Integration of an Enhanced Recovery after Anesthesia Program for Patients Undergoing Skull Base Tumor Surgery

Background: Utilization of evidence-based perioperative management paradigms has been demonstrated to improve outcomes and shorten length of stay. The benefits of early recovery after surgery (ERAS) programs have been established in several surgical specialties, including orthopedics, colorectal surgery, and head and neck surgery. There is sparse literature on the adoption of an ERAS program for patients with pituitary and other skull base tumors.

Objective: To assess the ability to implement an ERAS program for skull base surgery

Methods: An evidence-based, systematic review of the literature was performed with the manuscript accepted for publication. The best practices as outlined in the systematic review, which involved several elements of perioperative care, were discussed with all stakeholders, including surgeons, physicians involved in perioperative management (anesthesia, endocrine), nurse practitioners, inpatient and outpatient nursing, social work, physical therapy, nutrition, and administrative project managers. Utilizing these data, preoperative and postoperative order sets were developed and established as the standard of care in our institution. Intraoperative guidelines were adopted by the anesthesiology department. Milestones by hospital day were identified. Patient reported outcome surveys were initiated via an online portal. Educational materials were created by nursing and physician staff and were edited by the patient education group at our institution for the average reader to comprehend preoperatively.

Results: The standardized order sets are utilized in presurgical testing and postoperatively by the house staff. The care items include: preoperative consultation with endocrinology for assistance with hormonal and diabetes management, notice for patients with acromegaly and Cushing's disease to be aware of anesthesia challenges with intubation and postoperative obstructive sleep apnea, early cessation of antibiotics, avoidance of systemic steroids in the presence of an intact hypothalamic-pituitary-adrenal axis and in the setting of Cushing's, early Foley's catheter removal, and early ambulation. Other best practice milestones were identified for retrospective review and to track prospectively to measure success of our endeavors. Information technology infrastructure to track clinical milestones, patient reported outcome data, perioperative complication rates, and length of stay are underway.

Conclusion: The integration of ERAS protocols for pituitary and other skull base tumors has been demonstrated to be feasible with multidisciplinary engagement. This enables best evidence-based perioperative management, with prospective data collection that provides ample opportunity for assessment of quality of care and quality improvement initiatives.