SCAMPs for Multimodal Post-Operative Analgesia: A Concept to Standardize and Individualize Care

Improving the management of morbidly obese patients with postoperative bleeding undergoing Roux-en-Y gastric bypass

OBJECTIVE

Aim: To improve the management of morbidly obese patients who undergo gastric bypass surgery to reduce the number of postoperative complications, in particular, bleeding.

PATIENTS AND METHODS

Materials and Methods: From 2011 to 2022, a total of 348 patients with morbid obesity (MO) underwent laparoscopic gastric bypass treatment at the clinical base of the Department of General Surgery №2 of Bogomolets National Medical University. The retrospective group included 178 patients who received treatment between 2011 and 2019. 170 patients were enrolled in the prospective group for the period from 2019 to 2022.

RESULTS

Results: Retrospective group had 8 episodes of postoperative bleeding, representing a rate of 4.49%, prospective group - 3 episodes of postoperative bleeding, representing a rate of 1.76% Four factor characteristics associated with the probability of bleeding were identified: "number of comorbid conditions", "arterial hypertension", "chronic liver diseases" and "chronic obstructive pulmonary disease".

CONCLUSION

Conclusions: The factors responsible for the occurrence of postoperative bleeding in morbidly obese patients after laparoscopic gastric bypass surgery were the number of comorbid conditions, the presence of arterial hypertension, the presence of chronic liver diseases, and chronic obstructive pulmonary disease. A new strategy for the management of morbidly obese patients after laparoscopic gastric bypass was developed. This strategy involves changing cassettes to create gastroentero- and enteroenteroanastomoses, reducing the period of use of the nasogastric tube, drains, and urinary catheter from 3-4 days to 1 day, and resuming the drinking regimen 6 hours after extubation.

Enhanced Recovery After Surgery (ERAS) Program for Anterior Cervical Discectomy and Fusion (ACDF) in Patients Over 60 Years Old

Background

Enhanced recovery after surgery (ERAS) is currently widely used in many surgical specialties, but there is still a lack of concern about the cervical ERAS program for old patients (>60 years old). We aimed to determine whether our ERAS program significantly improved satisfaction and outcomes in old patients (>60 years old) with anterior cervical discectomy and fusion (ACDF).

Methods

This is a retrospective cohort study. The study enrolled patients if they were over the age of 60 years old underwent ACDF from July 2019 and June 2021 (ERAS group) and from January 2018 and June 2019 (non-ERAS group). Data including demographic, comorbidity, and surgical information were collected. We also evaluated ERAS process compliance, primary outcome, surgical complication, and length of stay (LOS).

Results

There were 135 patients in the ERAS group, and 122 patients in the non-ERAS group were included. A comparison of the demographic data revealed that there were no statistically significant intergroup differences observed between the group. Overall, ERAS pathway compliance was 91.9%. There were no significant differences in the fusion levels, operative time, intraoperative blood loss, postoperative VAS score, and complications between the ERAS and non-ERAS groups. In addition, there was no significant difference in readmission and mortality at 30-day follow-up between the two groups. However, we observed a statistically significant decrease in the LOS in the ERAS group (8.68±2.34 of ERAS group versus 10.43±4.05 in non-ERAS group, p=0.013).

Conclusion

This report describes the first ERAS protocol used in old patients with ACDF. Our ERAS program is safe and associated with incremental benefits with respect to LOS in old patients with ACDF.

Six-year trends in postoperative prescribing and use of multimodal analgesics following total hip and knee arthroplasty: A single-site observational study of pain management

BACKGROUND

Guidelines for acute postoperative pain management recommend administering analgesics in multimodal combination to facilitate synergistic benefit, reduce opioid requirements and decrease side-effects. However, limited observational research has examined the extent to which multimodal analgesics are prescribed and administered postoperatively following joint replacement.

METHODS

In this longitudinal study, we used three-point prevalence surveys to observe the 6-year trends in prescribing and use of multimodal analgesics on the orthopaedic wards of a single Australian private hospital. We collected baseline postoperative data from total hip and knee arthroplasty patients in May/June 2010 (Time 1, n = 86), and follow-up data at 1 year (Time 2, n = 199) and 5 years (Time 3, n = 188). During the follow-up, data on prescribing practices were presented to anaesthetists.

RESULTS

We found a statistically significant increase in the prescribing (p < 0.001) and use (p < 0.001) of multimodal analgesics over time. The use of multimodal analgesics was associated with lower rest pain (p = 0.027) and clinically significant reduction in interference with activities (p < 0.001) and sleep (p < 0.001). However, dynamic pain was high and rescue opioids were likely under-administered at all time points. Furthermore, while patients reported high levels of side-effects, use of adjuvant medications was low.

CONCLUSIONS

We observed significant practice change in inpatient analgesic prescribing in favour of multimodal analgesia, in keeping with contemporary recommendations. Surveys, however, appeared to identify a clinical gap in the bedside assessment and management of breakthrough pain and medication side-effects, requiring additional targeted interventions.

SIGNIFICANCE

Evaluation of 6-year trends in a large Australian metropolitan private hospital indicated substantial growth in postoperative multimodal analgesic prescribing. In the context of growing global awareness concerning multimodal analgesia, findings suggested diffusion of best-evidence prescribing into clinical practice. Findings indicated the effects of postoperative multimodal analgesia in real-world conditions outside of experimental trials. Postoperative multimodal analgesia in the clinical setting was only associated with a modest reduction in rest pain, but substantially reduced interference from pain on activities and sleep.

Perioperative neurocognition in elderly patients

PURPOSE OF REVIEW

The extrinsic risk factors for postoperative cognitive disturbance have been a source of concern during the perioperative period, and these risk factors remain the subject of controversy. This review of recent studies focuses on the effect of these factors on postoperative cognitive disturbance during the perioperative period.

RECENT FINDINGS

Impairment of cerebral autoregulation may predispose patients to intraoperative cerebral malperfusion, which may subsequently induce postoperative cognitive disturbance. The neurotoxicity of several volatile anesthetics may contribute to cognitive functional decline, and the impact of intravenous anesthesia on cognitive function requires further exploration. Multimodal analgesia may not outperform traditional postoperative analgesia in preventing postoperative delirium. Furthermore, acute pain and chronic pain may exacerbate the cognitive functional decline of patients with preexisting cognitive impairment. The nuclear factor-kappa beta pathway is an important node in the neuroinflammatory network.

SUMMARY

Several intraoperative factors are associated with postoperative cognitive disturbance. However, if these factors are optimized in perioperative management, postoperative cognitive disturbance will improve.

Essential Elements of Multimodal Analgesia in Enhanced Recovery After Surgery (ERAS) Guidelines

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.