Abstract P1-20-08: Breast surgery ERAS program: Trends since implementation on post-operative pain and discharge narcotic prescribing at our institution
Authors: Woodfin Ashley A , Ramirez Emily , Coogan Alison , Mehta Nehl , Antony Anuja K , Shenaq Deana , Hood Keith C , O'Donoghue Cristina , Perez Claudia , Alvarado Rosalinda , Madrigrano Andrea 
Published: March 2020

Introduction: Recently, enhanced recovery after surgery (ERAS) pathways have been gaining popularity within surgical sub-specialties. Key ERAS concepts include the standardization of perioperative care such as pre-operative counseling, protocolization of analgesia and anesthesia regimens as well as early mobilization, among others. This approach aims to achieve cost savings through decreased length of stay, reduced opioid complications, and overall improved outcomes. In concordance with this trend, many institutions are now implementing ERAS protocols for breast surgery, especially with cases of mastectomy followed by immediate reconstruction. Our institution implemented a Breast Surgery ERAS program in February of 2018, consisting of standardized peri-operative analgesia/anesthesia, most significantly including a pre-operative pectoral block performed by anesthesia. We hypothesize that the use of the pre-operative pectoral block in the ERAS cohort will result in improved post-operative pain scores from the Non-ERAS cohort; additionally, we expect that the percentage of patients requiring opioid prescriptions at discharge for pain control will be decreased in the ERAS cohort.

Methods: The EMR was queried for patients who underwent breast surgery with immediate reconstruction. The experimental group consisted of ERAS patients from February 6, 2018 to February 1, 2019 with an n = 107. The control group consisted of non-ERAS patients from April 19, 2016 to January 30, 2018 with an n=117. Chart review was performed for discharge medications, as well as pain scores recorded from time immediately post-operative, to just prior to discharge. Statistical analysis of the data was performed with a comparison of difference in means and Fischer exact test.

Results: The ERAS cohort was noted to have a statistically significant decrease in the mean immediate post-operative pain scores (ERAS 2.04, Non-ERAS 4.04; p-value &lt; 0.0001). There was no difference with comparison of the means of last pain scores recorded prior to discharge between the ERAS and Non-ERAS groups (ERAS 3.36, Non-ERAS 3.63, p-value 0.34). There was a statistically significant decrease in the percentage of patients discharged with opioid prescriptions in the ERAS group compared to the Non-ERAS group (ERAS 58.9% v 87.2% Non-ERAS; p-value &lt;0.0001). The ERAS cohort LOS was also statistically significantly less than the Non-ERAS (ERAS 1.28 days, Non-ERAS 1.61 days; p-value = 0.0002).

Discussion: Our ERAS protocol utilizes multi-modal pain control methods beginning pre-operatively, including the addition of a pectoral block placed by anesthesia, which we expect contributed highly to the lower mean immediate post-operative pain scores expressed by the ERAS cohort. This is important in the context of our nation’s current opioid epidemic, where decreasing discharge opioid prescriptions is imperative for reducing the risk for development of addictive behaviors, as well as the risk for opioid side effects such as nausea, constipation, and altered mental status. With the implementation of our Breast Surgery ERAS program, we have demonstrated clear progress towards this goal with the hope for continued improvement.

Citation Format: Ashley A Woodfin, Emily Ramirez, Alison Coogan, Nehl Mehta, Anuja K Antony, Deana Shenaq, Keith C Hood, Cristina O'Donoghue, Claudia Perez, Rosalinda Alvarado, Andrea Madrigrano. Breast surgery ERAS program: Trends since implementation on post-operative pain and discharge narcotic prescribing at our institution [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-08.