The impact of hospital grade, hospital-volume, and surgeon-volume on outcomes for adults undergoing appendicectomy

Pain control and analgesic requirements following laparoscopy-assisted transversus abdominus plane (TAP) block compared to port site infiltration post-paediatric laparoscopic appendicectomy. A Randomised controlled trial

BACKGROUND

Appendicectomy is a common procedure in children. Regional anaesthesia helps reduce requirements for opioids and hospital stay and enhances recovery. Laparoscopic-assisted Transversus Abdominus Plane block (L-TAP) was shown to be efficient and potentially superior to port site infiltration (PSI); however, this was not previously studied in paediatric appendicitis. This study aimed to evaluate the effectiveness of L-TAP compared to PSI in children undergoing laparoscopic appendicectomy (LA).

METHODS

A single-blinded RCT was performed to compare L-TAP to PSI with 0.25% plain bupivacaine at the end of an LA. Patients aged 6-16 years diagnosed with uncomplicated acute appendicitis (AAST grade 1) were randomised to either group in a 1:1 fashion. Complicated appendicitis, open or Lap-converted to open appendicectomies, were excluded. Outcome measures included the total amount and number of doses of opiates and clonidine required, length of stay (LOS), and visual analogue score (VAS) of pain.

RESULTS

49 patients in the PSI group and 41 in the L-TAP group were included; the mean age was 11.3 ± 2.4 years. There was no significant difference in age and weight between the groups. One patient in each group required opioid-based patient-controlled analgesia (PCA) in the theatre recovery room; however, on retrospective review, this was not clinically warranted. Seven patients in each group required morphine while in recovery (p = 0.4). There was no significant difference in total morphine (PSI 0.12 vs L-TAP 0.04 mg/kg body weight, p = 0.1) and clonidine (PSI 0.57 vs L-TAP 0.59 micro gm/kg body weight, p = 0.5) requirement during the hospital stay. Patients in the L-TAP group had two hours shorter LOS than the PSI group (38.0 ± 3.9 vs 39.7 ± 4.1, p = 0.38). There was no significant difference in VAS scores.

CONCLUSION

There was no difference between L-TAP and PSI. L-TAP was feasible, easy to earn, and safe. We recommend that it be considered in clinical protocols and local guidelines as part of the peri-operative analgesia regimen, especially when ultra-sound guided blocks are unavailable. Overall, patients with uncomplicated appendicitis who undergo LA have low VAS scores and require mostly simple analgesia.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes

BACKGROUND

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.

METHODS

Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.

RESULTS

The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

CONCLUSIONS

Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.