IMPROVED OUTCOMES WITH AN ENHANCED

RECOVERY APPROACH TO CESAREAN

DELIVERYKena Lackman, MD

TFM OB/Rural Fellow

Disclosures■ None

Thanks■ Many!

Objectives■ Define ERAS■ Learn the basic goals of ERAS protocol implementation and

post-operative benefits for patients■ Review basic ERAS protocols by phase■ Review procedures to implements ERAS protocols

Roadmap

Definition Epidemiology Benefits Guidelines Implementation Summary

ERAS: Enhanced Recovery After Surgery■ Designed with the goal of maintaining normal physiology in

the pre-op and perioperative period, thus optimizing patient outcomes in the post-operative period

■ Initially developed for colorectal surgery, and lead to decreased length of hospitalization.

■ Implemented in Europe for cesarean sections in 2012-2013

Surgical Stress

Increased Cardiac Demand

Tissue Hypoxia

Increased insulin

secretion

Insulin Resistance

Impaired Coagulation

Decreased Pulmonary Function

Delayed GI Function

Consequences of Surgical Stress

Why is ERAS Important for Cesarean Delivery?■ Cesarean Section is the most commonly performed surgery in the

United States – 1.27 million cesarean deliveries annually in the US– 32% of all births

■ Young and healthy population

Rates of Cesarean Sections in the USA from 1991 to 2007

Cesarean Delivery Rates by Race of Mother

Benefits of ERAS■ Increased patient satisfaction

■ Shorter length of hospital stay

■ Decreased postoperative pain or need for analgesia

■ More rapid return of bowel function

■ Decreased complication and readmission rates

■ Decreased cost of hospitalization

Enhanced Recovery After Cesarean Section Guidelines: Part 1, 2, 3■ Developed and published in 2018 by

a team of multidisciplinary team of surgeons, anesthesiologists through the Enhanced Recovery After Surgery Society

■ Part 1 : Preoperative Guideline

■ Part 2: Intraoperative Guideline

■ Part 3: Postoperative Guideline

Ituk U, et al 2018Macones GA, et al 2018Wilson RD, et al 2018

Preoperative•Patient Education•NPO Status•Breastfeeding Education•Hemoglobin Optimization•Patient Communication

■ American Society of Anesthesiologists(ASA) published Practice Guidelines for Obstetric Anesthesia, 2016– No clear data for risk of aspiration

based on time NPO for solids or liquids– ASA recommends

■ 6-8 hour fasting for solids■ 2 hours for clears

Preoperative: NPO Status

Tong J, et al 2020

Less Than 2 hours Prior To Surgery

NPO

2 hours Prior To SurgeryNon-Diabetic•Carbohydrate Drink

Diabetic•Low Carbohydrate Drink

8 Hours Prior To Surgery

No solids Continue Clear Fluids

■ Few studies available for cesarean section

■ In colorectal surgery patients (n=252), high-caloric carbohydrate drink 2 hours prior to surgery reduces:- pre-operative thirst (p<0.05), - hunger (p< 0.05)- anxiety (p< 0.05) - insulin resistance

Preoperative: Carbohydrate Drink

Hausel, et al, 2001

Intraoperative: Nausea and Vomiting Prophylaxis■ Postoperative nausea and vomiting (PONV) can delay early oral

intake

■ Etiology of PONV is multifactorial (ie. neuraxial analgesia associated hypotension, exteriorizing the uterus, dehydrations, postoperative opioids)

■ Multifaceted approach per ASA Guidelines on PONV 2020– IV antiemetics

■ Ondansetron 4 mg IV (NNT = 6)■ Metoclopramide 10 mg IV (NNT = 10)

– Steroids ■ Dexamethasone 4-10 mg IV

– Prophylactic phenylephrine– Avoid exteriorization of the uterus

Intraoperative•Prophylactic Antibiotics•Fluid management•Hypotension prevention•Active warming•PONV prophylaxis•Neuraxial Anesthesia

and neuraxial opioids•Normothermia

Tong J, et al 2020

Intraoperative: Neuraxial Anesthesia and Opioids■ Regional anesthesia is the preferred method of anesthesia for

cesarean delivery as a part of an enhanced recovery protocol

■ The use of intrathecal morphine results in improve postoperative analgesia, although the risk of side-effects (nausea, vomiting and pruritis) increases with the dosage used and the optimal dose is not established

■ In the absence of intrathecal morphine, the transversus abdominis plane field block providers superior analgesia when compared with a placebo, and can reduce the first 24 hour maternal morphine consumption in the setting of a multimodal analgesic regimen

Intraoperative•Prophylactic Antibiotics•Fluid management•Hypotension prevention•Active warming•Neuraxial

Anesthesia and neuraxial opioids

•PONV prophylaxis•Normothermia

Intraoperative: TAP Block

Postoperative•Early Oral Intake•Regular oral and

multimodal analgesia

•Early mobilization•Early removal of urinary

catheter•Audit of compliance

■ Pre-post design study of 3,679 cesarean deliveries (scheduled and emergent)

■ Interventions:– Neuraxial analgesia with opioid– IV acetaminophen and ketorolac nearing end of

procedure– Bilateral TAP block at completion of cesarean delivery

with 0.3% ropivacaine 30 mL per side– Scheduled acetaminophen 1000 mg q8h and ibuprofen

600 mg q6h– Scheduled dextromethorphan 30 mg/mL q8h– Prn oxycodone 5 mg q4h– Prn pregabalin 25 mg q8h for neuropathic pain

Postoperative: Analgesia

Mullman, et al 2020

Postoperative•Early Oral Intake•Regular oral and

multimodal analgesia

•Early mobilization•Early removal of urinary

catheter•Audit of compliance

■ Decreased:– Opioid Use: 84% pre-ERAS inpatients received opioids,

compared to 24% post-implementation period (OR 16.8, 95% CI 0.28-0.35)

– Length of hospital stay: 3.2 vs 2.7 days, mean relative change 0.82, 95% CI 0.8-0.83

– Median cost by $349 (mean relative change 0.93, 95% CI 0.91-0.95)

■ No change in 30-day readmission rates (1.4% vs 1.7%, OR 0.83, 95% CI 0.49-1.41)

■ Conclusion: An ERAS approach for the cesarean delivery population is associated with improved outcomes including decreases in opioid use, length of stay, and costs

Postoperative: Analgesia Continued

Mullman, et al 2020

■ Systematic Review of 14 RCTs and three non-RCTs (n=2966)– Early oral intake defined as intake within 6-8 hours after

cesarean– Delayed intake was > 8 hours after cesarean section– Primary outcome was return of bowel function and GI

complication rates– Results:

■ Decreased time to return of bowel sounds, time to passing flatus, and time to bowel movement (p < 0.001)

■ Trend towards decreased postoperative nausea, vomiting, ileus, abdominal pain

■ No significant increase in GI complications

■ Conclusion: Early oral intake significantly improved GI function compared with delayed oral intake, regardless of anesthesia type

Postoperative•Early Oral Intake•Regular oral and

multimodal analgesia•Early mobilization•Early removal of urinary

catheter•Audit of compliance

Postoperative: Early Oral Intake

Hsu YY, et al, 2013

Postoperative•Early Oral Intake•Regular oral and

multimodal analgesia•Early mobilization•Early removal of urinary

catheter•Audit of compliance

Postoperative: Sham Feeding

Hsu YY, et all, 2013

■ “Sham Postoperative Feeding” AKA Chewing Gum – Over 15 trials, including a Cochrane review have

reviewed time to recovery of gastrointestinal function after abdominal surgery

– Wide variety of protocols (ex. initiation of sham feeding immediate post-op to 12 hours post-op, duration of gum chewing 15-60 minutes, 3-6 times a day)

– 4 studies reported decreased post-op ileus (OR 0.39)– Length of hospital stays are not changed

■ Conclusion: Chewing gum is an effective and low risk intervention for decreasing the time to return of bowel function

■ Early Removal of Urinary Catheter– UTI is a common complication after cesarean section– Foleys increase rates of UTI, urethral pain, and delay

ambulation

■ Cochrane review (5 RCTs with 1065 pts) showed use of urinary catheter placement in patients who underwent scheduled cesarean delivery was associated with

– increased time to first voiding (CI 16.3-17.3, MD 16.8 hours)– higher discomfort (CI 4.7 – 23.24)– delayed post-op ambulation (1.37 – 7.31, MD 4.34 hours)– prolonged stay in hospital (0.15 – 1.1, MD 0.62 days)– Unable to assess rates of UTI due to variability in diagnostic

criteria used by studies

■ Conclusion: In a patient without an ongoing need for strict assessment of urine output, immediate removal after cesarean delivery is recommended

Postoperative•Early Oral Intake•Regular oral and

multimodal analgesia•Early mobilization•Early removal of

urinary catheter•Audit of compliance

Postoperative: Early Removal of Urinary Catheter

Menshawy A, et al 2020

Benefits of ERAS■ Increased patient satisfaction

■ Shorter length of hospital stay

■ Decreased postoperative pain or need for analgesia

■ More rapid return of bowel function

■ Decreased complication and readmission rates

■ Decreased cost of hospitalization

Implementations of ERAS TipsMultidisciplinary Program: Surgeons, anesthesia, nursing, patients

■ Protocol Development

■ Nursing and provider education

■ Patient handouts

■ Standardized order sets/protocols

Summary

■ ERAS protocol implementation is a safe and effective way to improve patient satisfaction and outcomes, while standardizing the care that patients receive

■ Implementation necessitates a multidisciplinary approach

Sources■ Gan TJ, Belani KG, Bergese S, Chung F, Diemunsch P, Habib AS, Jin Z, Kovac AL, Meyer TA, Urman RD, Apfel CC, Ayad S, Beagley L, Candiotti K, Englesakis M, Hedrick TL, Kranke

P, Lee S, Lipman D, Minkowitz HS, Morton J, Philip BK. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2020 Aug;131(2):411-448. doi: 10.1213/ANE.0000000000004833. Erratum in: Anesth Analg. 2020 Nov;131(5):e241. PMID: 32467512.

■ Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2007. National vital statistics reports; vol 57 no 12. Hyattsville, MD. National Center for Health Statistics, Released March 18, 2009.

■ Hausel, Jonatan MD*†,; Nygren, Jonas MD, PhD*,; Lagerkranser, Michael MD, PhD†,; Hellström, Per M. MD, PhD‡,; Hammarqvist, Folke MD, PhD§∥,; Almström, Caisa RN*,; Lindh, Annika MD, PhD¶,; Thorell, Anders MD, PhD*,; Ljungqvist, Olle MD, PhD*§ A Carbohydrate-Rich Drink Reduces Preoperative Discomfort in Elective Surgery Patients, Anesthesia & Analgesia: November 2001 -Volume 93 - Issue 5 - p 1344-1350 doi: 10.1097/00000539-200111000-00063

■ Ituk U and Habib AS. Enhanced recovery after cesarean delivery [version 1; referees 2 approved] F1000Research 2018, 7(F100 Faculty Rev):513 (doi 10,12688/f1000research.13895.1)

■ Macones GA, Caughey AB, Wood SL, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G, Wilson RD. Guidelines for postoperative care in cesarean delivery: Enhanced Recovery After Surgery (ERAS) Society recommendations (part 3). Am J Obstet Gynecol. 2019 Sep;221(3):247.e1-247.e9. doi: 10.1016/j.ajog.2019.04.012. Epub2019 Apr 14. PMID: 30995461.

■ Mullman, Luciana MPH; Hilden, Patrick MS; Goral, Jan MD; Gwacham, Nnamdi DO; Tauro, Caitlin BS; Spinola, Kristen RN; Rosales, Kim MSN; Collier, Sheila MSN; Holmes, Lynice MSN; Maccione, Janice MSN; Pitera, Richard MD; Miller, Richard MD; Yodice, Paul MD Improved Outcomes With an Enhanced Recovery Approach to Cesarean Delivery, Obstetrics & Gynecology: October 2020 -Volume 136 - Issue 4 - p 685-691 doi: 10.1097/AOG.0000000000004023

■ Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2016 Feb;124(2):270-300. doi: 10.1097/ALN.0000000000000935. PMID: 26580836.

■ Wilson RD, Caughey AB, Wood SL, Macones GA, Wrench IJ, Huang J, Norman M, Pettersson K, Fawcett WJ, Shalabi MM, Metcalfe A, Gramlich L, Nelson G. Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1). Am J Obstet Gynecol. 2018 Dec;219(6):523.e1-523.e15. doi: 10.1016/j.ajog.2018.09.015. Epub2018 Sep 18. PMID: 30240657.