Reducing pain and opioid use: Implementation of an enhanced recovery pathway for percutaneous nephrolithotomy with an erector spinae plane block

Abstract

Background: There is no standard analgesic pathway after percutaneous nephrolithotomy. At our institution, an Enhanced Recovery After Surgery (ERAS) pathway was instated that included a preoperative erector spinae plane (ESP) block to improve pain control and minimize opioid usage in the postoperative setting.

Materials and methods: At our institution, an ERAS pathway was created for patients undergoing percutaneous nephrolithotomy. This pathway involved a preoperative ESP block and the replacement of opioids with multimodal analgesia. Patient charts were retrospectively reviewed and placed into 2 cohorts: one cohort participated in the ERAS pathway, whereas the other received traditional pain control. The primary outcome evaluated was postoperative morphine equivalents received. Secondary outcomes included nursing pain scores, opioid prescriptions for home, and quality of life. Descriptive statistics were performed by nonparametric Mann-Whitney U and χ² tests for continuous and categorical variables, respectively.

Results: Sixty patients were identified in the ERAS cohort versus 70 in the traditional pain control cohort. There was a statistically significant difference in average postoperative morphine equivalents received (17.0 vs. 39.9, p < 0.01) and average postoperative nursing pain score (2.4 vs. 3.6, p < 0.01). Fifty-three percent (32/60) of patients in the ERAS cohort received an opioid prescription for home compared with 80% (56/70) in the traditional cohort (p < 0.01). There was no significant quality-of-life difference between the groups. No adverse patient events resulted from the block.

Conclusions: An ERAS pathway including a preoperative ESP block and multimodal analgesia decreased morphine equivalents received and nursing pain scores. Future randomized prospective studies with the ERAS protocol can be considered.

Keywords

Nephrolithiasis / Percutaneous nephrolithotomy / Opioid reduction / Erector spinae plane block / Enhanced Recovery After Surgery

Acknowledgments

None.

Statement of ethics

After review by the Office of Human Subject Protection at the University of Rochester, the protocol for this study was approved with the study ID: STUDY0008165. Patient consent was deemed not necessary as receiving a preoperative nerve block had become the standard of care for patients undergoing a PCNL at our institution. The nerve block was thoroughly discussed preoperatively by the anesthesia team, and patients were free to decline. All research performed abided by the Helsinki Declaration.

Conflict of interest statement

There are no declarations for any author other than SOQ, who has the following declarations: Wolf—Enucleation Proctor, Cook—Enucleation Proctor, and Coloplast—BPH Advisory Board.

Funding source

There was no funding for this study.

Author contributions

AS: Study conception, idea generation, data collection, manuscript writing;

DS: Data collection, manuscript writing, statistics;

CW: Study conception, manuscript editing;

AL: Study conception, manuscript editing;

TC: Manuscript editing, idea generation;

SH: Manuscript editing, idea generation;

YJL-S: Manuscript editing, figure and table creation, statistics;

SJ: Data collection;

KM: Co-principal investigator, study conception;

ST: Co-principal investigator, study conception;

RJ: Co-principal investigator, study conception;

SOQ: Co-principal investigator, study conception.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

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