Using an Enhanced Recovery After Surgery (ERAS) guided Multimodal Pathway to Reduce Opioid Consumption in Lumbar Spine Surgery

Using an Enhanced Recovery After Surgery (ERAS) guided Multimodal Pathway to Reduce Opioid Consumption in Lumbar Spine Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using an Enhanced Recovery After Surgery (ERAS) guided Multimodal Pathway to Reduce Opioid Consumption in Lumbar Spine Surgery La Donna Brown, Michelle Ardisson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3816877/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Spinal pathologies are increasingly prevalent among the aging population in the United States, leading to back pain as a common reason for adults seeking emergency care and necessitating surgical interventions. Lumbar and spinal fusions have been associated with high rates of opioid use, contributing to the opioid public health crisis. Enhanced Recovery After Surgery (ERAS) protocols have successfully reduced complications and hospital length of stay (LOS) across various surgical specialties, but their potential in spine surgery remains unexplored. The primary aim of this quality improvement project was to assess the impact of an ERAS multimodal pathway on opioid consumption rates in patients undergoing lumbar spine surgery. Methods: Patients undergoing lumbar spine surgery were included between August 30 and September 30, 2017 (PRE-ERAS Group n=12) and August 30 and September 30, 2018 (POST-ERAS Group n=13). Before the implementation of ERAS, there was no consistent use of multimodal pain modalities. The new ERAS multimodal pathway included non-opioid medications such as Acetaminophen, NSAIDs, gabapentinoids, and local anesthetics. Data were collected from electronic medical records, including demographics, intraoperative opioids, PACU LOS, pain scores, and opioid consumption in the recovery room until discharge. Results : Implementing an ERAS multimodal pathway was associated with significantly lower postoperative pain scores (p = .003) and a trend towards decreased patient opioid administration dosages( p =.22). Post-operative nausea and vomiting (PONV) scores were zero in both PRE- and POST-ERAS groups, while postoperative LOS increased ( p =.02) in the POST-ERAS group. Conclusion: Implementing an ERAS multimodal pathway is associated with improved pain scores and may reduce opioid consumption in elective lumbar spine surgery. Multi-modal analgesia postoperative pain ERAS pathway spine surgery Figures Figure 1 Figure 2 Figure 3 Introduction Spinal pathologies are increasingly prevalent among the aging population in the United States (1) Back pain is a leading cause of adults seeking emergency care, often necessitating surgical intervention, ranging from minimally invasive lumbar spine to complex reconstructive procedures (1,2) . Lumbar and spinal fusions have been associated with high rates of opioid use, with 88% of patients reporting significant postoperative pain following spinal procedures (2) . Uncontrolled pain after surgery has been linked to prolonged hospital stays, increased opioid consumption, and a higher incidence of postoperative nausea and vomiting (3) , negatively affecting patients' physical, social, and emotional well-being. The opioid public health crisis underscores the urgency for healthcare providers to explore alternative pain management strategies. Opioid consumption was associated with a staggering 70% of fatal overdose cases in 2017 (1) . The Centers for Disease Control and Prevention (CDC) estimates that opioid misuse in the United States incurs an annual economic burden of approximately $ 78.5 billion. (4) Evidence supports multimodal analgesia (i.e., combining multiple drugs for pain control), such as NSAIDS, local anesthetics, and acetaminophen, has numerous benefits, including reduced opioid consumption as pain perception is addressed along diverse pain pathways, effectively enhancing pain relief (5) . Anesthesia providers have responded by emphasizing multimodal analgesia and adopting evidence-based practice pathways and Enhanced Recovery After Surgery (ERAS) protocols, including multimodal anesthesia, to improve perioperative care and patient outcomes. ERAS protocols have significantly reduced complications, hospital stays (30–50%), readmissions, and associated costs by mitigating the surgical stress response and reducing perioperative morbidity and hospital LOS (6–9) . Implementing ERAS pathway protocols has been associated with a decrease in the need for opioids in various surgical procedures such as colorectal, bariatric, obstetric, and gynecological surgery (9, 10–12) .Despite the successful application of ERAS in other surgical specialties, its potential to improve patient outcomes in post-operative spine surgery has been largely unexplored in the literature. Therefore, this quality improvement project aimed to assess the impact of an ERAS multimodal pathway on opioid consumption rates (defined as the absolute dose of opioid-classified medications administered in the postoperative period) in patients undergoing elective lumbar spine surgery. Secondary objectives included evaluating postoperative numerical pain scores, postoperative nausea and vomiting (PONV) incidence, and the length of stay in the Post-Anesthesia Care Unit (PACU) before and after ERAS implementation. Methods This quality improvement project occurred at an urban community hospital in Maryland following approval from The Vanderbilt University Medical Institutional Review Board. It aimed to evaluate the impact of implementing ERAS pathways, utilizing a "PRE-" and POST-ERAS implementation group observational design. The surgical cohort involved patients (age ≥ 18 years) undergoing lumbar spine surgery between August 30 and September 30, 2017 (PRE group n = 12) and August 30 and September 30, 2018 (POST group n = 13). The surgeries included discectomy, microdiscectomy, or one to two-level laminectomies. Patients with spinal deformities (i.e., scoliosis) were excluded. All patients underwent the following standardized pre-procedure protocol where they received Aprepitant (EMEND) 40 mg by mouth (PO) in the preoperative holding area. At this time, Celecoxib 400 mg and Gabapentin 300–600 mg PO were also administered. During surgery, all patients underwent induction with propofol (1-1.5 mg/kg intravenous [IV]), Fentanyl 50–100 µg IV, and rocuronium (0.6–1.2 mg/kg IV) prior to endotracheal tube placement and general anesthesia. Maintenance of general anesthesia was achieved with intravenous infusion of Propofol (75–100 mcg/kg/min), ketamine (0.1–0.3 mg/kg/hr), and 1–2% Lidocaine (1 mg/kg/hr). Fentanyl 25–50 µg IV boluses were administered as needed if indicated when blood pressure and heart rate increased. Ofirmev 1 gram IV was administered in the operating room before the surgical incision. Prophylaxis for nausea and vomiting included dexamethasone 8 mg IV (administered after induction of anesthesia) and ondansetron 4 mg IV (administered at the end of the procedure). Hydromorphone 0.2–0.5 mg IV was given as needed before the end of surgery and titrated according to the patient’s respiratory rate and breathing pattern Although ERAS protocols can be implemented as early as in the pre-surgical consult phase and continue post-discharge to the outpatient follow-up, this project evaluated ERAS implementation during the intrahospital period associated with spine surgery. The ERAS-guided multimodal pathway structuring the intrahospital pre-, intra-, and post-operative care will be referred to as “ERAS” throughout the manuscript. To address the aims of evaluating the effect of ERAS on opioid consumption rates, postoperative pain scores, PONV, and PACU length of stay in patients undergoing elective spine surgery, data was obtained from a review of electronic medical records. Demographic data (i.e., age, gender, race, smoker) and opioid consumption (i.e., the amount of opioid medications administered to patients postoperatively) were recorded simultaneously with pain scores. Opioid doses were then converted to oral morphine equivalents for normalization (13) and summed to define total postoperative opioid consumption rates. To quantify PONV, the number of times subjects reported incidences of nausea or vomiting in the postoperative recovery period was recorded. In addition, pain scores were quantified using the numeric rating scale (NRS) on the day of surgery upon arrival in the PACU. Postoperatively, pain scores were assessed every 2 hours using a verbal NRS, with 0 = no pain and 10 = worst pain. Acetaminophen 650 mg PO was given for mild pain (NRS 1–3). Oxycodone 5–10 mg, PO, every four hours as needed, was administered for moderate pain (NRS 4–6). Rescue analgesics included hydromorphone 0.5-1 mg IV boluses every 2 hours, as needed, for severe pain (NRS ≥ 7/10). Finally, PACU stay length was measured in minutes and hours from when they arrived in PACU until they were either transferred to an inpatient unit or Same Day Surgery Unit. A difference-in-difference analysis was carried out to determine the impact of the ERAS multimodal pathway on pain scores before vs. after surgery, comparing the groups before and after the implementation of the intervention. A Wilcoxon rank-sum test was implemented to determine the impact of the ERAS multimodal pathway on PACU minutes, comparing the groups' PRE and POST implementation of the ERAS multimodal pathway. Comparisons were indicated as statistically significant using a threshold of p < .05. Results Groups were similar in age, sex, race, and smoking status (Table 1 ) for demographics and clinical data). The median opioid dosage (measured in morphine milligram equivalents; mme) decreased from 15.5 (IQR: 2.4, 18.3) in the PRE-intervention phase to 7.5 (IQR: 0, 10.5) in the POST-intervention phase, although the difference was not statistically significant ( p = .22; Table 2 ) . The median PACU minutes were increased from 125 (IQR: 110.5, 192) in the PRE-intervention phase to 210 (IQR: 154, 316) in the POST-intervention phase ( p = 0.019) ( Table 2 ) . There were no reported PONV cases in either phase. Table 3 compares preoperative and postoperative pain reduction before and after the ERAS intervention. Pain scores decreased from 6.8 (SD 2.7) in the PRE-intervention phase to 5.5 (SD 3.4) in the POST-intervention phase, but the difference was not statistically significant ( p = 0.30). However, there was a substantial decrease in the mean pain score from 6.1 (SD 2.8) preoperatively to 2.6 (SD 2.4) postoperatively in the POST-intervention phase ( p = 0.003)— Table 1 Demographic characteristics of participants Characteristics Level Pre-ERAS Group Post-ERAS Group N 12 13 Age, mean (SD) 55.5 (13.3) 51.2 (7.9) Gender Female 6 (50%) 6 (46%) Male 6 (50%) 7 (54%) Race Asian 0 (0%) 1 (8%) Black 5 (42%) 5 (38%) Declined to answer 1 (8%) 1 (8%) White 6 (50%) 6 (46%) Smoker Former 0 (0%) 1 (8%) No 8 (67%) 7 (54%) Yes 3 (25%) 5 (38%) Missing 1 (8%) 0 (0%) Table 2 Time spent in the PACU and opioid consumption rates (morphine equivalents) pre- and post-intervention Factor Pre-ERAS Group Post-ERAS Group p-value N 12 13 Postoperative opioid dosage (mme), median (IQR) 15.5 (2.4, 18.3) 7.5 (0, 10.5) 0.22 PACU minutes, median (IQR) 125 (110.5, 192) 210 (154, 316) 0.019 PONV 0 (0,0) 0 (0,0) - Legend : mme: morphine milligram equivalents Table 3 Preoperative vs. postoperative pain reduction pre- and post-ERAS intervention Factor Pre-Intervention Post-Intervention Preoperative Postoperative p-value Preoperative Postoperative p-value N 12 12 13 13 Pain score, mean (SD) 6.8 (2.7) 5.5 (3.4) 0.30 6.1 (2.8) 2.6 (2.4) 0.003 Discussion The overarching goal of this quality improvement project was to evaluate the impact of an ERAS-guided multimodal analgesic pathway on opioid administrative rates, along with postoperative pain scores, PONV, and PACU length of stay in patients undergoing spine surgery PRE- versus POST-implementation. We showed that implementing an ERAS multimodal pathway for spine surgery in our institution was associated with a significant reduction (6.1 vs. 2.6, p = 0.003) ( Fig. 1 ) in postoperative pain scores, statistically insignificant but clinically significant (50%) reduction in opioid consumption rates ( Fig. 2 ). Pain associated with spine surgery is unique, as it is multifactorial and involves pain stimuli from multiple inputs. For example, nociceptive pain is caused by tissue damage, such as incisions made during surgery or retraction of muscles. In contrast, inflammatory pain results from releasing inflammatory mediators in response to tissue damage. Neuronal pain involves sensitization of the nervous system, which can cause hyperalgesia (14) . Therefore, postoperative pain may not be adequately controlled without considering these different inputs with pharmacologic pain management and the selection of medications for preoperative and intraoperative pain control. An ERAS multimodal pathway is beneficial for this level of pain as the term “multimodal” indicates a combination of non-opioid medications that target various receptors along the pain pathway and work synergistically to ablate the pain associated with each stimulus (15) . In this project, non-opioids included acetaminophen, NSAIDs, gabapentinoids, and local anesthetics. (15) Implementing an ERAS multimodal approach, in conjunction with opioid augmentation for pain control, yielded significant pain reduction in our surgical patient population. The effectiveness of multimodal pain control in reducing opioid administration rates has been consistently demonstrated in various studies investigating ERAS multimodal pathways across other surgical interventions, including bariatric, gynecology, colorectal surgery, and orthopedic surgery (16, 9) . A systematic review examining outcomes of multimodal pain management techniques reported that non-opioid adjuncts, including NSAIDs, Ketamine, and Dexmedetomidine, effectively lowered pain scores and total opioid requirements, even in complex cases ( 17–18 ). As our project focused on subjects undergoing lumbar spine procedures, this current manuscript contributes to the body of literature supporting the broad applicability and efficacy of multimodal ERAS pain management strategies ( 9 , 17 – 18 ). Also, it supports the utility of ERAS in elective spinal surgery. Another critical key component of multi-modal/ERAS-guided management pathways is that medications are given preemptively before surgical insult to the tissues (18–19) . When given before surgery, the administered medications prevent the hyperexcitability of the central nervous system (18) and can decrease postoperative pain. In the ERAS group, several medications, including Gabapentin, COX-2 inhibitors, and intravenous acetaminophen, were given pre-operatively and intraoperatively before the first surgical incision. In addition to assessing postoperative opioid administration rates and pain scores, our objective was to examine the impact of the ERAS pathway on two additional factors: PONV and the length of stay in the Post-Anesthesia Care Unit (PACU). PONV is a common side effect associated with opioid use. However, in our study, the PONV scores were consistently zero in both the pre-ERAS and post-ERAS implementation groups, indicating that PONV was adequately controlled prior to the implementation of the ERAS pathway. Nonetheless, we believe that the implementation of our ERAS multimodal pathway, which effectively reduced postoperative pain scores through the use of various techniques, has the potential to decrease PONV rates in other groups with higher incidences of postoperative nausea, as seen in prior research studies (20–22) where the implementation of ERAS multimodal pathways resulted in lower reported PONV rates. Nevertheless, it is important to consider that PONV might not be a reliable outcome measure in future ERAS studies involving lumbar spine procedures. It should be considered when designing future quality improvement projects within this patient population. In our specific patient group, we observed a significant increase in the length of stay in the PACU in the post-ERAS intervention group compared to the pre-ERAS group ( Fig. 3 ). This finding was unexpected since we initially anticipated that the length of stay in the PACU would mirror the rates of opioid administration and reported pain scores. The increase in PACU length of stay may be attributed to various factors, such as the unavailability of hospital floor beds leading to more patients being accommodated. As demonstrated in our study, these logistical issues are crucial considerations when planning future quality improvement studies, as they can affect outcome measures beyond the specific focus of the ERAS process. Importantly, future research should confirm the impact of ERAS-guided pathways on PACU length of stay. It is worth noting that while our QI project monitored patients for immediate PACU recovery, other studies followed patients for a more extended postoperative period (21,23) . Therefore, to validate the sustained improvement in opioid administration rates and postoperative pain scores, conducting future research that follows subjects for an extended duration after surgery would be beneficial. Conclusion Implementing an ERAS multimodal pathway significantly alleviated pain and reduced opioid consumption for patients undergoing lumbar spine surgery. As both uncontrolled postoperative pain and high opioid consumption rates have the potential to increase the risk of complications and negatively impact patient outcomes, the benefits of ERAS should be considered for all patients undergoing elective spinal surgery. The clinical findings of this project also highlight the growing significance of multimodal pathways in surgery, although they have yet to become the standard of careERAS is a valuable tool for improving outcomes associated with lumbar spine surgery. The involvement of an interdisciplinary team is crucial for the success of projects like this, as it requires collaboration and support from various stakeholders, including pharmacy, surgeons, and nursing staff. Overall, this quality improvement project highlights the importance of using multimodal anesthesia in ERAS pathways to reduce postoperative pain and opioid consumption in hopes of reducing postoperative complications and increasing patient long-term outcomes. Abbreviations ERAS Enhanced Recovery After Surgery LOS Length of Stay PACU Post-Anesthesia Care Unit PONV Postoperative Nausea & Vomiting IRB Institutional Review Board BIS Bispectral index TIVA Total Intravenous Anesthesia PO By Mouth PRN As Needed NRS Numeric Rating Scale QI Quality Improvement Declarations Conflict of Interest : The author(s) declared no potential conflicts of interest for this article's research, authorship, and/or publication. Funding : Not Applicable Acknowledgments : Not Applicable Author Contributions Statement : LB contributed to the design, collection, and analysis of data, preparation, and manuscript drafting. MA contributed to the design and editing of the project draft. All authors read and approved the final manuscript. Availability of Data and Materials : The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request. Consent for Publication : Informed consent[MK([1] was waived by the University of Vanderbilt University Medical Center Institutional Review Board as this was a quality improvement project where de-identified patient data were collected. Ethics : This quality improvement project was approved and categorized as exempt by the Institutional Review Board (IRB) of Vanderbilt University Medical Center in Nashville, TN. Informed consent was waived by the University of Vanderbilt University Medical Center Institutional Review Board as de-identified patient data were collected. All methods were performed using the relevant guidelines and regulations. [MK([1]This is redundant but I think they are funny about these sections so it might be good to list this again here References Berardino, Kevin, et al. “An Update on Postoperative Opioid Use and Alternative Pain Control Following Spine Surgery.” Orthopedic reviews vol. 13,2 24978. 22 Jun. 2021, doi:10.52965/001c.24978 Gan, T. J. (2017). Poorly controlled postoperative pain: prevalence, consequences, and prevention. Journal of Pain Research, Volume 10, 2287-2298. doi:10.2147/jpr.s144066 Santa Cruz Mercado, Laura A., et al. “Association of Intraoperative Opioid Administration with postoperative pain and opioid use.” JAMA Surgery , vol. 158, no. 8, 2023, p. 854, https://doi.org/10.1001/jamasurg.2023.2009. Centers for Disease Control and Prevention (CDC). 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Bhatia, Alisha, and Asokumar Buvanendran. “Anesthesia and postoperative pain control-multimodal anesthesia protocol.” Journal of spine surgery (Hong Kong) vol. 5,Suppl 2 (2019): S160-S165. doi:10.21037/jss.2019.09.33 Xu, Siqi, et al. “Effects of Lidocaine, Dexmedetomidine, and Their Combination Infusion on Postoperative Nausea and Vomiting Following Laparoscopic Hysterectomy: A Randomized Controlled Trial.” BMC Anesthesiology , vol. 21, no. 1, 4 Aug. 2021, https://doi.org/10.1186/s12871-021-01420-8. Apfel, Christian C et al. “Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis.” Pain vol. 154,5 (2013): 677-689. doi:10.1016/j.pain.2012.12.025 Siu, Eric Y, and Tiffany S Moon. “Opioid-free and opioid-sparing anesthesia.” International anesthesiology clinics vol. 58,2 (2020): 34-41. doi:10.1097/AIA.0000000000000270 Wang, Lei, et al. “Enhanced Recovery after Elective Craniotomy: A Randomized Controlled Trial.” Journal of Clinical Anesthesia , vol. 76, Feb. 2022, p. 110575, https://doi.org/10.1016/j.jclinane.2021.110575. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3816877","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":264596761,"identity":"7e796dee-2f21-44f3-a907-a9703bf96318","order_by":0,"name":"La Donna Brown","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACNiBm/sHAYA/iHABiOf4GIOMBHi38IC08DAyJDVAtxhJA8kACHi2SDRAtcDWJG0AkPi0Gt5sPf+bdY5PAL33G8MCPirr0DWKHHwJtsZPTbcCh5c6xNOkfz9LsJftyDA72nDmcu0E6zQCoJdnY7AAOLTdyzJgZDhxm3HCGLeEwY9uB3I23E0BaDiRuw6HF/kb+588gLfvBWv7VpRvcTv+AVwvQFgZpsC08zECygTnB4HYOflsMbqSZAbWkJc44w3zgYM+xw4YzbucUHEgwwOeX5MdAh9nY8/cwNn/4UVMnzz87ffOHDxV2cri04AIGpCkfBaNgFIyCUYAKAAqFagZpqBiaAAAAAElFTkSuQmCC","orcid":"","institution":"Vanderbilt University","correspondingAuthor":true,"prefix":"","firstName":"La","middleName":"Donna","lastName":"Brown","suffix":""},{"id":264596762,"identity":"e4bd0d3f-8935-4625-8eee-79224501ffa3","order_by":1,"name":"Michelle Ardisson","email":"","orcid":"","institution":"Vanderbilt University","correspondingAuthor":false,"prefix":"","firstName":"Michelle","middleName":"","lastName":"Ardisson","suffix":""}],"badges":[],"createdAt":"2023-12-28 13:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3816877/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3816877/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49126508,"identity":"b7b901a2-e4e0-42ae-94c6-420c2721d82e","added_by":"auto","created_at":"2024-01-03 14:57:08","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8084,"visible":true,"origin":"","legend":"\u003cp\u003ePre-intervention vs. post-intervention pain reduction\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3816877/v1/d87346752f45df67167eb71a.png"},{"id":49128137,"identity":"decd607b-e4ca-4301-ae55-a71d7cd8e7f8","added_by":"auto","created_at":"2024-01-03 15:05:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":7450,"visible":true,"origin":"","legend":"\u003cp\u003eMorphine equivalents pre-intervention vs. post-intervention\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3816877/v1/b7a7f185dfcd94f2283383ea.png"},{"id":49128136,"identity":"f7a60f74-a753-4d06-9162-2ee05a459563","added_by":"auto","created_at":"2024-01-03 15:05:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":6573,"visible":true,"origin":"","legend":"\u003cp\u003eTime spent in the PACU pre-intervention vs. post-intervention\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3816877/v1/46c156f36e329db5e2478834.png"},{"id":49205117,"identity":"b652ec10-2e8f-4140-b931-21624511a339","added_by":"auto","created_at":"2024-01-05 07:01:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":276172,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3816877/v1/c6b0ef4a-9e58-4d1d-8337-6063af4143c9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using an Enhanced Recovery After Surgery (ERAS) guided Multimodal Pathway to Reduce Opioid Consumption in Lumbar Spine Surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSpinal pathologies are increasingly prevalent among the aging population in the United States\u003csup\u003e(1)\u003c/sup\u003e Back pain is a leading cause of adults seeking emergency care, often necessitating surgical intervention, ranging from minimally invasive lumbar spine to complex reconstructive procedures \u003csup\u003e(1,2)\u003c/sup\u003e. Lumbar and spinal fusions have been associated with high rates of opioid use, with 88% of patients reporting significant postoperative pain following spinal procedures \u003csup\u003e(2)\u003c/sup\u003e. Uncontrolled pain after surgery has been linked to prolonged hospital stays, increased opioid consumption, and a higher incidence of postoperative nausea and vomiting \u003csup\u003e(3)\u003c/sup\u003e, negatively affecting patients' physical, social, and emotional well-being.\u003c/p\u003e \u003cp\u003eThe opioid public health crisis underscores the urgency for healthcare providers to explore alternative pain management strategies. Opioid consumption was associated with a staggering 70% of fatal overdose cases in 2017 \u003csup\u003e(1)\u003c/sup\u003e. The Centers for Disease Control and Prevention (CDC) estimates that opioid misuse in the United States incurs an annual economic burden of approximately \u003cspan\u003e$\u003c/span\u003e78.5\u0026nbsp;billion. \u003csup\u003e(4)\u003c/sup\u003e \u003c/p\u003e \u003cp\u003eEvidence supports multimodal analgesia (i.e., combining multiple drugs for pain control), such as NSAIDS, local anesthetics, and acetaminophen, has numerous benefits, including reduced opioid consumption as pain perception is addressed along diverse pain pathways, effectively enhancing pain relief \u003csup\u003e(5)\u003c/sup\u003e. Anesthesia providers have responded by emphasizing multimodal analgesia and adopting evidence-based practice pathways and Enhanced Recovery After Surgery (ERAS) protocols, including multimodal anesthesia, to improve perioperative care and patient outcomes. ERAS protocols have significantly reduced complications, hospital stays (30\u0026ndash;50%), readmissions, and associated costs by mitigating the surgical stress response and reducing perioperative morbidity and hospital LOS \u003csup\u003e(6\u0026ndash;9)\u003c/sup\u003e. Implementing ERAS pathway protocols has been associated with a decrease in the need for opioids in various surgical procedures such as colorectal, bariatric, obstetric, and gynecological surgery \u003csup\u003e(9, 10\u0026ndash;12)\u003c/sup\u003e.Despite the successful application of ERAS in other surgical specialties, its potential to improve patient outcomes in post-operative spine surgery has been largely unexplored in the literature.\u003c/p\u003e \u003cp\u003eTherefore, this quality improvement project aimed to assess the impact of an ERAS multimodal pathway on opioid consumption rates (defined as the absolute dose of opioid-classified medications administered in the postoperative period) in patients undergoing elective lumbar spine surgery. Secondary objectives included evaluating postoperative numerical pain scores, postoperative nausea and vomiting (PONV) incidence, and the length of stay in the Post-Anesthesia Care Unit (PACU) before and after ERAS implementation.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This quality improvement project occurred at an urban community hospital in Maryland following approval from The Vanderbilt University Medical Institutional Review Board. It aimed to evaluate the impact of implementing ERAS pathways, utilizing a \"PRE-\" and POST-ERAS implementation group observational design. The surgical cohort involved patients (age\u0026thinsp;\u0026ge;\u0026thinsp;18 years) undergoing lumbar spine surgery between August 30 and September 30, 2017 (PRE group n\u0026thinsp;=\u0026thinsp;12) and August 30 and September 30, 2018 (POST group n\u0026thinsp;=\u0026thinsp;13). The surgeries included discectomy, microdiscectomy, or one to two-level laminectomies. Patients with spinal deformities (i.e., scoliosis) were excluded.\u003c/p\u003e \u003cp\u003eAll patients underwent the following standardized pre-procedure protocol where they received Aprepitant (EMEND) 40 mg by mouth (PO) in the preoperative holding area. At this time, Celecoxib 400 mg and Gabapentin 300\u0026ndash;600 mg PO were also administered. During surgery, all patients underwent induction with propofol (1-1.5 mg/kg intravenous [IV]), Fentanyl 50\u0026ndash;100 \u0026micro;g IV, and rocuronium (0.6\u0026ndash;1.2 mg/kg IV) prior to endotracheal tube placement and general anesthesia. Maintenance of general anesthesia was achieved with intravenous infusion of Propofol (75\u0026ndash;100 mcg/kg/min), ketamine (0.1\u0026ndash;0.3 mg/kg/hr), and 1\u0026ndash;2% Lidocaine (1 mg/kg/hr). Fentanyl 25\u0026ndash;50 \u0026micro;g IV boluses were administered as needed if indicated when blood pressure and heart rate increased. Ofirmev 1 gram IV was administered in the operating room before the surgical incision. Prophylaxis for nausea and vomiting included dexamethasone 8 mg IV (administered after induction of anesthesia) and ondansetron 4 mg IV (administered at the end of the procedure). Hydromorphone 0.2\u0026ndash;0.5 mg IV was given as needed before the end of surgery and titrated according to the patient\u0026rsquo;s respiratory rate and breathing pattern\u003c/p\u003e \u003cp\u003eAlthough ERAS protocols can be implemented as early as in the pre-surgical consult phase and continue post-discharge to the outpatient follow-up, this project evaluated ERAS implementation during the intrahospital period associated with spine surgery. The ERAS-guided multimodal pathway structuring the intrahospital pre-, intra-, and post-operative care will be referred to as \u0026ldquo;ERAS\u0026rdquo; throughout the manuscript.\u003c/p\u003e \u003cp\u003eTo address the aims of evaluating the effect of ERAS on opioid consumption rates, postoperative pain scores, PONV, and PACU length of stay in patients undergoing elective spine surgery, data was obtained from a review of electronic medical records. Demographic data (i.e., age, gender, race, smoker) and opioid consumption (i.e., the amount of opioid medications administered to patients postoperatively) were recorded simultaneously with pain scores. Opioid doses were then converted to oral morphine equivalents for normalization \u003csup\u003e(13)\u003c/sup\u003e and summed to define total postoperative opioid consumption rates. To quantify PONV, the number of times subjects reported incidences of nausea or vomiting in the postoperative recovery period was recorded. In addition, pain scores were quantified using the numeric rating scale (NRS) on the day of surgery upon arrival in the PACU. Postoperatively, pain scores were assessed every 2 hours using a verbal NRS, with 0\u0026thinsp;=\u0026thinsp;no pain and 10\u0026thinsp;=\u0026thinsp;worst pain. Acetaminophen 650 mg PO was given for mild pain (NRS 1\u0026ndash;3). Oxycodone 5\u0026ndash;10 mg, PO, every four hours as needed, was administered for moderate pain (NRS 4\u0026ndash;6). Rescue analgesics included hydromorphone 0.5-1 mg IV boluses every 2 hours, as needed, for severe pain (NRS\u0026thinsp;\u0026ge;\u0026thinsp;7/10). Finally, PACU stay length was measured in minutes and hours from when they arrived in PACU until they were either transferred to an inpatient unit or Same Day Surgery Unit.\u003c/p\u003e \u003cp\u003eA difference-in-difference analysis was carried out to determine the impact of the ERAS multimodal pathway on pain scores before vs. after surgery, comparing the groups before and after the implementation of the intervention. A Wilcoxon rank-sum test was implemented to determine the impact of the ERAS multimodal pathway on PACU minutes, comparing the groups' PRE and POST implementation of the ERAS multimodal pathway. Comparisons were indicated as statistically significant using a threshold of \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eGroups were similar in age, sex, race, and smoking status (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e for demographics and clinical data). The median opioid dosage (measured in morphine milligram equivalents; mme) decreased from 15.5 (IQR: 2.4, 18.3) in the PRE-intervention phase to 7.5 (IQR: 0, 10.5) in the POST-intervention phase, although the difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.22; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. The median PACU minutes were increased from 125 (IQR: 110.5, 192) in the PRE-intervention phase to 210 (IQR: 154, 316) in the POST-intervention phase (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.019) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. There were no reported PONV cases in either phase.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e compares preoperative and postoperative pain reduction before and after the ERAS intervention. Pain scores decreased from 6.8 (SD 2.7) in the PRE-intervention phase to 5.5 (SD 3.4) in the POST-intervention phase, but the difference was not statistically significant (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.30). However, there was a substantial decrease in the mean pain score from 6.1 (SD 2.8) preoperatively to 2.6 (SD 2.4) postoperatively in the POST-intervention phase (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003)\u0026mdash;\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDemographic characteristics of participants\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre-ERAS Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-ERAS Group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.5 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.2 (7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDeclined to answer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (46%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (67%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (54%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMissing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eTime spent in the PACU and opioid consumption rates (morphine equivalents) pre- and post-intervention\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-ERAS Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-ERAS Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative opioid dosage (mme), median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.5 (2.4, 18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5 (0, 10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePACU minutes, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (110.5, 192)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e210 (154, 316)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePONV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0,0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eLegend\u003c/em\u003e: mme: morphine milligram equivalents\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePreoperative vs. postoperative pain reduction pre- and post-ERAS intervention\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePre-Intervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePost-Intervention\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain score, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.8 (2.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.5 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.6 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overarching goal of this quality improvement project was to evaluate the impact of an ERAS-guided multimodal analgesic pathway on opioid administrative rates, along with postoperative pain scores, PONV, and PACU length of stay in patients undergoing spine surgery PRE- versus POST-implementation. We showed that implementing an ERAS multimodal pathway for spine surgery in our institution was associated with a significant reduction (6.1 vs. 2.6, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.003) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e in postoperative pain scores, statistically insignificant but clinically significant (50%) reduction in opioid consumption rates \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePain associated with spine surgery is unique, as it is multifactorial and involves pain stimuli from multiple inputs. For example, nociceptive pain is caused by tissue damage, such as incisions made during surgery or retraction of muscles. In contrast, inflammatory pain results from releasing inflammatory mediators in response to tissue damage. Neuronal pain involves sensitization of the nervous system, which can cause hyperalgesia \u003csup\u003e(14)\u003c/sup\u003e. Therefore, postoperative pain may not be adequately controlled without considering these different inputs with pharmacologic pain management and the selection of medications for preoperative and intraoperative pain control. An ERAS multimodal pathway is beneficial for this level of pain as the term \u0026ldquo;multimodal\u0026rdquo; indicates a combination of non-opioid medications that target various receptors along the pain pathway and work synergistically to ablate the pain associated with each stimulus \u003csup\u003e(15)\u003c/sup\u003e. In this project, non-opioids included acetaminophen, NSAIDs, gabapentinoids, and local anesthetics. \u003csup\u003e(15)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eImplementing an ERAS multimodal approach, in conjunction with opioid augmentation for pain control, yielded significant pain reduction in our surgical patient population. The effectiveness of multimodal pain control in reducing opioid administration rates has been consistently demonstrated in various studies investigating ERAS multimodal pathways across other surgical interventions, including bariatric, gynecology, colorectal surgery, and orthopedic surgery \u003csup\u003e(16, 9)\u003c/sup\u003e. A systematic review examining outcomes of multimodal pain management techniques reported that non-opioid adjuncts, including NSAIDs, Ketamine, and Dexmedetomidine, effectively lowered pain scores and total opioid requirements, even in complex cases (\u003csup\u003e17\u0026ndash;18\u003c/sup\u003e). As our project focused on subjects undergoing lumbar spine procedures, this current manuscript contributes to the body of literature supporting the broad applicability and efficacy of multimodal ERAS pain management strategies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Also, it supports the utility of ERAS in elective spinal surgery.\u003c/p\u003e \u003cp\u003eAnother critical key component of multi-modal/ERAS-guided management pathways is that medications are given preemptively before surgical insult to the tissues \u003csup\u003e(18\u0026ndash;19)\u003c/sup\u003e. When given before surgery, the administered medications prevent the hyperexcitability of the central nervous system \u003csup\u003e(18)\u003c/sup\u003e and can decrease postoperative pain. In the ERAS group, several medications, including Gabapentin, COX-2 inhibitors, and intravenous acetaminophen, were given pre-operatively and intraoperatively before the first surgical incision.\u003c/p\u003e \u003cp\u003eIn addition to assessing postoperative opioid administration rates and pain scores, our objective was to examine the impact of the ERAS pathway on two additional factors: PONV and the length of stay in the Post-Anesthesia Care Unit (PACU). PONV is a common side effect associated with opioid use. However, in our study, the PONV scores were consistently zero in both the pre-ERAS and post-ERAS implementation groups, indicating that PONV was adequately controlled prior to the implementation of the ERAS pathway. Nonetheless, we believe that the implementation of our ERAS multimodal pathway, which effectively reduced postoperative pain scores through the use of various techniques, has the potential to decrease PONV rates in other groups with higher incidences of postoperative nausea, as seen in prior research studies \u003csup\u003e(20\u0026ndash;22)\u003c/sup\u003e where the implementation of ERAS multimodal pathways resulted in lower reported PONV rates.\u003c/p\u003e \u003cp\u003eNevertheless, it is important to consider that PONV might not be a reliable outcome measure in future ERAS studies involving lumbar spine procedures. It should be considered when designing future quality improvement projects within this patient population.\u003c/p\u003e \u003cp\u003eIn our specific patient group, we observed a significant increase in the length of stay in the PACU in the post-ERAS intervention group compared to the pre-ERAS group \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e This finding was unexpected since we initially anticipated that the length of stay in the PACU would mirror the rates of opioid administration and reported pain scores. The increase in PACU length of stay may be attributed to various factors, such as the unavailability of hospital floor beds leading to more patients being accommodated. As demonstrated in our study, these logistical issues are crucial considerations when planning future quality improvement studies, as they can affect outcome measures beyond the specific focus of the ERAS process. Importantly, future research should confirm the impact of ERAS-guided pathways on PACU length of stay. It is worth noting that while our QI project monitored patients for immediate PACU recovery, other studies followed patients for a more extended postoperative period \u003csup\u003e(21,23)\u003c/sup\u003e. Therefore, to validate the sustained improvement in opioid administration rates and postoperative pain scores, conducting future research that follows subjects for an extended duration after surgery would be beneficial.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImplementing an ERAS multimodal pathway significantly alleviated pain and reduced opioid consumption for patients undergoing lumbar spine surgery. As both uncontrolled postoperative pain and high opioid consumption rates have the potential to increase the risk of complications and negatively impact patient outcomes, the benefits of ERAS should be considered for all patients undergoing elective spinal surgery. The clinical findings of this project also highlight the growing significance of multimodal pathways in surgery, although they have yet to become the standard of careERAS is a valuable tool for improving outcomes associated with lumbar spine surgery. The involvement of an interdisciplinary team is crucial for the success of projects like this, as it requires collaboration and support from various stakeholders, including pharmacy, surgeons, and nursing staff. Overall, this quality improvement project highlights the importance of using multimodal anesthesia in ERAS pathways to reduce postoperative pain and opioid consumption in hopes of reducing postoperative complications and increasing patient long-term outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eERAS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Enhanced Recovery After Surgery\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLOS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Length of Stay\u003c/p\u003e\n\u003cp\u003ePACU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Post-Anesthesia Care Unit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePONV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Postoperative Nausea \u0026amp; Vomiting\u003c/p\u003e\n\u003cp\u003eIRB\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Institutional Review Board\u003c/p\u003e\n\u003cp\u003eBIS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bispectral index\u003c/p\u003e\n\u003cp\u003eTIVA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Total Intravenous Anesthesia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;By Mouth\u003c/p\u003e\n\u003cp\u003ePRN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;As Needed\u003c/p\u003e\n\u003cp\u003eNRS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Numeric Rating Scale\u003c/p\u003e\n\u003cp\u003eQI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Quality Improvement\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e: The author(s) declared no potential conflicts of interest\u0026nbsp;for\u0026nbsp;this article\u0026apos;s research, authorship, and/or publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Not\u0026nbsp;Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e:\u0026nbsp;LB\u0026nbsp;contributed to the design, collection,\u0026nbsp;and analysis of data, preparation,\u0026nbsp;and manuscript drafting.\u0026nbsp;MA\u0026nbsp;contributed to the design\u0026nbsp;and editing of the project draft. All authors read and approved the\u0026nbsp;final\u0026nbsp;manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e: The datasets used and analyzed during the current study are available from\u0026nbsp;the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003efor Publication\u003c/strong\u003e: Informed consent[MK([1] \u0026nbsp;was waived by the University of Vanderbilt University Medical Center Institutional Review Board as this was a quality improvement project where de-identified patient data were collected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e:\u0026nbsp;This quality improvement project was approved and categorized as exempt by the Institutional Review Board (IRB) of Vanderbilt University Medical Center in Nashville, TN. Informed consent was waived by the University of Vanderbilt University Medical Center Institutional Review Board as de-identified patient data were collected. All methods were performed using the relevant guidelines and regulations.\u003c/p\u003e\n\u003cdiv id=\"_com_1\" language=\"JavaScript\"\u003e\n \u003cp\u003e\u0026nbsp;[MK([1]This is redundant but I think they are funny about these sections so it might be good to list this again here\u003c/p\u003e\n\u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBerardino, Kevin, et al. \u0026ldquo;An Update on Postoperative Opioid Use and Alternative Pain Control Following Spine Surgery.\u0026rdquo; \u003cem\u003eOrthopedic reviews\u003c/em\u003e vol. 13,2 24978. 22 Jun. 2021, doi:10.52965/001c.24978\u003c/li\u003e\n \u003cli\u003eGan,\u0026nbsp;T.\u0026nbsp;J. (2017). Poorly controlled postoperative pain: prevalence, consequences, and prevention.\u0026nbsp;Journal of Pain Research,\u0026nbsp;Volume 10, 2287-2298. doi:10.2147/jpr.s144066\u003c/li\u003e\n \u003cli\u003eSanta Cruz Mercado, Laura A., et al.\u0026nbsp;\u0026ldquo;Association of Intraoperative Opioid Administration with postoperative pain and opioid use.\u0026rdquo; \u003cem\u003eJAMA Surgery\u003c/em\u003e, vol. 158, no. 8, 2023, p. 854, https://doi.org/10.1001/jamasurg.2023.2009.\u003c/li\u003e\n \u003cli\u003eCenters for Disease Control and Prevention (CDC). (2017). Understanding the epidemic. Retrieved from https://www.cdc.gov/drugoverdose/epidemic/index.html\u003c/li\u003e\n \u003cli\u003eGelman, S. (2018). Combining drugs for improved pain relief and reduced opioid consumption in postoperative patients. Anesthesia and Analgesia, 125(6), 1950-1962.\u003c/li\u003e\n \u003cli\u003eChakvarthy, M. V. (2020). Enhanced Recovery After Surgery (ERAS) for spine surgery: A systematic review. World Neurosurgery, 134, 211-221.\u003c/li\u003e\n \u003cli\u003eWang L, Cai H, Wang Y, Liu J, Chen T, Liu J, et al. Enhanced recovery after elective craniotomy: A randomized controlled trial. J Clin Anesth [Internet]. 2022;76(110575):110575. Available from: http://dx.doi.org/10.1016/j.jclinane.2021.110575\u003c/li\u003e\n \u003cli\u003eLi, Man, et al. \u0026ldquo;Enhanced Recovery after Surgery Pathway for Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial.\u0026rdquo; \u003cem\u003eEuropean Journal of Cardio-Thoracic Surgery\u003c/em\u003e, vol. 54, no. 3, 5 Mar. 2018, pp. 491\u0026ndash;497, academic.oup.com/ejcts/article/54/3/491/4921288, https://doi.org/10.1093/ejcts/ezy100.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eElvira L\u0026oacute;pez, Jordi, et al.\u0026nbsp;\u0026ldquo;Outpatient management of acute uncomplicated appendicitis after laparoscopic appendectomy: a randomized controlled trial.\u0026rdquo; \u003cem\u003eWorld Journal of emergency surgery: WJES\u003c/em\u003e vol. 17,1 59. 23 Nov. 2022, doi:10.1186/s13017-022-00465-5\u0026zwnj;\u003c/li\u003e\n \u003cli\u003eStenberg, A. C., et al. (2021). ERAS guidelines in bariatric surgery: A systematic review of implementation and outcomes. Obesity Surgery, 31(2), 400-412.\u003c/li\u003e\n \u003cli\u003eCaughey, B. P. et al. (2018). ERAS protocols in obstetric surgery: A multicenter study of implementation and impact on outcomes. Journal of Maternal-Fetal Medicine, 25(3), 178-185.\u003c/li\u003e\n \u003cli\u003eDebono, B., et al. (2021). Enhanced Recovery After Surgery (ERAS) in lumbar and spinal surgery: A feasibility study. Spinal Surgery Journal, 10(1), 45-52.\u003c/li\u003e\n \u003cli\u003eNielsen, Suzanne, et al. \u0026ldquo;A synthesis of oral morphine equivalents (OME) for opioid utilisation studies.\u0026rdquo; \u003cem\u003ePharmacoepidemiology and drug safety\u003c/em\u003e vol. 25,6 (2016): 733-7. doi:10.1002/pds.3945\u003c/li\u003e\n \u003cli\u003eS, Dilip Chand Raja, et al. \u0026ldquo;A Prospective Randomized Study to Analyze the Efficacy of Balanced Pre-Emptive Analgesia in Spine Surgery.\u0026rdquo; \u003cem\u003eThe Spine Journal\u003c/em\u003e, vol. 19, no. 4, 1 Apr. 2019, pp. 569\u0026ndash;577,\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBarr, Linda F et al.\u0026nbsp;\u0026ldquo;Postoperative Multimodal Analgesia in Cardiac Surgery.\u0026rdquo; \u003cem\u003eCritical care clinics\u003c/em\u003e vol. 36,4 (2020): 631-651. doi:10.1016/j.ccc.2020.06.003\u003c/li\u003e\n \u003cli\u003eWalker, K. J. (2020). Enhanced Recovery After Surgery: An opportunity to improve care of older adults. Clinics in Geriatric Medicine, 36(2), 285-301.\u003c/li\u003e\n \u003cli\u003eWaelkens, M. (2021). Multimodal pain management in total hip arthroplasty: A systematic review. European Journal of Anaesthesiology, 38(4), 402-412.\u003c/li\u003e\n \u003cli\u003eKim, K. M. (2016). Multimodal analgesia for spine surgery. Korean Journal of Anesthesiology, 69(6), 543-548.\u003c/li\u003e\n \u003cli\u003eBhatia, Alisha, and Asokumar Buvanendran. \u0026ldquo;Anesthesia and postoperative pain control-multimodal anesthesia protocol.\u0026rdquo; \u003cem\u003eJournal of spine surgery (Hong Kong)\u003c/em\u003e vol. 5,Suppl 2 (2019): S160-S165. doi:10.21037/jss.2019.09.33\u003c/li\u003e\n \u003cli\u003eXu, Siqi, et al. \u0026ldquo;Effects of Lidocaine, Dexmedetomidine, and Their Combination Infusion on Postoperative Nausea and Vomiting Following Laparoscopic Hysterectomy: A Randomized Controlled Trial.\u0026rdquo; \u003cem\u003eBMC Anesthesiology\u003c/em\u003e, vol. 21, no. 1, 4 Aug. 2021, https://doi.org/10.1186/s12871-021-01420-8.\u003c/li\u003e\n \u003cli\u003eApfel, Christian C et al. \u0026ldquo;Intravenous acetaminophen reduces postoperative nausea and vomiting: a systematic review and meta-analysis.\u0026rdquo; \u003cem\u003ePain\u003c/em\u003e vol. 154,5 (2013): 677-689. doi:10.1016/j.pain.2012.12.025\u003c/li\u003e\n \u003cli\u003eSiu, Eric Y, and Tiffany S Moon. \u0026ldquo;Opioid-free and opioid-sparing anesthesia.\u0026rdquo; \u003cem\u003eInternational anesthesiology clinics\u003c/em\u003e vol. 58,2 (2020): 34-41. doi:10.1097/AIA.0000000000000270\u003c/li\u003e\n \u003cli\u003eWang, Lei, et al. \u0026ldquo;Enhanced Recovery after Elective Craniotomy: A Randomized Controlled Trial.\u0026rdquo; \u003cem\u003eJournal of Clinical Anesthesia\u003c/em\u003e, vol. 76, Feb. 2022, p. 110575, https://doi.org/10.1016/j.jclinane.2021.110575. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Multi-modal analgesia, postoperative pain, ERAS pathway, spine surgery","lastPublishedDoi":"10.21203/rs.3.rs-3816877/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3816877/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Spinal pathologies are increasingly prevalent among the aging population in the United States, leading to back pain as a common reason for adults seeking emergency care and necessitating surgical interventions. Lumbar and spinal fusions have been associated with high rates of opioid use, contributing to the opioid public health crisis. Enhanced Recovery After Surgery (ERAS) protocols have successfully reduced complications and hospital length of stay (LOS) across various surgical specialties, but their potential in spine surgery remains unexplored. The primary aim of this quality improvement project was to assess the impact of an ERAS multimodal pathway on opioid consumption rates in patients undergoing lumbar spine surgery.\u003cbr\u003e\n \u003cstrong\u003eMethods:\u003c/strong\u003e Patients undergoing lumbar spine surgery were included between August 30 and September 30, 2017 (PRE-ERAS Group n=12) and August 30 and September 30, 2018 (POST-ERAS Group n=13). Before the implementation of ERAS, there was no consistent use of multimodal pain modalities. The new ERAS multimodal pathway included non-opioid medications such as Acetaminophen, NSAIDs, gabapentinoids, and local anesthetics. Data were collected from electronic medical records, including demographics, intraoperative opioids, PACU LOS, pain scores, and opioid consumption in the recovery room until discharge.\u003cbr\u003e\n \u003cstrong\u003eResults\u003c/strong\u003e: Implementing an ERAS multimodal pathway was associated with significantly lower postoperative pain scores (p = .003) and a trend towards decreased patient opioid administration dosages(\u003cem\u003ep\u003c/em\u003e=.22). Post-operative nausea and vomiting (PONV) scores were zero in both PRE- and POST-ERAS groups, while postoperative LOS increased (\u003cem\u003ep\u003c/em\u003e=.02) in the POST-ERAS group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003e\u0026nbsp;Implementing an ERAS multimodal pathway is associated with improved pain scores and may reduce opioid consumption in elective lumbar spine surgery.\u003c/p\u003e","manuscriptTitle":"Using an Enhanced Recovery After Surgery (ERAS) guided Multimodal Pathway to Reduce Opioid Consumption in Lumbar Spine Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 14:57:04","doi":"10.21203/rs.3.rs-3816877/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1bd5ca10-6c0c-415d-9de8-f11560f483d9","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-05T07:01:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 14:57:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3816877","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3816877","identity":"rs-3816877","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}