Enhanced recovery after elective craniotomy: A randomized controlled trial

Study objectives: Enhanced recovery after surgery (ERAS) protocols have been proven to improve outcomes but have not been widely used in neurosurgery. The purpose of this study was to design a multidisciplinary enhanced recovery after elective craniotomy protocol and to evaluate its clinical efficacy and safety after implementation. Design: A prospective randomized controlled trial. Setting: The setting is at an operating room, a post-anesthesia care unit, and a hospital ward. Patients: This randomized controlled trial (RCT) prospectively analyzed 151 patients who underwent elective craniotomy between January 2019 and June 2020. Interventions: The neurosurgical ERAS group was cared for with evidence-based systematic optimization approaches, while the control group received routine care. Measurements: The primary outcomes were the postoperative length of stay (LOS) and hospitalization costs. The secondary outcomes included 30-day readmission rates, postoperative complications, postoperative pain scores, length of intensive care unit (ICU) stay, duration of the drainage tube, time to oral intake, time to ambulation, and postoperative functional recovery status. Main results: After ERAS protocol implementation, the median postoperative LOS (4 days to 3 days, difference [95% confidence interval, CI], 2 [1 to 2], P < 0.0001) and hospitalization costs (6266 USD to 5880 USD, difference [95% CI], 427.0 [234.8 to 633.6], P < 0.0001) decreased. Compared to routine perioperative care, the ERAS protocol reduced the incidence of postoperative nausea and vomiting (PONV) (28.0% to 9.2%, adjusted odds ratio [OR] 0.3, 95% CI 0.1-0.7, P = 0.003), shortened urinary catheter removal time by 24 h (64.0% to 83.0%, adjusted OR 2.9, 95% CI 1.3-6.5, P = 0.031), improved ambulation on postoperative day 1 (POD 1) (30.7% to 75.0%, adjusted OR 7.5, 95% CI 3.6-15.8, P < 0.0001), shortened the time to oral intake (15 h to 13 h, difference [95% CI], 3 [1 to 4], P < 0.001), and improved perioperative pain management. Conclusions: Implementation of an enhanced recovery after elective craniotomy protocol had significant benefits over conventional perioperative management. It was associated with a significant reduction in postoperative length of stay, medical cost, and postoperative complications.