EP159 - Piloting an enhanced recovery protocol after colectomy for older adults

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Purpose/Background: Enhanced recovery after surgery (ERAS) protocols have been widely utilized with substantial evidence for improved patient care after elective colorectal surgery. While the literature suggests that ERAS protocols are safe to use and lead to similar results, there is minimal information about the implementation of ERAS protocols specific to older adults. Older adults have increased risks of acute kidney injury, which can be exacerbated by traditional non-narcotic adjuncts to pain control in ERAS protocols. They are also at higher risk of delirium postoperatively, which can be increased by gabapentin and traditional dosing of medications in ERAS protocols that can contribute to sleep disturbance. Given the unique physiology and risks of surgery in this patient population, we aim to design and implement a tailored protocol for older adults.

Methods/Interventions: This is a prospective quality improvement project in which all patients age ≥75 undergoing elective colorectal surgery will have an ERAS protocol specific to older adults (Group OAERAS). This protocol was developed with review of the literature and refined by geriatricians, pharmacists and surgeons. Specifically, this involves: dose reduction of starting dose opioids and addition of scheduled lidocaine patches as well as heat/ice packs; avoiding deleriogenic medications (pregabalin, gabapentin, scopolamine, promethazine) and a nursing-led assessment and intervention for delirium prevention; limiting celecoxib to 5 days total postoperatively; changing of medication timing and de-escalating vital sign checks after postoperative day 3 to improve sleep hygiene if clinically appropriate. Data was collected starting 6/24/2024 until there are a minimum of 60 patients undergoing the OAERAS protocol have been recruited, which was powered to detect a 50% reduction in total postoperative morphine milligram equivalents (MME). These patients will be matched to historical controls age ≥75 who underwent elective colorectal surgery prior to implementation of the older adult-specific ERAS protocol between 1/1/2022-6/1/2024 (Group ERAS). Outcomes were analyzed using Fisher’s Exact, Chi-Squared, and Mann Whitney U tests. Primary endpoint is protocol compliance. Secondary endpoints include rate of postoperative acute kidney injury, inpatient and outpatient postoperative opioid use, rate of postoperative delirium, length of stay, functional status at discharge, and unplanned 30-day hospital readmission.

Results/Outcomes: Since implementing the geriatric-specific ERAS protocol, 10 patients have been recruited in the pilot study. Preliminary analysis shows that there were no significant differences between patients in Group OAERAS and Group ERAS in terms of age, gender distribution, ASA class, rate of chronic opioid use pre-operatively, or operative approach (Table). There was no significant difference between groups in terms of length of stay, opioid use both inpatient and prescribed at discharge, or functional status at discharge, although rate of postoperative acute kidney injury was observed to be lower in the OAERAS group. Patients in Group OAERAS did have slightly higher rate of readmission at 30 days (Table). There is no difference in rate of postoperative delirium between groups so far.

Conclusion/Discussion: Implementation of an older adult-specific enhanced recovery after surgery protocol is feasible and safe. Repeat analysis is planned after recruitment reaches 60 patients in the OAERAS group to determine any changes in outcomes.