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S270: ERAS ELIMINATES INTRAOPERATIVE KETOROLAC, INCREASES NSAID USE, AND REDUCES EARLY POSTOPERATIVE OPIOIDS WITHOUT WORSENING PAIN AFTER TRANSSPHENOIDAL SURGERY
Oumou Kalsoum Mbacke, MSII; Heran Solomon Tadesse, MSII; Afua Sekyere Nyantakyi, MSII; Zaynab Dantsoho, MSII; Spencer Payne, MD; Jose Mattos, MD, MPH; Melike Mut Askun, MD, PhD; Michael P Catalino, MD, MSc; University of Virginia Medical Center

Objective: While Enhanced Recovery After Surgery (ERAS) protocols are well-established in other surgical disciplines, their impact on analgesia-related outcomes in transsphenoidal pituitary surgery (TSS) remains undercharacterized. This study assessed ERAS implementation impact on opioid and non-opioid analgesic utilization and recovery metrics.

Methods: A retrospective study of 574 patients undergoing TSS between Jan 2021–May 2025 was conducted. Patients were stratified into pre-ERAS (n=524) and post-ERAS (n=50). Primary outcomes were postoperative pain scores [Numeric Rating Scale, POD0-3]) and opioid consumption (morphine milligram equivalents [MME]). Multivariate analysis was conducted along with linear adjusted models ((p< 0.05).

Results: Among 574 patients (52% female, BMI 32±7 kg/m², 61% ASA ≥3), ERAS implementation significantly reduced pain scores (POD0: 4.70±2.05 vs 4.18±1.73, p=0.051), and was not associated with higher pain through POD2. A 53% reduction in POD0 opioid use was observed (277±185 vs 132±116 MME, p<0.001) despite no significant change in its intraoperative use (227±252 vs 264±190 MME (p=0.228). Intraoperative ketorolac was eliminated (31±284 vs 0±0 mg, p=0.012). Postoperatively, ibuprofen use rose by 253% (683±1428 vs 2408±2238 mg, p<0.001), while ketorolac increased by 46% (294±332 mg vs 429±441 mg, p=0.041). Total NSAID use increased by 260% (717±1423 vs 2579±2237 mg, p<0.001). Acetaminophen exposure increased by 60%, with mean total dosing rising from 4676±3951 to 7463±3891 mg (Welch t test~1.0×10^-5), reflecting higher preoperative dosing (262 vs 832 mg), postoperative IV administration (237 vs 540 mg), and postoperative oral use (4177 vs 6091 mg). LOS (338±253 vs 306±160 days, p=0.217) and home discharge rates (94 vs 98%, p=0.507) were unchanged.

Conclusions:  ERAS transformed analgesic management in TSS, eliminating intraoperative ketorolac, increasing NSAID and acetaminophen use, and reducing early postoperative opioid consumption without compromising pain control, LOS, or discharge outcomes. This underscores ERAS as an effective framework for optimizing multimodal analgesia in pituitary surgery.

Figure 1: Opioid Consumption by Time Period (MME)

Figure 2: Pain Score Trajectories by Postoperative Day

Figure 3: Length of Stay by Time Period

Figure 4: Bubble Lollipop the 28 variables significant pre- vs post-ERAS by FDR-adjusted p-value within Domain Within each domain: lower p (more significant) shown lower; bubble size = |% change|; stems to 0; 95% CIs

 

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