Colorectal ERAS: the impact of unique updates in opioid administration
Ming Cai*, Jessica R. Henkin, Sara W. Mayo
Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
Objective: To implement a quality improvement project utilizing novel routes of opioid administration within a colorectal enhanced recovery after surgery (ERAS) protocol and to measure the effects of this intervention by evaluating inpatient postoperative opioid exposure and opioid prescriptions at time of discharge.
Design: Quality improvement project developed through multidisciplinary collaboration with anesthesia pain team.
Setting: Inpatient colorectal surgery service at an academic quaternary care referral center.
Patients: All patients undergoing elective colorectal resections were included (39 pre-intervention July-September 2022 and 37 post-intervention October-December 2022).
Interventions: We created a revised postoperative order set utilizing subcutaneous hydromorphone as the preferred route of administration, replacing intravenous hydromorphone. Nursing staff received education regarding the pharmacokinetic rationale for these changes, as well as the importance of multimodal pain management within an ERAS protocol.
Main Outcome Measure(s): We measured opioid use in the immediate postoperative period and by the proportion of new opioid prescriptions at time of discharge.
Results: The mean morphine milligram equivalents (MME) given during the immediate postoperative period was 24.5 pre-intervention vs. 18.0 post-intervention. The proportion of patients prescribed opioid medications at discharge decreased from 41.0% to 21.6% pre- to post-intervention. The number of patient phone calls, emergency room visits, and 30-day readmissions did not significantly change between the two periods.
Conclusions: Changing the route of opioid administration is beneficial in reducing overall opioid use when implemented through a multidisciplinary team education program. We observed a decrease in opioids given during the immediate postoperative period, as well as opioids prescribed upon discharge. Both measures are below the national averages previously reported for colorectal surgery patients.
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