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Published on November 04, 2019

Hospital Broadens Enhanced Recovery After Surgery Program

ERAS Pain Management

Under ERAS, TAP blocks and local anesthetic, IV acetaminophen, gabapentin and nonsteroidal anti-inflammatory drugs reduce patient narcotic requirements. This translates into advantages in the timing of when patients consume food and drink liquids, which are:

  • Six hours before surgery: Eat solids and drink liquids
  • Three hours before surgery: Drink clear electrolytes
  • Immediately after surgery: Eat food and drink liquids

Since implementing an enhanced recovery after surgery strategy with five patients in February 2018, NKCH has grown the program to an average of 180 ERAS patients per month.

The evidence-based perioperative care strategy brings patients to normal function earlier than current standards by minimizing the use of narcotics for pain management, optimizing preoperative and postoperative nutrition, and promoting early mobility after surgery.

Launched with colorectal surgery the ERAS program at NKCH now includes bariatric, general, gynecologic, spinal, orthopedic and urologic surgeries.

Improved Recovery

Stephen L. Reintjes Jr., MD, a neurosurgeon with Meritas Health Neurosurgery, was an early adopter of ERAS. He joined NKCH in August 2018 and began performing spinal surgeries under ERAS the following October. Today, he averages 22 ERAS spinal cases each month, in addition to performing non-ERAS brain surgeries.

“Most of my elective spinal surgery patients, whether they have a deformity, a bulging disc or a tumor, go on the ERAS protocol,” Dr. Reintjes Jr. said.

The average length of stay for his patients on ERAS is 1.75 days. In his residency and fellowship training, where ERAS was not used, a lumbar decompression surgery or fusion surgery meant hospital stays lasting a few nights and a week, respectively.

“During my fellowship, patients required IV narcotics and needed patient-controlled anesthesia postoperatively,” Dr. Reintjes Jr. added. “That’s not needed at North Kansas City Hospital. Our patients don’t have as much pain as non-ERAS patients, so they have less use for postoperative narcotics. Because they typically don’t require catheterization, they don’t experience urinary retention. Our patients get up sooner, move faster, feel better
and go home sooner.”

A systematic review of the use of ERAS strategies after spine surgery, published in the April 2019 issue of the Journal of Neurosurgery, looked at 20 full-text articles. The studies demonstrated reduced lengths of stay and no increase in rates of readmissions or complications. The authors concluded the studies demonstrated the potential of ERAS protocols, when applied to spinal procedures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain and save costs.

Fasting for 8-12 hours prior to surgery has been the standard in delivering anesthesia, but ERAS patients do not need to fast as long.

“By collaborating with our anesthesiologists, we can get patients through the perioperative period with a reduced fasting period,” Dr. Reintjes Jr. said. “Patients cannot heal very well on an empty stomach. This is also important for our patients with diabetes because we don’t want their blood sugars to go too high or too low.”

Patient Buy-In

David D. Paul, DO, an orthopedic surgeon with Orthopedic Surgeons Inc., said most patients, after learning about the ERAS program, buy into the concept. Prior to implementing ERAS, he found patients focused mentally on preparing for post-surgery pain management.

“When we discuss ERAS, they may initially express shock at the thought of a speedy release from the hospital,” Dr. Paul said. “However, they quickly get on board after they attend the pre-surgery conditioning classes. They realize they will have less pain (knee surgery patients go home with a non-narcotic peripheral nerve block), recover more quickly and feel better sooner, so they become more involved in their care. Post-surgery, I frequently hear patient stories about their friends who were hospitalized seven days and struggled afterward. My patients often
say, ‘I’ve done so much better than my friends.’”

ERAS also has caught on by word of mouth. “Patients come in and actually ask for ERAS now because they have friends who had good experiences under ERAS,” Dr. Paul added.

Staff Support

Both surgeons said they appreciate how nursing and physical therapy staff help keep ERAS patients on track.

“They are major players,” Dr. Paul said. “Nurses are with patients a lot more than I am after surgery. It’s important they make sure patients get up and moving. Physical therapists play a big part because patients must have therapy before they are discharged. They are doing a great job here.”

For Dr. Reintjes Jr., early patient ambulation is a mainstay. “Our nursing and therapy staff excel at quickly getting patients up and moving,” he said. “My patients who have had prior back surgeries with lengthy hospitalizations don’t remember their previous hospital stays because such high doses of narcotics were required to control their pain, whereas now they come back and say, ‘It was a really pleasant experience, and my nurses and therapists were great.”

David Paul, D.O.David D. Paul, DO

Dr. Paul earned his medical degree from Kansas City University of Medicine and Biosciences, where he completed his residency in orthopedic surgery.

Stephan Reintjes Jr.Stephen L. Reintjes Jr., MD

Dr. Reintjes Jr. earned his medical degree from the University of Missouri. During his neurosurgery residency at the University of South Florida, he completed a one-year neurosurgery fellowship in epilepsy surgery at the college and a one-year complex spine and skull base fellowship at the Swedish Neuroscience Institute in Seattle.