Commentary: Semper ad meliora: Continuous improvement in enhanced recovery pathways.

Robert M. Van Haren, MD, MSPH, and Aaron M. Delman, MD, MS

Continuous improvement in enhanced recovery after thoracic surgery protocols can decrease opioid use in the hospital and at discharge.

See Article page 317.

Despite significant advances in opioid-mitigation strategies, more than 70,000 deaths in the United States were attributed to drug overdoses in 2019. Furthermore, surgical intervention is associated with a high incidence of new and persistent opioid use in opioid-naïve patients.2, 3, 4 Enhanced Recovery After Surgery (ERAS) pathways were developed to improve outcomes for surgical patients while simultaneously decreasing the amount of prescribed opioids. In patients who undergo thoracic surgery, ERAS pathways are associated with improved patient outcomes such as decreased complications, length of stay, and narcotic usage., While ERAS protocols have been implemented worldwide, the optimal protocol remains unknown.

Kodia and colleagues, in their investigation “Optimization of an Enhanced Recovery Protocol for Opioid-Free Pain Management Following Robotic Thoracic Surgery,” detail their institutional results following a change in their ERAS protocol to further decrease opioid use postoperatively. Their updated ERAS protocol involved diluting liposomal bupivacaine with 30 mL of 0.25% bupivacaine instead of normal saline to better mitigate pain in the immediate postoperative setting and potentially decrease the need for intravenous hydromorphone. In addition, they converted a scheduled tramadol dose to as needed. Subsequently, they conducted a retrospective comparative analysis to evaluate the association of the updated protocol with in-hospital and postdischarge opioid requirements. The authors report significantly less opioids were required in the postanesthesia care unit, in the hospital, and after discharge in the optimized ERAS protocol when compared with their original ERAS protocol, without a significant difference in patient-reported pain levels or operative complications.

This investigation pushes the ERAS discipline forward by validating liposomal bupivacaine diluted with 0.25% bupivacaine's ability to drastically reduce in-hospital opioids and achieve near independence from schedule II opioids at discharge. Second, the investigators from University of Miami have set a strong example for continuous improvement in ERAS protocols. Their commitment to optimizing pain control in hospital and postdischarge is commendable, and they confirm that small, scalable, and reproducible modifications can have a drastic effect on minimizing opioid overdispensing, diversion, and abuse. As ERAS protocols come of age, thoracic surgeons can consider continued robust evaluation of the effectiveness and impact of optimized ERAS protocols. In particular, multicenter retrospective collaboratives of a single protocol or prospective interrupted time–series evaluations of ERAS protocols are warranted to evaluate the impact of comprehensive ERAS care. In addition, questions still remain regarding the impact of ERAS protocols on long-term outcomes and narcotic use for both opioid-naïve and chronic opioid users.

We congratulate the Kodia and colleagues on their commitment to continuous improvement in ERAS protocols for their patients and community at large. The near-elimination of schedule II opioids at discharge is encouraging for thoracic surgery patients nationwide.