JACKSONVILLE, FLA. (FRONTLINE MEDICAL NEWS) – Surgeons at the University of Alabama at Birmingham embraced the enhanced recovery pathway for elective colorectal surgery, but after they initiated the program, they noted high rates of postoperative acute kidney injury. They set about tweaking their approach to bring their results into line with national averages, according to a report presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.

Their response is an example of how surgery departments can use American College of Surgeons National Surgical Quality Improvement Program ( ACS NSQIP ) data to monitor and improve their outcomes.

With data from a prospectively maintained ACS NSQIP database containing 480 patients in the pre-ERAS group and 572 in the ERAS group, researchers noted a concerning trend. They examined their institution’s semiannual ACS NSQIP report after they implemented the Enhanced Recovery After Surgery (ERAS) pathway. “We noticed there was a 2.04% observed rate of renal failure, putting us in the 10th decile,” said Jameson G. Wiener, a medical student at the University of Alabama at Birmingham. That raised the question, “Is there an association between implementation of the ERAS pathway and development of acute kidney injury in patients undergoing elective colorectal surgery?” according to Mr. Wiener.

The rate of acute kidney injury (AKI) before ERAS was 7.1% ,compared with 13.6% after ERAS (P less than .01). After researchers adjusted for significant covariates, “ERAS patients were 2.3 times more likely to develop postoperative acute kidney injury,” Mr. Wiener said (P less than .01). That led the researchers to conclude that the ERAS protocol was independently associated with AKI following colorectal surgery. Average hospital stays for the ERAS group were less than half of those for the non-ERAS group, Wiener said: 3 days for the former vs. 7 days for the latter (P less than .01).

He noted that when UAB implemented ERAS for colorectal surgery, it also adopted the PDSA – Plan, Do, Study, Act – a cyclical quality improvement tool. “So we had done the study,” he said. “How do we act?”

Further investigation revealed the surgeons were using a stacked dosing of ketorolac with one dose at the end of the case and the next dose with initiation of the postoperative order set. “We eliminated the last intraoperative ketorolac dose to avoid the stacked dosing,” Wiener said. “Furthermore, we educated our residents to use ERAS as a guideline, but to always remember to treat the patient individually first.”

After that change, the subsequent semiannual ACS NSQIP report showed that UAB’s outcomes had improved. “We were able to go from the 10th decile for kidney failure after colorectal surgery to the first decile,” Wiener said.

“Moving forward, we will continue to monitor protocol outcomes in our ERAS patients and customize a pathway based on individual preoperative risk,” he said. That includes identifying optimal perioperative IV fluid management and refining multimodal pain management.

Mr. Wiener and coauthors had no financial relationships to disclose.

SOURCE: Wiener JG et al. Abstract 76.03


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