A new study shows that adults in San Diego who went through open inguinal hernia repair experienced reduced post-op pain. Besides, they made fewer visits to the emergency room when the hospital staff adhered to a standard clinical protocol prior, during and post surgery.
The protocols for Enhanced Recovery After Surgery (ERAS) are usually discussed and mostly applied in hernia repair, even though few published studies show what works effectively and how. Most of the information on ERAS emanates from colorectal surgery with the focus being on the length of stay at the hospital and re-admission.
However, the most unusual aspect of this study is that it centers around hernia repair, and instead of looking at re-admission, it looks at the unplanned visits. In the study’s analysis, the most influential ERAS elements are patient education before the surgery and monitored anesthesia care (MAC).
• First efficiency protocol in 2011 – Surgeons, nurses and anesthesiologists developed an efficiency protocol specifically for ambulatory surgery in Kaiser Permanente Southern California region. Their objective was to reduce time spent by patients at the facility. Although this led to over 50 percent drop in time that patients spent at the hospital, the staff was worried that patients could be re-admitteddue to nausea and post-op pain, or they would make more visits to the ER.
• Refined program – So the health professionals refined the program and devised an eight-element bundle based on the best practices and well-known ERAS protocols. Preoperatively, it included patient education, prescriptions, and the need for patients to carb-load prior to surgery. Preoperatively, patients were given analgesia with meloxicam or ketorolac IV, gabapentin and acetaminophen, and MAC, or local anesthesia along with regional and field blocks. The amount of intravenous fluids was below 500 ml. After operation, analgesia was continued and patients received a follow-up call within 72 hours.
During the study period, 2,390 patients went through open inguinal hernia repair and:
• Only 6 percent of patients received all of the protocol’s elements
• 5.6 of the 8 elements were conducted for each patient
• The most completed steps include preoperative prescriptions and education, at 95 percent
• 89 percent of patients received multimodal analgesia
• 38 percent had MAC anesthesia
• Only 24 percent received limited IV fluids
• The 150 people who received the eight elements experienced less post-op pain and their likelihood of returning to the hospital for urgent care was 80 percent.
Two important aspects: Researchers discovered two essential elements of the protocol – patient education and use of MAC rather than general anesthesia. Patients who got preoperative education had a higher chance (60%) of not returning to the emergency department.
On the other hand, MAC lowered the scores of post-anesthesia care unit (PACU) by 1.43. It resulted in a 66 percent lower risk that patients would go back to the emergency department to seek pain control.