In light of today’s opioid addiction crisis, Stacy Brethauer, MD, a staff physician in Cleveland Clinic’s Bariatric and Metabolic Institute and President of the American Society for Bariatric and Metabolic Surgery, is leading work on a protocol for enhanced recovery for surgical patients that emphasizes pain control with minimal use of opioids. This focus on minimizing the use of opiates for surgical pain management sets the new enhanced recovery protocol apart from many of the established pathways used in bariatric surgery.
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While acknowledging that clinicians cannot always entirely avoid the use of opioids, he cautions that some patients who receive a prescription for opioids after an elective surgical procedure are at high risk for future dependency. “We know that when patients are exposed to opioids for an elective procedure, up to 15 percent will still be taking opioids a year later. Some studies show an even higher rate of opioid use a year after surgery,” says Dr. Brethauer. “Minimizing the use of opiates in this very susceptible group of people is one of the driving forces behind what we are doing.” Besides the risk of addiction, opiates can cause adverse medical problems that can impede a patient’s recovery. These problems may include respiratory depression, nausea and vomiting, and delayed return of bowel function.
“Enhanced recovery is a concept that revolves around efforts to maintain normal physiologic functions throughout the entire surgical episode,” says Dr. Brethauer. Some surgical disciplines such as orthopaedic and colorectal surgery have been earlier adopters of enhanced recovery protocols, he says. While there have been some prior efforts to foster enhanced recovery for bariatric patients, different centers have been following diverse pathways, naturally leading to considerable variability and degrees of success among programs.
Dr. Brethauer’s protocol presents a variety of options for pain control throughout the surgical episode utilizing a multimodal pain management strategy.
To minimize risk of both dependency and side effects, says Dr. Brethauer, clinicians should learn to use the many other highly effective pain control options available. Valuable alternatives for preoperative and/or postoperative use include acetaminophen, celecoxib, gabapentin and ketorolac.
In addition to pharmaceutical approaches for pain control, the enhanced recovery protocol offers suggestions for regional nerve blocks, specifically the transversus abdominis plane (TAP) blocks, which, when done either by the surgeon or the anesthesia team at the beginning of the case, can offer excellent pain control.
Although various bariatric programs are employing their own recovery protocols, the approaches vary dramatically. “One of our goals is to decrease variability not just among surgeons within a program, but also across different programs,” says Dr. Brethauer. “Anytime you standardize care and decrease variability, you will save money and improve patient outcomes.” The advantages of standardization for cost saving and better patient care have been proven in many different areas of medicine, says Dr. Brethauer. While there will always be room for clinical judgment and some personalized care for individual patients, the more the standardized pathway can be adhered to, the more the center will benefit from its implementation.
Also, with evidence-based standardized care, patients can safely be discharged earlier. “You can decrease their length of stay without increasing the readmission rate,” says Dr. Brethauer. He calls this a big win for the hospital itself and for the healthcare system overall.
“In coming months, we are going to take all the lessons that we have learned and offer the protocol and related materials to other bariatric centers, on a broad scale,” says Dr. Brethauer.
He and his colleagues in the national bariatric surgery accreditation program will lead that rollout effort for bariatric surgery. The project has won the support of The Agency for Healthcare Research and Quality. The AHRQ has awarded the American College of Surgeons quality improvement group a $12 million grant for a large-scale rollout of enhanced recovery protocols across several different specialties. Dr. Brethauer will be taking the lead on the bariatric rollout of the AHRQ project after the current pilot project is completed and the data is analyzed.
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