Effect of Multimodal Analgesia on Opioid Use After Open Ventral Hernia Repair.

BACKGROUND: There is limited data on enhanced recovery after surgery (ERAS) protocols after ventral hernia repair (VHR). This study reports the impact of multimodal analgesia on opioid use after open VHR. METHODS: Retrospective review of open VHR treated during the initial 6 months after ERAS implementation. Protocol focused on opioid sparing using intraoperative ketamine and/or lidocaine infusion, selective epidural anesthesia, and postoperative ketamine infusion, ketorolac, and acetaminophen. Four groups were analyzed: 1-ERAS protocol with epidural analgesia, 2-historical controls with epidural analgesia prior to ERAS, 3-ERAS protocol without epidural, and 4-historical controls without epidural analgesia, prior to ERAS. Continuous variables were analyzed using ANOVA or Kruskal-Wallis tests, and subgroup analysis using Student's t test or Mann-Whitney U test. Discrete variables were analyzed using Pearson's chi-square test or Fisher's exact test. RESULTS: Patients differed in hernia width, but were similar in comorbidity and operative technique. There was no difference in length of stay or readmission. Use of ERAS nearly eliminated patient-controlled analgesia use (group 1, 2.7%; group 2, 68.4%; group 3, 0%; group 4, 65.7%; p < 0.001). ERAS significantly reduced narcotic requirements on postoperative days 0, 1, and 2 (p < 0.001). To account for the bias of selective epidural analgesia, groups 1 and 2 (epidural) and groups 3 and 4 (no epidural) were compared separately. Opioid requirement and PCA use remained significantly lower in patients in the ERAS pathway. CONCLUSION: Implementation of multimodal analgesia in the perioperative and postoperative setting significantly reduced opioid use after VHR.

Evaluation of Cost Reduction Measures at a State University Medical Center.

Components of a Perioperative Surgical Home (PSH), implemented at a large State University Medical Center (SUMC), have driven significant reductions in Surgical Site Infections (SSIs) and Day of Surgery (DOS) cancellations. Refined methodology for efficient and accurate assessment of these reductions was developed based on available electronic data systems and proven strategies adapted from literature. At our institution, the practice of evidence-based protocol-driven medicine has contributed to the prevention of an estimated 1073 SSIs over a 6 year period, representing avoided costs in excess of $24M. Management of logistics surrounding patients' surgeries starting in the preoperative clinic has yielded exceedingly low DOS cancellation rates (3.47% of scheduled procedures). This level of efficiency is critical given that a 1% increase in DOS cancellation rates can represent as much as a $5.6M loss of revenue to a large SUMC.