Putting ERAS to Work in Spine
As for Dr. Soffin, she always has the fundamental question in mind, “What are the gaps in our knowledge or willingness that are preventing us from providing the highest-level of care on a consistent basis, and how can ERAS help us do better?”
“In spine surgery we have been late to the party with regard to ERAS. I think this is partly because the evidence base is somewhat underdeveloped to guide us in choosing ERAS components that may benefit spine surgery patients.”
But now that ERAS is gaining traction in the orthopedic arena, there is no going back. Patients will begin asking for it.
Dr. Soffin, also a co-investigator on these studies, told OTW, “It’s no accident that the first component of an ERAS pathway is usually patient education, something that starts when the decision is made to proceed with surgery. These protocols may be anesthesia-driven, but surgeons have a huge opportunity to introduce the concept of recovery. Patients are informed early and often how they can take control of their recovery process.”
“In many cases, the physical therapist meets with patients in advance of surgery.”
“We have formal preoperative classes that are mandatory for joint replacement (not for spine at the moment).”
“Nutrition is also part of the protocol. Professor Kehlet hypothesized that if patients fast after midnight before an elective procedure then they are presenting the OR in a catabolic state, which is not optimal for recovery. Healing and tissue repair depend on an anabolic state. We advocate for a safe, shorter fast of approximately four hours depending on the surgery. Our work has shown that early, postoperative oral nutrition is beneficial, thus we allow patients to eat in the recovery room whenever they are ready. Our ongoing research indicates that early oral nutrition is driving patient satisfaction…and indeed the quality of the recovery does appear to be superior when this aspect of the protocol is followed.”
The Key Is Pain Management and the Anesthesiologist
Dr. Soffin notes, “One major complication that impedes recovery is pain. If you are incapacitated by pain then you cannot work with physical therapy. Postoperative immobility is too often followed by respiratory compromise and thromboembolic events. And to treat the pain, opioids have so many side effects (constipation, nausea, vomiting, sedation, respiratory depression, etc.).”
“The reason anesthesiologists are so well poised to advance ERAS is that we have the tools to address pain, namely regional analgesia, peripheral nerve blocks, and multimodal analgesia.”
So where should a hospital start if it wants to embark on an ERAS pathway?
Dr. Soffin says, “The perceived wisdom says that you start locally to show benefits, and then approach the hospital administration. Find the key champions who will propel the effort forward. Show them what our team of committed anesthesiologists and surgeons has done using ERAS for spine at our facility.”
“Go to the literature and uncover evidence for the components of care that work. There are now even major societies such as The ERAS Society and The American Society for Enhanced Recovery that have a wealth of resources on how to construct and implement an ERAS pathway.”
The future looks promising for these evidence-based protocols, says Dr. Soffin. “Virtually every study published to date has obtained results indicating that ERAS definitely improves outcomes, reduces LOS, and enhances patient care. By using the best available medical science to craft a reproducible experience we can offer patients the most up-to-date and high-quality recovery available.”
