Adverse cardiac outcomes after pulmonary function testing with recent myocardial infarction

ATS/ERS Guidelines list pulmonary function testing (PFT) within one month of myocardial infarction (MI) as a contraindication, based on expert opinion. This retrospective review of 136 patients undergoing Coronary Artery Bypass Graft (CABG) surgery identified 21 patients who had PFTs despite MI in the preceding month (MI + PFT group). The MI + PFT Group had zero incidence of MI or serious cardiac arrhythmia between PFTs and surgery. Comparison of post-operative outcomes between the MI + PFT Group and all other CABG patients showed no significant differences. In this small sample size, PFTs appear safe within one month of MI.

A Preoperative Workup of a "Hip-Spine" Total Hip Arthroplasty Patient: A Simplified Approach to a Complex Problem

BACKGROUND

A large body of evidence has confirmed that patients with spinal deformity, lumbar fusion, and abnormal spinopelvic mobility are at significantly increased risk for instability, dislocation, and revision after total hip arthroplasty (THA).

METHODS

Achieving a stable construct in patients with pre-existing spine disease requires an understanding of basic spinopelvic parameters and the compensatory mechanisms associated with abnormal spinopelvic motion. Indicated patients with concomitant hip-spine pathology should be assessed for (1) the presence of spinal deformity and (2) the presence of spinal stiffness before undergoing THA. Preoperative imaging should include a standing anteroposterior pelvis x-ray, as well as two lateral spinopelvic radiographs in the standing and seated position.

RESULTS

Based on the presence of spinal deformity and/or spinal stiffness, patients may be categorized as one of the four groups of the "Hip-Spine Classification in THA." A series of illustrative case examples is provided.

CONCLUSION

A simple three-step assessment with minimal measurements will effectively identify the complex "hip-spine" THA patient at high risk for postoperative instability. Adhering to group-specific recommendations for acetabular cup position can help to further reduce the burden of instability and related revisions in this challenging population.

The presurgical episode: an untapped opportunity to improve value

Expansion of episode of care measurement models to include presurgical care is an added opportunity to improve quality, value, and efficiency in healthcare delivery.

Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference

IMPORTANCE

Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs.

OBJECTIVE

To develop a set of evidence-based recommendations for patient blood management (PBM) and for research.

EVIDENCE REVIEW

The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018.

FINDINGS

From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization.

CONCLUSIONS AND RELEVANCE

The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.

Consensus on the digestive endoscopic tunnel technique

With the digestive endoscopic tunnel technique (DETT), many diseases that previously would have been treated by surgery are now endoscopically curable by establishing a submucosal tunnel between the mucosa and muscularis propria (MP). Through the tunnel, endoscopic diagnosis or treatment is performed for lesions in the mucosa, in the MP, and even outside the gastrointestinal (GI) tract. At present, the tunnel technique application range covers the following: (1) Treatment of lesions originating from the mucosal layer, e.g., endoscopic submucosal tunnel dissection for oesophageal large or circular early-stage cancer or precancerosis; (2) treatment of lesions from the MP layer, per-oral endoscopic myotomy, submucosal tunnelling endoscopic resection, etc.; and (3) diagnosis and treatment of lesions outside the GI tract, such as resection of lymph nodes and benign tumour excision in the mediastinum or abdominal cavity. With the increasing number of DETTs performed worldwide, endoscopic tunnel therapeutics, which is based on DETT, has been gradually developed and optimized. However, there is not yet an expert consensus on DETT to regulate its indications, contraindications, surgical procedure, and postoperative treatment. The International DETT Alliance signed up this consensus to standardize the procedures of DETT. In this consensus, we describe the definition, mechanism, and significance of DETT, prevention of infection and concepts of DETT-associated complications, methods to establish a submucosal tunnel, and application of DETT for lesions in the mucosa, in the MP and outside the GI tract (indications and contraindications, procedures, pre- and postoperative treatments, effectiveness, complications and treatments, and a comparison between DETT and other operations).

ERAS protocol in gynecologic oncology

OBJECTIVE

To summarize current knowledge of the ERAS protocol in gynecologic oncology surgery.

DESIGN

Review article.

SETTINGS

Department of Obstetrics and Gynecology, University Hospital Ostrava, Ostrava, Department of Obstetrics and Gynecology, University of Ostrava, Ostrava.

METHODS

Literature review, PubMed and Medline databases were used to search relevant literature from 1995 to 2019.

CONCLUSION

ERAS (Enhanced Recovery after Surgery) is a perioperative treatment program based on evidence-based medicine. Guidelines consist of pre-operative, perioperative and post-operative care items. Implementation of the ERAS protocol leads to a decrease in complications up to 40% and a reduction in hospitalization by up to 30%, thereby reducing overall costs without increasing the number of rehospitalizations. Multidisciplinary cooperation not only with anesthesiologists and consultant surgeons, but also with nutritional specialists and nurses is crucial.

Value of preoperative spirometry test in predicting postoperative pulmonary complications in high-risk patients after laparoscopic abdominal surgery

Whether preoperative spirometry in non-thoracic surgery can predict postoperative pulmonary complications (PPCs) is controversial. We investigated whether preoperative spirometry results can predict the occurrence of PPCs in patients who had undergone laparoscopic abdominal surgery. This retrospective observational study analyzed the records of patients who underwent inpatient laparoscopic gastric or colorectal cancer surgery at Seoul National University Bundang Hospital between January 2010 and June 2017. Preoperative spirometry was performed for patients at a high risk of PPCs, such as elderly patients (age >60 years), patients aged <60 years with chronic pulmonary disease, and current smokers. The main outcome was the association between the results of spirometry tests performed within 1 month prior to surgery and the occurrence of PPCs, as determined by multivariable logistic regression analysis. Of the 898 included patients who underwent laparoscopic gastric (372 patients) or colorectal cancer surgery (526 patients), PPC occurred in 117 patients (gastric cancer: 74, colorectal cancer: 43). A 1% greater preoperative forced vital capacity (FVC) was associated with a 2% lower incidence of PPCs after laparoscopic gastric or colorectal cancer surgery (odds ratio: 0.98, 95% confidence interval: 0.97–0.99, P = 0.018). However, the preoperative forced expiratory volume in 1 second (FEV1) (%) and FEV1/FVC (%) were not significantly associated with PPCs (P = 0.059 and P = 0.147, respectively). In conclusion, lower preoperative spirometry FVC, but not FEV1 or FEV1/FVC, may predict PPCs in high-risk patients undergoing laparoscopic abdominal surgery.

Instructor-led vs. peer-led debriefing in preoperative care simulation using standardized patients

BACKGROUND

Debriefing involves the active participation of learners to identify and close gaps in knowledge and skills. Varied debriefing methods are used in simulation, but no empirical studies have examined the effectiveness of peer-led debriefing in simulation using standardized patients. The purpose of this study was to compare the effects of two debriefing methods (instructor-led vs. peer-led) on nursing skills, knowledge, self-confidence, and quality of debriefing among undergraduate nursing students in South Korea.

METHOD

A nonequivalent control group pretest-posttest design was used. Fifty-seven third-year nursing students were randomly assigned to instructor-led (n = 26) or peer-led (n = 31) debriefing groups after a simulation of preoperative care. Structured questions and areas for discussion guided debriefing in both groups. Self-administered questionnaires were used to collect data on students' knowledge and self-confidence in providing preoperative care. Faculty evaluated students' nursing skills during pre- and post-simulation practice. Students evaluated the quality of the debriefings.

RESULTS

Nursing skills for preoperative care (p < .001) and the quality of debriefing (p < .001) were statistically higher in the instructor-led group compared to the peer-led group. There were no statistically significant differences in knowledge (p = .445) and self-confidence (p = .686). Knowledge and self-confidence from pre-test to posttest were improved in both groups.

CONCLUSION

The instructor-led debriefing showed improved nursing skills and higher quality debriefing. However, peer-led debriefing led by a non-trained peer also rendered positive results. Thus, peer-led debriefing may be considered a useful strategy for improving nursing students' self-confidence.

Improvements in blood transfusion management: cross-sectional data analysis from nine hospitals in Zhejiang, China

BACKGROUND

Since 2008, updated perioperative blood management (PoBM) guidelines have been implemented in Zhejiang, China. These guidelines ensure that the limited blood resources meet increasing clinical needs and patient safety requirements. We assessed the effects of implementing updated PoBM guidelines in hospitals in Zhejiang, China.

METHODS

We performed a retrospective multicenter study that included adult patients who received blood transfusions during surgical care in the years 2007 and 2011. The volume of allogeneic red blood cells or autologous blood transfusions (cell salvage and acute normovolemic hemodilution [ANH]) for each case was recorded. The rates of performing appropriate pre-transfusion assessments during and after surgery were calculated and compared between the 2 years.

RESULTS

We reviewed 270,421 cases from nine hospitals. A total of 15,739 patients received blood transfusions during the perioperative period. The rates of intraoperative allogeneic transfusion (74.8% vs. 49.9%, p <  0.001) and postoperative transfusion (51.9% vs. 44.2%, p <  0.001) both decreased from 2007 to 2011; the rates of appropriate assessment increased significantly during (63.0% vs. 78.0%, p <  0.001) and after surgery (70.6% vs. 78.4%, p <  0.001). The number of patients who received cell salvage or ANH was higher in 2011 (27.6% cell salvage; 9.3% ANH) than in 2007 (6.3% cell salvage; 0.1% ANH).

CONCLUSION

Continuing education and implementation of updated PoBM guidelines resulted in significant improvements in the quality of blood transfusion management in hospitals in Zhejiang, China.

Acute Kidney Injury in the Age of Enhanced Recovery Protocols

BACKGROUND

Acute kidney injury is a prevalent complication after abdominal surgery. With increasing adoption of enhanced recovery protocols, concern exists for concomitant increase in acute kidney injury.

OBJECTIVE

This study evaluated effects of enhanced recovery on acute kidney injury through identification of risk factors.

DESIGN

This was a retrospective cohort study comparing acute kidney injury rates before and after implementation of enhanced recovery protocol.

SETTINGS

The study was conducted at a large academic medical center.

PATIENTS

All of the patients undergoing elective colorectal surgery between 2010 and 2016, excluding patients with stage 5 chronic kidney disease, were included.

MAIN OUTCOME MEASURES

Patients before and after enhanced recovery implementation were compared, with rate of acute kidney injury as the primary outcome. Acute kidney injury was defined as a rise in serum creatinine ≥1.5 times baseline within 30 days of surgery. Multivariable logistic regression identified risk factors for acute kidney injury.

RESULTS

A total of 900 cases were identified, including 461 before and 439 after enhanced recovery; 114 cases were complicated by acute kidney injury, including 11.93% of patients before and 13.44% after implementation of enhanced recovery (p = 0.50). Five patients required hemodialysis, with 2 cases after protocol implementation. Multivariable logistic regression identified hypertension, functional status, ureteral stents, nonsteroidal anti-inflammatory drugs, operative time >200 minutes, and increased intravenous fluid administration on postoperative day 1 as predictors of acute kidney injury. Laparoscopic surgery decreased the risk of acute kidney injury. The enhanced recovery protocol was not independently associated with acute kidney injury.

LIMITATIONS

The study was limited by its retrospective and nonrandomized before-and-after design.

CONCLUSIONS

No difference in rates of acute kidney injury was detected before and after implementation of a colorectal enhanced recovery protocol. Independent predictors of acute kidney injury were identified and could be used to alter the protocol in high-risk patients. Future study is needed to determine whether protocol modifications will further decrease rates of acute kidney injury in this population. See Video Abstract at http://links.lww.com/DCR/A568.

PRE-OPERATIVE FASTING: WHY ABBREVIATE?

INTRODUCTION

Considering the practice of preoperative fasting based on observations on the gastric emptying delay after induction and the time of this fast is closely linked to organic response to trauma, arise the question about preoperative fasting period necessary to minimize such response and support the professional with clinical and scientific evidence.

AIM

To review the aspects related to the abbreviation of preoperative fasting from the metabolic point of view, physiology of gastric emptying, its clinical benefits and the currently recommendations.

METHOD

Literature review was based on articles and guidelines published in English and Portuguese, without restriction of time until January 2017, in PubMed, SciELO and Cochrane with the descriptors: surgery, preoperative fasting, carbohydrate. From the universe consulted, 31 articles were selected.

RESULTS

The literature suggests that the abbreviation of fasting with beverage added carbohydrates until 2 h before surgery, can bring benefits on glycemic and functional parameters, reduces hospitalization, and does not present aspiration risk of healthy patients undergoing elective surgery. Another nutrient that has been added to the carbohydrate solution and has shown promising results is glutamine.

CONCLUSION

The abbreviation of preoperative fasting with enriched beverage with carbohydrates or carbohydrate and glutamine seems to be effective in the care of the surgical patient, optimizing the recovery from of postoperative period.

Effect of routine pre-anesthetic laboratory screening on pre-operative anesthesia-related decision-making in healthy dogs

The usefulness of pre-anesthetic laboratory screening of healthy veterinary patients is controversial and clear evidence-based guidelines do not exist. The purpose of our study was to determine the influence of preanesthetic laboratory screening on peri-anesthetic plans in canine patients undergoing elective surgery. One hundred medical records were randomly selected between the years 2008 and 2013 and patient information was presented to 5 Diplomates of the American College of Veterinary Anesthesia and Analgesia (ACVAA) for review. They were given pre-anesthetic laboratory screening test results for each patient and asked whether the results would change the way they managed the case from an anesthesia perspective. Peri-operative anesthetic management was altered in 79% of patients based on pre-anesthetic screening results; however, the overall agreement among anesthesiologists was weak with 64% of changes made by only a single anesthesiologist. Pre-anesthetic laboratory screening test results may influence pre-operative anesthesia case management but major discrepancies can occur among ACVAA diplomates.

Decreasing Resource Utilization without Compromising Care through Minimizing Preoperative Laboratories

Approximately 18 billion dollars is spent annually on preoperative testing. The purpose of this study was to determine whether implementation of an algorithm aimed at minimizing preoperative tests resulted in decreased costs without compromising care. We performed a pre-post trial comparing January 2016 to April 2016 with May 2016 to July 2017. In May 2016, an algorithm was instituted in which laboratories were canceled based on an algorithm that incorporated patient and procedural factors. Total number of laboratories canceled before orthopedic, urologic, or general surgical procedures was documented. Case cancellations during this time were recorded. There were 22,175 laboratories during the study time frame. There was a significant decrease of 2.4 per cent in expected laboratories in the post-intervention group. There was an overall cost savings of $33,032.00. The per cent of patients who were seen in preoperative testing clinic and still needed medical optimization decreased after algorithm implementation (3.3% vs 2.1% P < 0.01). No cases were canceled because of lack of laboratory information. An algorithm for selective preoperative laboratory testing provides overall cost savings. Decreasing the number of unnecessary laboratories ordered reduced case cancellations. Instituting an algorithm for preoperative laboratory testing is cost-effective without compromising care.

Quality and accuracy of electronic pre-anesthesia evaluation forms

BACKGROUND AND OBJECTIVE

Paper-based forms have been widely used to document patient health information for anesthesia; however, hospitals are now switching to electronic patient file documentation for anesthesia. The aim of this study is to compare the quality of paper-based and electronic pre-anesthesia assessment forms.

METHODS

The research conducted in this study was quasi-experimental using a pretest-posttest design without a control group. The study was conducted at King Abdulaziz Medical City, Riyadh (KAMC-RD) during November 2015. Paper-based forms were converted into electronic forms, and the paper-based pre-anesthesia forms were used during the first two weeks of the data collection period while electronic forms were completed in the last two weeks. The quality of each (electronic vs. paper) was evaluated with respect to missing items, errors, and unreadable items. The sample size included all 15 anesthetists working in the pre-anesthesia clinic at KAMC-RD. The anesthetists completed 25 pre-anesthesia forms daily during a five-day week schedule. A total of 500 patient forms were completed during the study (250 paper-based and 250 electronic forms). Anesthetists' satisfaction with the electronic pre-anesthesia form was also measured using a questionnaire.

RESULTS

The electronic form shows significantly higher quality in all assessment categories (missing items, errors, and unreadable items; X² (2, N = 500) = 171.64, p < 0.001). The satisfaction survey found 81.65% of the anesthetists were satisfied with the electronic pre-anesthesia form for all questions.

CONCLUSION

Our study demonstrates that the electronic pre-anesthesia form has better data quality, meets the expectations of anesthetists and aids to decrease missing key preoperative information. This type of approach is imperative for the safety of perioperative patients.

Establishing a Successful Outpatient Joint Arthroplasty Program

Many surgical procedures are performed in outpatient settings, and outpatient joint replacements are one of the emerging trends in orthopedics. Rising consumer demand for value-driven health care, new technology, and pain management advancements, and more physicians training in minimally invasive surgical techniques during their residency have driven this change. When a facility is considering the establishment of an outpatient joint arthroplasty program, leaders must take into consideration the outcomes data from the facility's current joint arthroplasty program. Additional factors in establishing a successful outpatient program include careful patient selection, preoperative patient education, the presence of a case manager, and specialized protocols and techniques.

Comprehensive Preoperative Assessment and Global Optimization

To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.

Preoperative ANemiA among the elderly undergoing major abdominal surgery (PANAMA) study: Protocol for a single-center observational cohort study of preoperative anemia management and the impact on healthcare outcomes

INTRODUCTION

Preoperative anemia and old age are independent risk factors for perioperative morbidity and mortality. However, despite the high prevalence of anemia in elderly surgical patients, there is limited understanding of the impact of anemia on postoperative complications and postdischarge quality of life in the elderly. This study aims to investigate how anemia impacts elderly patients undergoing major abdominal surgery in terms of perioperative morbidity, mortality and quality of life for 6 months postoperatively.

METHODS AND ANALYSIS

We will conduct a prospective observational study over 12 months of 382 consecutive patients above 65 years old, who are undergoing elective major abdominal surgery in Singapore General Hospital (SGH), a tertiary public hospital. Baseline clinical assessment including full blood count and iron studies will be done within 1 month before surgery. Our primary outcome is presence of morbidity at fifth postoperative day (POD) as defined by the postoperative morbidity survey (POMS). Secondary outcomes will include 30-day trend of POMS complications, morbidity defined by Clavien Dindo Classification system (CDC) and Comprehensive Complication Index (CCI), 6-month mortality, blood transfusion requirements, days alive out of hospital (DaOH), length of index hospital stay, 6-month readmission rates and Health Related Quality of Life (HRQoL). HRQoL will be assessed using EuroQol five-dimensional instrument (EQ-5D) scores at preoperative consult and at 1, 3, and 6 months.

ETHICS AND DISSEMINATION

The SingHealth Centralised Institutional Review Board (CIRB Ref: 2017/2640) approved this study and consent will be obtained from all participants. This study is funded by the National Medical Research Council, Singapore (HNIG16Dec003) and the findings will be published in peer-reviewed journals and presented at academic conferences. Deidentified data will be made available from Dryad Repository upon publication of the results.

Prophylactic Antibiotics for Elective Laparoscopic Cholecystectomy

Surgical site infections with elective laparoscopic cholecystectomy are less frequent and less severe, leading some to suggest that prophylactic antibiotics (PA) are no longer indicated. We compared the incidence of surgical site infections before and after an institutional practice change of withholding PA for elective laparoscopic cholecystectomy. Between May 7, 2013, and March 11, 2015, no PA were given to patients selected for elective cholecystectomy by two surgeons at a single center. The only patients excluded were those who received antibiotics before surgery for any reason. All others, including those at high risk for infection, were included. The incidence and severity of infections were compared with historical controls treated with prophylaxis by the same two surgeons from November 6, 2011, to January 13, 2013. There were 268 patients in the study group and 119 patients in the control group. Infection occurred in 3.0 per cent in the study group compared with 0.9 per cent in the controls (P = 0.29). All infections were mild except one. Based on these data, the routine use of PA for elective laparoscopic cholecystectomy is not supported.

Knowledge of Nurses About Preoperative Fasting in a Corporate Hospital

BACKGROUND

Preoperative fasting is a requirement to be made by anesthesiologists, but they generally depend on nurses to ensure it is carried out by patients. Lack of updated knowledge among nurses may cause complications.

METHOD

The objective of this study was to understand the knowledge of nurses about preoperative fasting. The multi-unit study was conducted in the units of our hospitals using an Internet-based survey. The responders were anonymous to the authors.

RESULTS

The survey was sent to approximately 5,000 nurses, with more than 600 responding to the survey. Most of the respondents were aware of the preoperative fasting guidelines. The understanding regarding preoperative fasting appeared to be insufficient among nurses. The nurses appreciated the concern of the anesthesiologists about fasting. The nurses opined that additional training regarding preoperative fasting might benefit them.

CONCLUSION

This survey conveyed to the authors that the nurses of our hospitals were knowledgeable but required further training to update them. J Contin Educ Nurs. 2018;49(3):127-131.

Anemia - the Neglected Problem in Patients with Orthopedic Conditions

Anemia and the necessity of blood product transfusion in perioperative procedures is an important and frequently discussed clinical issue. Presently, a constantly growing interest in this problem is observed among clinicians who search the ways to reduce the number of blood or blood product transfusions in patients after surgical procedures, both during the preoperative period and during and after the surgery. Generally, the decision whether to start transfusion or not should follow the analysis of pros and cons, considering the beneficial effect of transfusion and the risk of undesirable effects. The most effective approach in prophylaxis and treatment of anemia among patients on the orthopedic service should combine surgical anesthetic and pharmacological procedures during the preoperative, perioperative and postoperative periods. The aim of the paper is presenting the latest knowledge of the practical determinants concerning anemia pharmacological treatment, especially considering the principles, value and therapeutic effectiveness of iron supplementation, both at orthopedic injury clinics and outpatient clinics.