Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction

Abstract

Background The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution.

Methods This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance.

Results Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time.

Conclusion The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Keywords

breast reconstruction - autologous breast reconstruction - free flap - deep inferior epigastric perforator - microsurgery - enhanced recovery after surgery - ERAS - enhanced recovery pathway - ERP

Publication History

Received: 21 March 2021

Accepted: 26 September 2021

Article published online:
24 November 2021

• References

• 1 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183 (06) 630-641
• 2 Temple-Oberle C, Shea-Budgell MA, Tan M. et al; ERAS Society. Consensus review of optimal perioperative care in breast reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations. Plast Reconstr Surg 2017; 139 (05) 1056e-1071e
• 3 Danna BJ, Wood EL, Baack Kukreja JE, Shah JB. The future of enhanced recovery for radical cystectomy: current evidence, barriers to adoption, and the next steps. Urology 2016; 96: 62-68
• 4 Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Enhanced Recovery After Surgery Study Group. Adherence to the Enhanced Recovery After Surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146 (05) 571-577
• 5 Leeds IL, Boss EF, George JA, Strockbine V, Wick EC, Jelin EB. Preparing Enhanced Recovery After Surgery for implementation in pediatric populations. J Pediatr Surg 2016; 51 (12) 2126-2129
• 6 Lyon A, Solomon MJ, Harrison JD. A qualitative study assessing the barriers to implementation of Enhanced Recovery After Surgery. World J Surg 2014; 38 (06) 1374-1380
• 7 Martin D, Roulin D, Grass F. et al. A multicentre qualitative study assessing implementation of an Enhanced Recovery After Surgery program. Clin Nutr 2018; 37 (6, Pt A): 2172-2177
• 8 Stone JP, Siotos C, Sarmiento S. et al. Implementing our microsurgical breast reconstruction Enhanced Recovery After Surgery pathway: consensus obstacles and recommendations. Plast Reconstr Surg Glob Open 2019; 7 (01) e1855
• 9 Harris PA, Taylor R, Minor BL. et al; REDCap Consortium. The REDCap consortium: building an international community of software platform partners. J Biomed Inform 2019; 95: 103208
• 10 Soteropulos CE, Tang SYQ, Poore SO. Enhanced Recovery After Surgery in breast reconstruction: a systematic review. J Reconstr Microsurg 2019; 35 (09) 695-704
• 11 Astanehe A, Temple-Oberle C, Nielsen M. et al. An Enhanced Recovery After Surgery pathway for microvascular breast reconstruction is safe and effective. Plast Reconstr Surg Glob Open 2018; 6 (01) e1634
• 12 Batdorf NJ, Lemaine V, Lovely JK. et al. Enhanced Recovery After Surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2015; 68 (03) 395-402
• 13 Offodile II AC, Gu C, Boukovalas S. et al. Enhanced Recovery After Surgery (ERAS) pathways in breast reconstruction: systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2019; 173 (01) 65-77
• 14 Oh C, Moriarty J, Borah BJ. et al. Cost analysis of Enhanced Recovery After Surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2018; 71 (06) 819-826
• 15 Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA. Implementation of a fast-track perioperative care program: what are the difficulties?. Dig Surg 2007; 24 (06) 441-449