on continued nutrition up to 2 hours prior to surgery, limits fluids given during surgery and uses a laparoscopic technique whenever possible for a smaller incision site, all of which help to improve patient satisfaction.

Following surgery, patients are mobilized and given solid foods as early as possible to facilitate the return to bowel function, and effective pain management is emphasized.

In the current crisis, the widespread use of these protocols has the potential to help turn the tide of the epidemic by eliminating a large percentage of post-surgical opioid prescriptions. The results speak to the success of these protocols and make a case for wider implementation by meeting each of these challenges head on, leading to real, measurable change that benefits both patient and practitioner.

Lisa A. Coleman, DO, FACS, FASCRS is a Colorectal Surgeon with TPMG General Surgery and Hernia Center. She is Board certified in Colon and Rectal Surgery and General Surgery.