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Ongoing optimization of enhanced recovery after thoracic surgery protocol to mitigate postoperative pain with least opioid utilization following robotic pulmonary resections.
Daniel J. Gross, Alex Chacone, Nestor R. Villamizar, Dao M. Nguyen.
University of Miami, Miami, FL, USA.

OBJECTIVE:Our ERATS protocol was implemented on 2/1/2018. While ERATS was associated with significant reduction of postoperative pain and opioid use, there was room for improvement. We initiated systematic, sequential adjustments of our protocol to further decrease postoperative pain and opioids needs by modifying the local anesthetic agents used for intercostal nerve block (ICNB). This study aims to summarize our results.METHODS:We retrospectively analyzed our prospectively maintained robotic thoracoscopy database between 1/1/2017-10/31/2021. The pain management component of ERATS includes scheduled non-opioid analgesics, intraoperative ICNB with local anesthetic (long-acting liposomal bupivacaine (LipoB) 1:1 dilution with normal saline (ERATS-V1) or 0.5% bupivacaine + 1:200,000 epinephrine (ERATS-V2) or LipoB + 0.25% bupivacaine (ERATS-V3), surgical wound infiltration), PRN narcotics and tailoring post-discharge opioid prescription based on in-hospital utilization. Demographics, clinical details, postoperative outcomes, subjective pain measure and total post-operative opioid utilization were recorded.
RESULTS:Our study cohort included 750 patients (126 pre-ERATS, 147 ERATS-V1, 135 ERATS-V2, 342 ERATS-V3). There were no differences in demographics, clinical characteristics or resection types by grouping. ERATS was associated with reduced postoperative complications, most pronounced in ERATS-V3 (6.2% versus pre-ERATS 17.6%, p=0.001). Compared to pre-ERATS cohort, ERATS patients reported significantly less pain and 1.5-fold to >10-fold reduction of post-operative opioid use with the ERATS-V3 protocol provided the most pronounced opioid-sparing effect. Under 40% ERATS-V3 patients required an opioid prescription at discharge (100% of pre-ERATS and 80% of earlier ERATS patients, p<0.0001). CONCLUSIONS:The ERATS-V3 protocol was the most efficient in reducing postoperative pain and opioid consumption in patients undergoing robotic pulmonary resections.


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