Order Sets for Enhanced Recovery After Surgery Protocol

Enhanced Recovery After Surgery (ERAS) protocols are designed to facilitate recovery from surgical procedures. They have been shown to reduce surgical morbidity and length of stay in hospital1,2 and may be associated with better cancer-specific survival.3 Until recently, there was no specific ERAS protocol for breast reconstruction. A newly developed and internationally relevant protocol, based on a systematic review and consensus recommendations, can now guide the optimal perioperative management of this patient population.4 Based on this protocol, we have developed detailed order sets, with specific drug names and doses. Such information may be useful for centers intending to implement an ERAS protocol for breast reconstruction. PREOPERATIVE ORDER SETS Preoperative ERAS guidelines call for limited fasting and carbohydrate loading, medications to reduce postoperative pain, nausea and vomiting, and risk of venous thromboembolism, and management of fluids.4 Our institution’s orders (Table 1) include a light snack up to 8 hours before surgery, clear fluids up to 3 hours before surgery, and consumption of a carbohydrate-rich juice the evening before and morning of surgery. We have included cefazolin, aprepitant, celecoxib, acetaminophen, dalteparin, hydromorphone, and gabapentin; doses are provided in Table 1. Our orders also include lactated ringers infusion by peripheral line at 125 mL/h continuous.Table 1.: Preoperative Order Sets for Patients Electing to Follow ERAS for Breast ReconstructionPOSTOPERATIVE DAY SURGERY ORDER SETS (IMPLANT RECONSTRUCTION) Intra- and postoperative ERAS guidelines for day surgery patients are relatively straight forward.4 Our postoperative day surgery order set (Table 2) includes lactated ringers infusion by peripheral line at 30 mL/h continuous and saline lock once the patient is drinking well. Postoperative medications may include acetaminophen and gabapentin, as well as the following, as needed: codeine, ketorolac, hydromorphone or morphine, ondansetron, dimenhydrinate, and metoclopramide; doses are provided in Table 2. Discharge instructions include wound observation, drain care, and dressing care.Table 2.: Postoperative Order Sets for Day Surgery Patients Electing to Follow ERAS for Breast ReconstructionPOSTOPERATIVE INPATIENT ORDER SETS (FLAP RECONSTRUCTION) The order sets for patients undergoing abdominal flap reconstruction are more extensive (Table 2) and include early activity, early refeeding, nutritional supplementation, drain care teaching, regular surgical flap checks, and fluid management. Postoperative analgesic medications may include acetaminophen and gabapentin, as well as the following, as needed: oxycodone, codeine, and hydromorphone or morphine; doses are provided in Table 2. Postoperative antinauseants may include, as needed, ondansetron, dimenhydrinate, and metoclopramide. Laxatives may be used as needed. Measures for thromboembolism prophylaxis include dalteparin and a sequential compression device. Our order set also includes referral for physiotherapy assessment and treatment, including teaching around mobility and precaution with certain activities and patient education around wound care, drain care, and VTE prophylaxis. We have collected and analyzed data on outcomes associated with this order set in patients undergoing flap reconstruction, and a paper is pending. Our order sets operationalize ERAS recommendations that can be implemented into the health system. They add depth to the existing ERAS recommendations by providing a specific set of medications and interventions that institutions considering ERAS breast reconstruction protocols can adopt. Depending on the context, some custom tailoring of the order sets may be required. Our hope is that as other institutions adopt ERAS for breast reconstruction, we will see a growing body of comparably treated patients to allow for robust evaluation of quality, safety, and cost of care.

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