The Enhanced Recovery After Surgery (ERAS) protocol is helping evolve spinal postoperative recovery, including better pain control, eliminating the need for IV pain medications, reducing opioids. These advancements allow your medical team to use the best data-driven practices to help patients mobilize after surgery, recover faster, and go home sooner. We’ll take a look at what ERAS means, from the experience of a spinal medical team at Reston Hospital Center, located in Reston, VA.
A Physician’s Perspective
ERAS is an innovative program designed to help educate patients, prepare them for surgery, and allow them to have a speedy recovery from their surgery so that they can resume their life activities expeditiously. We at the Virginia Spine Institute, in collaboration with Reston Hospital Center, have developed a tailored program for patients undergoing spine surgery.
Preparing for and undergoing spine surgery is analogous to training, completing, and recovering from a marathon. Before training for a marathon, a runner must undergo dedicated fitness training, nutrition program, and mental preparedness prior to a successful completion of a run. ERAS is meant to be a marathon training program that is used before, during, and after the marathon of surgery. Before undergoing spine surgery, intensive preparation must be done to ensure that preparation of the physical body is done – for example, proper nutrition and avoiding detrimental habits such as smoking or excessive drinking. As part of this preparation, educating patients on their expectations regarding the surgery and their recovery is critical.
In the morning of the surgery, the patient is given a cocktail of medications that help support the nerve and muscle function, minimizing the need of pain medications. In conjunction with our anesthesiologists, we also use local anesthetics to help reduce the need for pain medications during surgery, as well as after surgery.
In the recovery unit, patients are mobilized within two hours of surgery in order to start the function of their muscles and joints, which has been shown to help reduce the need for pain medications post-surgery. The patients are then placed on both long- and short-acting pain medications to help avoid the acute crisis of uncontrolled pain, reducing the risk of delayed recovery. Using this regimen, we have been able to avoid the use of Patient Controlled Analgesic (PCA) pumps, often referred to as “pain pumps”, which were found to be ineffective in controlling post-surgical pain control, even requiring more pain medications to be used when compared to the ERAS protocol.
The Virginia Spine Institute, in collaboration with the National Spine Health Foundation, has made great strides in innovation and research with regards to enhancing our patients’ recovery after spine surgery. We have evaluated how patients were doing before and after the program was instituted for both patients with smaller surgeries and larger, complex deformity surgeries. We were able to demonstrate tremendous decrease in pain medication need and usage in patients after spine surgery. We also found that patients were walking faster, and also able to return to home sooner. We have presented our findings at both national and international meetings where we have shared our findings with other national leaders in spine surgery.
A Nurse’s Perspective
As a Registered Nurse and Spine Navigator, my role is to help patients as they recover after spine surgery. Prior to a procedure, I reach out to patients in helping them prepare for and understand what to expect through their recovery process. Because this is a very anxious time for patients, reaching out and educating them on what can be expected helps reduce anxiety and provides them with a sense of comfort and control as they begin their recovery process.
Pain Relief
A patient is given a “cocktail” of medications that consist of a short- and long-acting pain medication, muscle relaxers, and Tylenol. These medications are given on a scheduled basis throughout the stay. Giving the medication prior to surgery allows for a “jumpstart” on the pain management. Because patients may or may not have already been using narcotics, we devised a formula for “narcotic tolerant” patients (those that are used to taking narcotics on a semi- or regular basis) and “narcotic naïve” patients (those that have rarely taken any narcotics). We start with one of these two formulas and adjust based on the individual need of the patient. For example, if someone is too drowsy, we will go down on doses or take a certain medication out of the mix. If the patient is not getting adequate pain relief, then we increase the dosage or make a change in the medications. Patients are seeing the benefit of this multimodal regimen because it hits multiple receptors, providing greater relief than just using one medication alone. The use of oral medications, as opposed to intravenous allow for an easier transition for weaning down and eventually off of opiods, therefore reducing the instances of opioid addiction.
Faster Recovery
Prior to the multimodal regimen, patients would easily become over sedated since most of the time we were controlling their pain with heavy IV narcotics. There were various and often dangerous side effects from these IV narcotics, such as over sedation, confusion, nausea, and urinary retention, often preventing patients from walking like they needed to. In some cases where the medication was prohibiting a patient from eliminating waste, requiring a prolonged use of a catheter.
Now with this ERAS program and multimodal pain regimen put in place, patients recover in the postanesthesia care unit (PACU), then are taken up to the floor where the stretcher is parked in front of a recovery room. A physical therapist meets the patient and nurse and then assists the patient to walk into the room to the bed – just hours after surgery! This is considered the first evaluation of the patient’s mobility, which allows for physical therapist to address any potential issues more immediately. Patients are then encouraged to walk once or twice more that day, increasing the frequency of ambulation the day after and throughout their recovery. In addition to the medication regimen we have other therapies available such as ice, music, and pet therapy. Ice is offered and used on almost every patient. There are two TV channels in each patient’s room that have soothing music and nature sounds, along with comforting pictures that cycle through to help distract and calm patients. Pet therapy has grown in a short period of time; a trained dog is brought around in which patients can interact with if they like, also roviding great distraction from the pain. As we first introduced this regimen, you could mmediately see the difference in the patients. Many would remark that their pain was better controlled because the oral medications last longer as opposed to a pain pump, which rarely provided steady relief, often leading to spikes in pain, disturbing a patient’s sleep throughout the night – a critical component to recovery. With the oral medications, we see patients getting 4-6 hours of relief at a time, leading to better sleep, more frequent ambulation, and overall faster recovery. It is clear that the more mobile a patient is after surgery, the quicker they go home, less pain they have, and more satisfied they are with their overall post-operative experience. The frequent ambulation also greatly reduces complications, such as pneumonia and blood clots.
Thanks to ERAS, we are able to get patients better, faster, and see a reduction in hospital lengths of stay, immediate and more frequent ambulation, reduced time with a catheter, better sleep, and overall greater patient satisfaction. Enhanced recovery after surgery will continue to evolve, providing patients with more comfort and control during their recovery
