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Predicting Failure in Enhanced Recovery After Surgery (ERAS)
Tyler S. Wahl*1, Allison A. Gullick1, Jacob A. Mills2, Jamie A. Cannon1, Melanie S. Morris1, Daniel I. Chu1
1General Surgery, UAB, Birmingham, AL; 2Anesthesiology and Perioperative Medicine, UAB, Birmingham, AL
Background ERAS reduces post-operative length-of-stays after major surgery and may work best with increasing compliance to individual ERAS-specific processes. While overall compliance to ERAS is important, it is unknown which factors are most critical to failure or success. We hypothesized that there would be patient, procedure and ERAS-related factors such as nasogastric tubes that would predict ERAS failures.
Methods All ERAS colorectal surgery patients from January to October 2015 at a single, tertiary-referral center were included in this retrospective study. ERAS failure was defined as any patient with an observed post-operative length-of-stay (poLOS) greater than the predicted poLOS by the American College of Surgeon’s Risk Calculator. Patients were stratified to ERAS failure or no-ERAS failure. Patient, procedure and ERAS-specific parameters were compared using Chi-Square analysis and Wilcoxon Rank Sums tests. Adjusted analysis via stepwise logistic regression identified significant predictors of ERAS failure.
Results Of 132 patients, 29 (22%) failed ERAS with an overall ERAS compliance of 11.67 (± 2.08) out of 14 measures. Patients who failed ERAS had a median poLOS of 9 days (IQR 6-13) compared to 3 days (IQR 2-4) among those not failing (p < 0.01). Both groups were similar with respect to patient age, gender, ASA, BMI, and Modified Frailty Index (p > 0.05). ERAS failure, however, was associated with White race and being transferred/admitted to the ICU (p < 0.05). Notable similar procedural factors include indication for surgery, procedure type, operative approach, rate of ostomy construction, EBL, and operative time (p < 0.05). ERAS failure was associated with type of bowel preparation, returning to the OR, post-op blood transfusion, and wound complication (p < 0.05). Despite sharing many ERAS measures, having a persistent nasogastric tube (NGT) from surgery, having an NGT placed post-op, failure to ambulate post-op day 1, and using a post-op Patient Controlled Administration (PCA) IV opioids were associated with ERAS failure (p < 0.05). On multivariate analysis, post-op NGT placement, use of a post-op PCA, and post-op blood transfusion were independent predictors of ERAS failure.
Conclusion ERAS failures are associated with significantly longer poLOS. Specific predictors of ERAS failure included nasogastric tube placement, IV PCA pain control, and post-operative blood transfusions. Future studies will be needed to better understand the mechanism(s) behind these observations.
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