al pain and make them more likely to reach for more pain medica-
tion.
"We tell our patients that pain control is very important, but it's bet-
ter if you can get by with less," says Dr. Martin. After surgery, they
keep the patients on a regular regimen of non-opioids, but they do
offer opioids as an option if the patients think it's necessary. "We've
found the need for things like Percocet have gone way down with the
program. Some haven't needed any at all, which was a surprise to us,"
explains Dr. Martin. In her thoracic surgery program, one group of
patients had a 74% reduction in opioid use and another group had a
59% reduction.
The decrease in use is a product of the education they do before the
procedure and some of the steps they take during and after surgery.
They noticed a big difference after a thoracic procedure if they
removed the chest tubes earlier than before. If no air, blood or chyle
(a milky fluid of fat droplets and lymph) is draining from the tube, it
can be removed safely. The patients who had their tubes removed ear-
lier were in less pain and got on their feet much faster than if the
tubes were removed based on traditional criteria, says Dr. Martin.
"One common criteria used is to look for less than 200 cc of any-
thing — pleural fluid or blood — coming out of the chest tube per 24
hours and no air leaks. This often led to tubes being in place for 5 or
more days after lung surgery," she explains.
Their use of opioids during surgery was also drastically reduced
with the implementation of this program — signaling that a multi-
modal approach is an important part of the success of any ERAS pro-
gram. Before the patient is put to sleep for a thoracic procedure they
are given an anti-inflammatory drug like Tylenol, Celebrex and
Gabapentin. The idea is that these medications will be in effect before
they go to sleep and also when they wake up from surgery, explains
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