What is Enhanced Recovery After Surgery (ERAS) for Mastectomy?
Enhanced recovery protocols or pathways have been proven to help with the physical recovery from surgery. The pathways usually include a combination of methods and medications from different drug classes to reduce pain and minimize nausea while using fewer opioids.
Each hospital may have a different ERAS pathway, so the one recommended for you may have different components. It is important to discuss your pain management with your surgeon and anesthesiologist before surgery so your physicians are aware of your sensitivities, allergies and medications (like blood thinners), which may alter your pain management protocol.
The components of ERAS include:
- Pain control (analgesia) — Gabapentin is a nerve medication that reduces pain when taken the night before surgery. Some pathways recommend continuing this medication at home for several weeks as it may also help reduce chronic pain from mastectomy.
Opioids are types of narcotics like morphine, hydrocodone (Vicodin/ Lortab) and oxycodone (Percocet). You may be given narcotics as part of the anesthesia during surgery. These medications are helpful to reduce pain, but can be highly addictive and have a wide range of adverse side effects (such as nausea, vomiting, restlessness and hallucinations). Opioids are more effective when taken with the anti-inflammatory medications listed below. Opioids often cause constipation. Taking a stool softener, staying hydrated and eating fiber can reduce the chance of constipation.
- Nausea prevention — Post-operative nausea is more common after breast surgery than after other surgeries. If you have a history of this, please let your surgeon know ahead of time. A scopolamine patch can be placed behind your ear either the night before or morning of the surgery. You will need a prescription for this if your surgeon wants you to apply it before you come to the hospital. Most insurance covers this medication.During surgery, you may be given dexamethasone (a steroid) and/or ondansetron (Zofran) to prevent nausea. If you still have nausea, you may be given ondansetron or another oral anti-nausea medication to take at home. Staying well hydrated also helps prevent nausea.
- Regional anesthesia — This is the use of a local anesthetic like lidocaine or bupivicaine to numb up the nerves responsible for sensation at the surgery site. This can be done with a block of the nerves before surgery or a long-acting local anesthetic injected at the time of surgery. If you’re having a mastectomy, you may be discharged with a pain pump that is placed in the mastectomy site and stays in for several days.
- Anti-inflammatory medicines — These medicines reduce pain by reducing the inflammation caused by surgery. When taken in combination with opioids, they are even more effective than when taken alone.
Celecoxib is an anti-inflammatory medication with fewer side effects than ibuprofen or naproxen. It can be given before and after surgery to reduce post-surgical pain.
Celecoxib and ibuprofen are equally effective. They do not require a prescription and can be started right after surgery. It is best to take anti-inflammatory medications on a scheduled basis for at least the first week, to give a baseline of pain relief. Many patients find they only need the anti-inflammatory medicine after the first few days and are able to stop the narcotic medications.
Acetaminophen is incorporated into many pathways as a medication given either just before or just after surgery. In combination with the other medications, it is a powerful pain reliever. Many narcotics have acetaminophen in them, so carefully read the labels to check the dose.
- Reducing surgical infections — Washing with an antibacterial soap before and after surgery may help reduce the risk of a wound infection. You will be thoroughly cleansed in the operating room before surgery begins. Washing hands before and after handling drains and dressings reduces infection. Controlling blood sugars, if diabetic, and quitting smoking before surgery also reduce the risk of infections. You will receive one dose of antibiotics before the surgery begins and your surgeon may prescribe antibiotics while the drain is in place.
- Activity after surgery — Getting out of bed the night after surgery is a very important part of ERAS. Patients who move early have less pain and recover faster. Many pathways give patients instruction in upper body exercises to be started right after surgery to improve range of motion and maintain strength. Although most surgeons recommend no lifting more than 10lbs for a few weeks, moving your arms and shoulders is important to prevent future stiffness and lymphedema.
As with any surgery, the recovery period will not be pain free. But this method of caring for you will give you the best pain control possible with better recovery and fewer complications. Knowing your plan of care and being an active participant will help you recover.