Implementing an Enhanced Recovery After Breast Surgery Protocol to Reduce Opioid Use

Patients undergoing breast surgery are at risk of developing persistent post-operative pain and prolonged opioid use. Most patients who receive breast surgery do not have chronic pain pre-operatively, but up to 60 percent will experience chronic pain post-operatively. AtlantiCare Medical Center made opioid minimization a top priority in the institution and has openly adopted Enhanced Recovery After Surgery (ERAS) protocols for other surgical specialties. After performing a systematic literature review, an ERAS protocol for breast surgery patients was developed for use in a quality improvement project. Patients selected included those undergoing unilateral or bilateral mastectomy and/or, staged reconstruction surgery. The protocol was implemented via an electronic application utilized by the Anesthesia Department for ERAS anesthesia techniques. Key aspects of the protocol were broken down into pre-operative, intra-operative and post-operative aspects. Preoperatively, Acetaminophen and Gabapentin were administered. Intraoperatively, pectoralis blocks were performed by anesthesia, administration of long-acting opioids were minimized, and adequate prevention of post-operative nausea and vomiting (PONV) were utilized. Post-operatively, patients were encouraged early oral intake and reduced use of opioid for pain control. Total morphine milliequivalents (MMEs) during anesthesia care were analyzed pre- and post-protocol implementation via deidentified medication administration reports. Patients of similar American Society of Anesthesiologists (ASA) status, weight and surgical procedure were compared to provide consistent analysis between pre-intervention and post-intervention groups