Table 3. Iterative improvements during the ERAS implementation process.

Intervention

Addition of ondansetron, glycopyrrolate, and oxymetazoline nasal spray to the pre-operative anesthesia order

Changing the approach for liposomal bupivacaine administration, such that injection occurs prior to creation of the soft tissue tract rather than into the previously accessed tract

Addition of 1 g vancomycin to the endoscopic irrigation solution and improvement of central sterile processing of endoscopic equipment

Use of a radiopaque contrast balloon to inspect end plate preparation

Changing the placement of the rhBMP sponge

Description

Prevent intraoperative emesis and epistaxis that would force conversion to general anesthesia

Administer the local anesthetic before creation of the soft tissue tract maintains a pressure gradient and thus allows more efficient diffusion and delivery. Post-operative analgesia greatly improved

This change helped to resolve infection within the interbody device

This technique helped improve discectomy and end plate preparation to reduce risk of cage migration

Moving the sponge anterior to the cage rather than within the cage may prevent dissolution of the cage. This approach is still under investigation

ERAS, enhanced recovery after surgery; TLIF, technique for lumbar interbody fusion.