Reducing Length of Stay Through ERAS Protocols

Raoul Concepcion, MD: John, from an anesthesia standpoint, we talked over and over about this over the years—standardization. There’s 2 things, obviously, where anesthesia has a huge role: the type of anesthesia, as well as intraoperative, perioperative, and postoperative analgesia. Can you comment on those for us?

John Dalton, MD: Right. We get an opportunity to evaluate patients from all specialties—surgical specialties and, really, even outpatient. Traci did a really nice job of outlining the basic tenets. We’re talking about big operations, but we see the same problems even in outpatient surgery. If we could apply these principles in all surgeries and decrease ileus, or nausea and vomiting (that’s how we measure in anesthesia—it’s just postoperative nausea and vomiting), we can impact length of stay not only for inpatient but also outpatient surgeries and increase throughput.

We touch every phase of surgical care. There are things we need to do preoperatively, and we need to do those in a standardized fashion based on what’s best for the patient and the literature, not based on the fact that you and I trained at different places. So, we try to apply standardization to the preoperative phase, the risk stratification, the intraoperative course—as mentioned, there is pain management there, as well as fluid therapy that we need to pay attention to—and then, postoperatively we try to make sure that we reduce the use of narcotics as much as possible throughout. Different procedures require, or are amenable to, different regional techniques. But injections or subfascial catheterization, which really takes collaboration between anesthesia and the surgeons, has to be collaborative all the way through the process.

Raoul Concepcion, MD: John, let’s talk a little about epidurals. Are there particular cases, or particular specialties, where epidurals (because, again, there is obviously a cost associated with placing an epidural as well as the maintenance and use postoperatively) show a clear benefit for use versus not using an epidural?

John Dalton, MD: I think you and I had experience early on, a number of years back, with epidurals for prostatectomies and so forth. At that time, we decreased length-of-stay. We were going from a couple of weeks and cutting a couple days off of it. We thought we were really doing a good job. As it turns out, over the years, we found that the narcotics we were putting in the epidurals were actually causing ileus in some patients. It was not as much as if we gave a big slug of IV, but it was still causing some ileus. So, we’ve gotten away from epidurals in most specialties. Probably, the specialty we continue to do epidurals in is thoracic surgery. We’ve gotten away from narcotics there, as well. It’s mostly just an infusion of local anesthetic, sometimes with very, very low concentrations of a narcotic.

Raoul Concepcion, MD: Sanjay, what are you seeing? What about open versus laparoscopic, versus robotic cases? I know you’re very talented and well-versed in all.

Sanjay Patel, MD: When I was training, it was a time when robotic surgery was getting big. I had a little mix of open and robotic and, fortunately, I got trained in both. I now lean more toward the robotic approach, especially with cystectomies and in doing intracorporeal urinary diversions. From a pain standpoint, the pain is significantly less. The incisions are smaller. That’s pretty apparent. I think the patients, overall, functionally recover better. I think that the extra time you spend in the operating room (doing it minimally invasively) translates in a postoperative period to better recovery with less readmissions. Certainly, I’m seeing less wound-related complications. I do think that contributes to it, but I think it’s a multifactorial thing. It’s one component of many things that are involved. I also think that you do manipulate the bowel less. We do cystectomies in steep Trendelenburg position, and I only really grasp the segment of bowel that I’m using. I’m not tacking it back and forth and handling it a lot. That has been shown to potentially increase the ileus rate. It hasn’t been studied super well. It’s hard to study that, but I think all that matters. And I think those little incremental things translate, down the road, to a quicker overall recovery.

Raoul Concepcion, MD: It’s interesting. As we move into this arena of metrics, which physicians have never been forced to do, it’s the standard joke. You can ask a surgeon who the 3 best surgeons in his area are. He doesn’t mind. He can always name himself. He just can’t think of the other 2. We know that’s always the case. We’ve talked about technique, robotic, laparoscopic, and open. We’ve talked about, again, minimization of handling of the bowel, epidural, and trying to decrease the use of opioids. We’ve briefly touched about which became popular. Is there anything that you can do, preoperatively, that is built into all of your protocols?

Sanjay Patel, MD: Yes. I think we started working on this. There’s a big push for prehab—prehabilitation. Once we got our basic framework for an ERAS pathway, we started really focusing on the earlier aspect of it, which is educating the patient. I think this has been the biggest thing that changes everything. A patient knows exactly why they’re supposed to do it, and I think that matters a lot. But also, optimizing their nutrition.

In patients whom I operate on for cystectomy, the median age is 70. They’re smokers. They have a lot of comorbid conditions. They’re not the healthiest people right out of the gate (from a surgical candidate standpoint). And so, we get them set up with the nutritionist. We’re fortunate we have one on the floor below us. Logistically, it is easier. They sign up for surgery, they meet the nutritionist, and they also meet a physical therapist. We’re trying to work on finding out a way to assess how many steps they do, or measure some activity pre-surgery, and we try to motivate them to get back to that level after surgery. I think all of that education really helps. We have really good physical therapists, and they always talk about how it’s like Rocky. They’re going in for their big fight. “You’ve to get yourself ready for the big fight,” which is a big surgery. I think this is very true. You’ve got to optimize not just the physical aspect, but also the nutrition aspect.

Raoul Concepcion, MD: I think that’s a point well made. I don’t have any data to support this, but I bet that there is probably less litigation when you match patients' expectations and outcomes—when they know exactly what “this” is and why we’re doing things. If they have an understanding of that (as opposed to them just going in blind where we say, “Hey, sign the consent form. You’re getting this operation.”). Right? That’s a great point—prehabilition.

John Dalton, MD: I write a lot about it in educational materials, and I can’t get my spell checker to leave that one alone.

Raoul Concepcion, MD: Exactly.

John Dalton, MD: It’s not a thing yet.

Transcript edited for clarity.