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Implementing an Enhanced Recovery Pathway in Microvascular Breast Reconstruction Minimizes Narcotic Use and Shortens Length of Stay
Juan L. Rendon
Roman Skoracki
Michael J. Miller
Michelle L. Humeidan
The Ohio State University Wexner Medical Center
2018-02-14
Presenter: Juan L Rendon
Affidavit:
I certify that the material proposed for presentation in this abstract has not been published in any scientific journal or previously presented at a major meeting.
Director Name: Gregory Pearson
Author Category: Resident Plastic Surgery
Presentation Category: Clinical
Abstract Category: General Reconstruction
Purpose
A multidisciplinary enhanced recovery pathway (ERP) was implemented to minimize narcotic use, optimize intraoperative fluid management and shorten time to diet advancement and ambulation at the James Cancer Center. Herein, we report initial outcomes.
Methods
We retrospectively reviewed consecutive microvascular breast reconstruction patients from six surgeons following implementation of an ERP that includes: preoperative doses of acetaminophen, gabapentin, oxycodone, and scopolamine; intraoperative maintenance of euvolemia, minimization of narcotics, ketamine administration, and placement of bupivacaine elastomeric pain pumps; postoperative oral diet, mobilization, and scheduled acetaminophen, ibuprofen and gabapentin starting POD 0. A number of parameters were reviewed.
Results
In the first 6 months following implementation of an ERP, 60 patients underwent microvascular breast reconstruction: 42 immediate and 18 delayed reconstructions, 38 unilateral and 22 bilateral reconstructions. Median age 50 ± 10 years, BMI 30.1 ± 5.73 kg/m2. Comorbidities included: HTN 15(25%), DM 4(7%), active smokers 3(5%) and previous smokers 11(23.4%). Seven (12.0%) required neither IV nor oral opioids after discharge from recovery. Only one patient required patient controlled analgesia. Thirty-nine (65%) patients were discharged home on POD3, 17(28%) patients on POD4, and 4(6.7%) patients on POD5 (all 4 required delayed flap inset due to partial mastectomy skin necrosis). There were no significant complications.
Conclusions
Our initial outcomes demonstrate that a multi-disciplinary approach facilitates implementation of an ERP that is safe and effective in microvascular breast reconstruction patients. Overall, our ERP reduces narcotic pain medication requirements and ultimately results in shorter lengths of stay.
