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Decreasing Opioid Consumption In Autologous Free-flap Breast Reconstruction Patients With Eras Protocols - An Examination Of Sustainability And Patient Reported Outcomes
Thais O. Polanco, MD, Meghana G. Shamsunder, MPH, Jonas A. Nelson, MD, Anoushka Afonso, MD, Babak J. Mehrara, MD, Robert J. Allen, Jr., MD, Joseph H. Dayan, MD.
Memorial Sloan Kettering, New York, NY, USA.

Introduction:
Given the opioid crisis in the United States, increased focus has been placed on multimodality perioperative pain regimen and enhanced recovery pathways (ERPs). Enhanced recovery pathways (ERPs) aim to achieve early, postoperative recovery and improve surgical and quality of life outcomes. However, there is limited data regarding ERPís efficacy in decreasing opioid consumption for autologous, free-flap breast reconstruction patients. This study aims to determine the efficacy of ERPs on patient outcomes, primarily focusing on opioid consumption and physical well-being among autologous, free-flap breast reconstruction patients.
Methods:
A multidisciplinary ERP was developed for patients undergoing autologous free-flap breast reconstruction in April 2015 at this tertiary care center. ERP patients underwent breast reconstruction after April 2015 and were compared with a non-ERP cohort (reconstructions before from 2007 to 2015). Core elements of this ERP included a multimodal pain regimen of intravenous ketorolac, aspirin, and transversus abdominis plane blocks with liposomal bupivacaine. The primary outcome was total postoperative opioid consumption (intravenous morphine equivalents [IV-ME]). An analysis of factors influencing high versus low opioid consumption was conducted. Secondary outcomes included overall complications and short-term patient-reported outcomes using the BREAST-Q.
Results:
Among 602 included patients, 230 were in the ERP and 372 in the non-ERP cohort. There was a significant decrease in average total intraoperative (ERP: 29.71 IV-ME; non-ERP: 41.00 IV-ME; p<0.001) and postoperative inpatient morphine (ERP: 69.10 IV-ME; non-ERP: 116.00 IV-ME; p<0.001) for ERP patients versus non-ERP patients (Figure 1.). ERP patients were more likely to receive ketorolac intra-operatively (p<0.001) and postoperatively (p=0.001) compared to non-ERP patients. Complications did not differ between the two groups (p= 0.232). Examining patient reported outcomes; there were no significant differences in BREAST-Q Physical Well-being of the Chest or Physical Well-being of the Abdomen scores at three-months postop.
Conclusion:
ERPs are an effective strategy to systematically reduce opioid consumption in ABR patients, both intraoperatively and postoperatively without impacting perioperative complications. Such protocols may not directly alter patient reported physical wellbeing, which warrants further examination.


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