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Enhanced Recovery Protocol after Fronto-Orbital Advancement Reduces Blood Transfusions, Narcotic Usage and Hospital Length of Stay
Rebecca Knackstedt MD, PhD; Niyant Patel MD
Cleveland Clinic
2020-01-31
Presenter: Rebecca Knackstedt
Affidavit:
I agree
Director Name: Steven Bernard
Author Category: Resident Plastic Surgery
Presentation Category: Clinical
Abstract Category: Craniomaxillofacial
Introduction
Enhanced recovery after surgery (ERAS) protocols utilize multi-modal approaches to decrease morbidity, narcotic usage and length of stay. In 2013, we made several changes to our peri-operative approach to children undergoing complex craniofacial procedures. The goal of this study is to analyze our protocol for children undergoing fronto-orbital advancement (FOA) for craniosynostosis.
Methods
A retrospective chart review was performed after IRB approval for children who underwent FOA for craniosynostosis from 2010-2018. The ERAS protocol involves hemoglobin optimization, cell-saver technology, tranexamic acid, specific post-operative fluid titration and a transfusion algorithm. The analgesic regimen focuses on narcotic reduction through the utilization of scheduled acetaminophen, ibuprofen or ketorolac, and a dexmedetomidine infusion with opioids only for breakthrough pain.
Results
Fifty-five ERAS protocol children and 23 control children were analyzed. ERAS children had a decreased rate (13/53 versus 23/23, p=0.05) and volume of intraoperative transfusion (183.4cc versus 339.8cc, p<0.0001). Fewer ERAS children required morphine/dilaudid (12/55 versus 22/23 p<0.0001) and for children who required morphine, fewer doses were required (2.8 versus 11, p=0.02). For ERAS protocol children who required PO narcotics, fewer doses were required (3.2 compared to 5.3, p=0.02). ERAS children had a decreased length of stay (2.3 versus 3.6 nights, p<0.0001). No patients were re-admitted due to poor oral intake, pain, hemodynamic or pulmonary concerns.
Conclusion
Our ERAS demonstrated a reduction in overall and intraoperative allogenic blood transfusion rate, narcotic use and hospital length of stay. This is a safe and effective multimodal approach to managing complex craniofacial surgical recovery.
