The pain she expected never came.
As Linda Patrick was preparing for colorectal surgery on her colon, she expected that her recovery would be riddled with pain. An infection had left her with a hole in her colon, and surgeons at Johnson Memorial Health would need to remove the damaged section.
Patrick was worried about the kinds of medicines she would need to take, and if narcotic opioid painkillers would hinder her recovery. But her medical team explained that a new process would hopefully prevent her from needing opioids at all.
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They were right.
“I ended up getting the prescription, but never filled it,” Patrick said. “I really didn’t have any pain afterwards, it was just a little uncomfortable.”
As the opioid epidemic has raged, hospitals are re-assessing the ways the treat pain for patients undergoing surgery. Changes in the way that patients prepare for their surgery in the days leading up to it, as well as different ways that the surgical team conducts the surgery and recommendations for the healing process, has led to shorter stays in the hospital, fewer complications and faster healing.
Significantly, the processes have allowed patients to avoid narcotic or opioid pain medicine if they prefer. They are still able to manage their pain as effectively as with narcotics, but avoid the unpleasant side effects such as nausea, dizziness and delayed healing that can come with using those drugs.
“Not only does it benefit society to decrease the amount of opioids on the street, but people do better,” said Dr. Dana Lindsay, a surgeon at Johnson Memorial Health. “With regards to bowel surgery, the less narcotics you take, the quicker your bowels recover from surgery.”
An increasing number of hospitals around the world, including in the U.S., have started implementing the Enhanced Recovery After Surgery process. According to a review of the process published in 2017 by the Journal of American Medical Associations Surgery, patients are reporting hospital stays reduced 30 to 50 percent. A similar decrease in the number of complications have been seen.
“It’s looking to optimize not only the short-term success of their surgery, but in terms of their long-term health,” said Dr. Wade Wrightson, an anesthesiologist with Southeast Anesthesiologists and part of Franciscan Health.
Franciscan Health’s program is called Fit for Surgery. The process focuses on smoking cessation, good blood sugar control and nutritional status, as well as medication management.
The hope is for shorter hospital stays, quicker return to normal functions and fewer incidences of complications.
“We want to help patients before surgery, so they have a better outcome after surgery,” Wrightson said. “If they hear that these are the things to do to possibly have a better surgery, their ears kind of perk up.”
Such outcomes are overwhelmingly positive, Lindsay said. But one of the most encouraging results from using Enhanced Recovery After Surgery has been the reduction in opioid use surrounding these surgeries.
Studies have shown following the steps can reduce opioid prescriptions by up to 21 percent.
The approach does not completely eliminate opioid use in surgery, as anesthesiologists may decide its necessary. But to decrease the need after surgery, patients are given a mix of non-narcotic painkillers such as oral Tylenol and a nerve pain medicine called gabapentin before their procedure.
“We’re controlling their pain before that first incision,” said Dr. Nicholas Vornehm, a surgeon with Johnson Memorial Health who has used the protocol with his patients. “
The protocol is not a new one. Enhanced Recovery After Surgery was developed in 2001 by a group of academic surgeons in Europe. The goal was to emphasize quality of recovery, rather than speed.
A list of 24 core elements were developed to guide surgical teams in better treating their patients. Aspects of the process included stressing the need to quit smoking and excessive drinking leading up to surgery and using minimally invasive surgical techniques. A major theme was to avoid long-acting opioids, both during surgery and in the recovery process.
“We’re fully aware of the opioid epidemic. There is a percentage of those patients who get and receive their first opioid prescription in a hospital. From that, has led to a number of difficulties,” Wrightson said. “Over time, we as physicians want to make sure our patients are comfortable, and one of the things we use is opioids. But I think the literature is pointing to use less, use other methods that we’ve learned to decrease our opioid use.”
Franciscan Health has also implemented a multi-modal approach to pain care, meaning that different plans aim to minimize narcotics during surgery, then offer non-narcotic painkilling options as they recover.
“We only use narcotics when we really have to,” Wrightson said. “We’ve been able to decrease our intra-hospital narcotic use by over 50 percent. Patients are more awake, they have less nausea and vomiting, and their pain scores are the same. They’re leaving the hospital sooner. With that, we have happier patients.”
In November, Johnson Memorial Health implemented Enhanced Recovery After Surgery. A committee including Lindsay, gynecologist Dr. John Norris, anesthesiologists and other members of the surgical team was formed to put together a formal process.
They examined available data and created a protocol that could be used with a majority of patients, with flexibility for each type of surgery to better fit patients’ needs.
When a patient comes to Johnson Memorial Health needing surgery, Lindsay and her staff walk them through the Enhanced Recovery After Surgery process. Nurses go through the protocol step-by-step, giving them a checklist and reviewing the timing of each step once the surgery is complete.
Before surgery, patients are given special wipes to help reduce wound infections. They are allowed to drink high-carbohydrate beverages up to three hours before surgery and are also able to eat or drink liquids such as juice or broth just hours after surgery.
“The goal is not only to have good pain care but to get people in a position where they can be able to go home sooner,” Vornehm said.
Formerly, patients had to take laborious steps to prepare their bowels for surgery. They had to drink special beverages to clear out the colon, and could not eat or drink anything for hours before the procedure.
“They come in and they’re dehydrated, so they go to the operating table dehydrated,” Lindsay said. “Under this new protocol, patients are given a high-carb drink to drink in certain intervals, so they come in hydrated for surgery. What it’s shown is wound infections are less when they’re hydrated, return to bowel-function is better when they’re hydrated.”
Patrick had been experiencing severe problems in her abdomen earlier this year, so much so that she’d often double over in pain. When the situation persisted, she went to see Lindsay.
A CT scan revealed that she had an infection in her colon, which had caused a hole to form in the organ. After a round of antibiotics to treat the infection, Lindsay recommended surgery to remove a portion of her colon.
Her medical team explained the different processes that would help her recover best from her surgery, as well as going though the mix of non-narcotic medicines that would help her manage pain.
“They were hoping I wouldn’t have to be on any kind of narcotics for pain,” Patrick said. “I’m pretty good with pain as it is. If it meant I wouldn’t have to take those things, then that was good for me.”
The protocol does not call for patients to be cut off from opioid painkillers, Lindsay said. But by following these steps, patients can minimize the amount of narcotics they are given, as well as avoiding them as much as possible as they recover.
None of the patients that Lindsay has used the protocol with have needed any kind of narcotics after their surgery.
“They can get it if they want it, so the patients aren’t suffering, but many don’t want it,” Lindsay said.
For Patrick, that option was overwhelming a positive one. Though she was prepared if she needed opioid painkillers after surgery, she never felt the need for them.
“I had no problems with it. I was walking around just fine afterwards.”
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Enhanced Recovery After Surgery
What is it: A protocol of accelerated recovery following surgery designed to get patients back to health as quickly as possible.
Why use it: The process improves the outcome of your surgery, reduces the chance of complications and allows patients to recover and go home sooner.
Before surgery:
- Prepare your skin using rinse-free, antiseptic wipes to prevent infection.
- Drink high-carbohydrate beverages, often provided by your doctor, according to the prescribed timetable. Doing so will ensure you are properly hydrated at the time of surgery.
- Drink clear liquids up until two hours before surgery. Being properly hydrated will help speed the return of bowel function after surgery and aid in recovery.
After surgery:
- Get out of bed and move around soon after surgery, including sitting in a chair, standing or walking.
- Drink clear liquids provided soon after surgery to help recovery.
- Manage pain using non-narcotic medications.
Information: erassociety.org
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