A national online questionnaire-based survey, regarding the awareness and implementation of enhanced recovery after surgery practices in neurosurgical procedures.

INTRODUCTION The rapid and unsustainable rise in health care costs has created an urgent need to develop innovative solutions to deliver quality care at lower costs without compromising patient outcomes. Enhanced recovery after surgery (ERAS), a multi-disciplinary approach aimed at hastening post-operative recovery, has gained popularity and found widespread acceptance after demonstrable changes in outcomes in colorectal surgeries.[1] The implementation of ERAS practices in neurosurgical practice has been slow. Hagan et al.[2] demonstrated feasibility and irrefutable benefits by implementing ERAS in neurosurgery. Despite the interest in understanding and implementing ERAS protocols for neurosurgical procedures, there is a paucity of large multi-centric randomised trials providing the necessary evidence to support their implementation. We conducted an online questionnaire-based survey to assess the current state of ERAS practices in neurosurgical patients in the country. The objective was to provide insight into knowledge, awareness, and implementation of ERAS practice in India. METHODS A questionnaire consisting of questions pertaining to the participants’ awareness regarding ERAS protocols, the degree of implementation, and the obstacles they perceive in implementation was designed by the authors. The questionnaire was then validated by experts to assess for its internal validity (Cronbach’s alpha = 0.79). After obtaining approval from the Institutional Ethics Committee (IRB/1501/AL/22/15), the survey was sent out to the 690 registered members of the Indian Society of Neuroanaesthesia and Critical Care (ISNACC) and other anaesthesiologists who practice neuroanaesthesia but were not members of ISNACC via email and WhatsApp over 14 days. They were informed that the objective of the study was not to test the technical knowledge of the participants but to gain information regarding awareness regarding the concept and any obstacles they face while implementing the ERAS protocols, and implied consent was obtained. A total of 184 participants from all over India completed the questionnaire (response rate = 15%). All the participants completed the entire survey. A descriptive analysis was performed for all the groups of data. Demographic data of the participants and the implementation are mentioned in percentages, and analysis of demographic factors that can influence the implementation of ERAS protocols has been assessed using the two-sided asymptotic significance expressed as a P value, where P < 0.05 is considered significant. RESULTS Most participants were between the ages of 31 and 40 years (41.3%), and 29.3% had received special training in neuroanaesthesia. Our survey elicited responses from anaesthesiologists working across various practice settings. 67.4% of the participants responded that they were already implementing ERAS, with an additional 8.7% preparing to implement ERAS in their hospitals [Table 1]. Thus, we estimate that at least 76.1% of the participants were aware about the utility of ERAS in neurosurgical patients. Additional training in neuroanaesthesia (P = 0.022) and regular institutional audits (P = 0.018) were the only demographic factors that were found to influence the ERAS practices in hospitals. Of all the surgical procedures, ERAS was most commonly implemented in spine surgeries (54.4%).Table 1: DemographicsThe implementation of the components of ERAS by participants was as follows [Figure 1]: Of the 41.7% that allowed clear liquids up to 2 hours prior to surgery, only 5.9% used complex carbohydrate solutions. Thromboembolic deterrent (TED) stockings were used most frequently (57%) among those using any modality for deep vein thrombosis (DVT) prophylaxis (56%). The intra-operative goal-directed fluid therapy (80.4%) appeared to be used by most participants, of which 67.3% of the participants used pulse-pressure variation to guide fluid therapy. Bupivacaine was the most commonly used drug for scalp blocks (71.1%). Non-opioid analgesics such as paracetamol (92.9%), dexmedetomidine (63%), and diclofenac (45.1%) were most commonly used for analgesia, and a combination of ondansetron and dexamethasone was found to be the most commonly used strategy to prevent post-operative nausea and vomiting (59.4%). ‘Regular auditing’ (40.8%) was the only post-operative component where the compliance was less than desirable. Unavailability of clear protocols or guidelines and untrained staff (51.08%, 50.54%) were most commonly cited reasons for non-compliance with ERAS bundles. Inter-departmental co-operation and planning were suggested as the best strategy (44.56%) to promote better implementation.Figure 1: Implementation of individual components of ERASDISCUSSION ERAS protocols in neuroanaesthesia are a newer concept, unlike in other surgical faculties where they are a well-established part of routine practice.[1] The sparse papers that do discuss ERAS in neurosurgical cases suggest reduction of metabolic stress, maintenance of fluid homeostasis, reduction of post-operative inflammation, and a shorter length of hospital stay (5.75 ± 2.46 versus 7.67 ± 3.45 days, P < .001) as probable benefits.[2–5] Unfortunately, this sparcity of data translates into a lack of uniformity and consensus with regard to the factors that must be included in ERAS in neurosurgical procedures. Our survey thus based its questions on the two landmark papers by Hagan et al. and Elayat et al. in devising the right interventions to be implemented.[2,6] The components of ERAS can be segregated into three distinct bundles, that is, pre-operative, intra-operative, and post-operative. As a part of the survey, we assessed each component of these bundles to ascertain the current practices. Pre-operative optimisation or prehabilitation, which forms an integral core of ERAS practices, becomes difficult to execute because most neurosurgical procedures are not truly elective and patients could have neuro-deficits, which could impede prehabilitatory efforts.[7] Among the intra-operative parameters, goal-directed fluid therapy has not been commonly implemented.[6] However, given the impact of good fluid balance on patient outcomes in neurosurgery, we felt it pertinent to include it in our questionnaire.[8] In our study, we found that complete application of ERAS was reported by only 24.5% of the participants, which they attributed to a perceived lack of training and inter-departmental implementation strategy (45.1% and 44.16%). Similar results were obtained by Agarwal et al.,[4] who additionally cited the lack of evidence from studies with holistic, inter-disciplinary design. The few systematic literature reviews that have been conducted to assess the impact of ERAS on neurosurgical practices also reiterate a lack of uniformity in the proposed interventions and need for higher-volume studies.[2,9,10] This lack of clear evidence to suggest a definitive benefit on implementation of ERAS in neurosurgical patients may also be responsible for the current low rate of implementation. The landmark paper by Hagan et al.,[2] which provided not only the plausible components of ERAS for neurosurgical patients but also evidence to support their use, still serves as a scaffolding on which newer programmes have been developed. However, because ERAS is both implemented and assessed in bundles, it is unclear which of the many interventions have been the true drivers of the better patient outcomes.[11] The aim of our survey was to understand the current level of acceptance and implementation of ERAS practices in India among neuro-anaesthetic practitioners, so we did not attempt to assess for the level of satisfaction among them, making this a limitation of our study. Another limitation of our study is that because the number of participants is small, that too with a large number of them having some form of training in neuroanaesthesia, it is likely that the results are likely to change if a larger sample size was used. CONCLUSION ERAS in neuroanaesthesia is gaining footing in India in spite of a myriad of difficulties while implementing protocols. Using a team approach including the surgeons, anaesthesiologists, nursing staff, and the administrative staff alike is likely to allow an easy transition into the same. It is heartening to note that the awareness among Indian anaesthesiologists regarding ERAS practices is reasonably high, with 67.4% of the participants already implementing ERAS either partially or completely. Because possessing any amount of training in neuroanaesthesia improves the chances of implementation of ERAS, it gives the authors a reason to hope that in the coming years, the use of ERAS in neuroanaesthesia will be the norm, rather than the exception. To conclude, the key to successful implementation would be to ensure a well-developed, easy-to-use protocol that has measurable outcomes and can be used in all resource settings. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.