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Yoon SH, Lee HJ. Challenging issues of implementing enhanced recovery after surgery programs in South Korea. Anesth Pain Med (Seoul) 2024; 19:24-34. [PMID: 38311352 PMCID: PMC10847003 DOI: 10.17085/apm.23096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/25/2023] [Accepted: 12/22/2023] [Indexed: 02/08/2024] Open
Abstract
This review discusses the challenges of implementing enhanced recovery after surgery (ERAS) programs in South Korea. ERAS is a patient-centered perioperative care approach that aims to improve postoperative recovery by minimizing surgical stress and complications. While ERAS has demonstrated significant benefits, its successful implementation faces various barriers such as a lack of manpower and policy support, poor communication and collaboration among perioperative members, resistance to shifting away from outdated practices, and patient-specific risk factors. This review emphasizes the importance of understanding these factors to tailor effective strategies for successful ERAS implementation in South Korea's unique healthcare setting. In this review, we aim to shed light on the current status of ERAS in South Korea and identify key barriers. We hope to encourage Korean anesthesiologists to take a leading role in adopting the ERAS program as the standard for perioperative care. Ultimately, our goal is to improve the surgical outcomes of patients using this proactive approach.
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Affiliation(s)
- Soo-Hyuk Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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Seif MA, Kruse BC, Keramati CA, Aloia TA, Amaku RA, Bhavsar S, DeCarlo KR, Erfe RJD, Eska JS, Iniesta MD, Prakash LR, Zhang T, Gottumukkala V. Development and implementation of an institutional enhanced recovery program data process. HEALTH INF MANAG J 2023; 52:151-156. [PMID: 35695132 DOI: 10.1177/18333583221095139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: With increasing implementation of enhanced recovery programs (ERPs) in clinical practice, standardised data collection and reporting have become critical in addressing the heterogeneity of metrics used for reporting outcomes. Opportunities exist to leverage electronic health record (EHR) systems to collect, analyse, and disseminate ERP data. Objectives: (i) To consolidate relevant ERP variables into a singular data universe; (ii) To create an accessible and intuitive query tool for rapid data retrieval. Method: We reviewed nine established individual team databases to identify common variables to create one standard ERP data dictionary. To address data automation, we used a third-party business intelligence tool to map identified variables within the EHR system, consolidating variables into a single ERP universe. To determine efficacy, we compared times for four experienced research coordinators to use manual, five-universe, and ERP Universe processes to retrieve ERP data for 10 randomly selected surgery patients. Results: The total times to process data variables for all 10 patients for the manual, five universe, and ERP Universe processes were 510, 111, and 76 min, respectively. Shifting from the five-universe or manual process to the ERP Universe resulted in decreases in time of 32% and 85%, respectively. Conclusion: The ERP Universe improves time spent collecting, analysing, and reporting ERP elements without increasing operational costs or interrupting workflow. Implications: Manual data abstraction places significant burden on resources. The creation of a singular instrument dedicated to ERP data abstraction greatly increases the efficiency in which clinicians and supporting staff can query adherence to an ERP protocol.
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Affiliation(s)
- Mohamed A Seif
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brittany C Kruse
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cameron A Keramati
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ruth A Amaku
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shreyas Bhavsar
- Anesthesiology and PeriOperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kenneth R DeCarlo
- EHR Analytics and Reporting, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rose Joan D Erfe
- Department of Anesthesia, Critical Care, and Pain Management, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jarrod S Eska
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Gynecology Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tao Zhang
- EHR Analytics and Reporting, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vijaya Gottumukkala
- Anesthesiology and PeriOperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Cukierman DS, Cata JP, Gan TJ. Enhanced recovery protocols for ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:285-303. [PMID: 37938077 DOI: 10.1016/j.bpa.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION In the United States, ambulatory surgeries account for up to 87% of all surgical procedures. (1) It was estimated that 19.2 million ambulatory surgeries were performed in 2018 (https://www.hcup-us.ahrq.gov/reports/statbriefs/sb287-Ambulatory-Surgery-Overview-2019.pdf). Cataract procedures and musculoskeletal surgeries are the most common surgical interventions performed in ambulatory centers. However, more complex surgical interventions, such as sleeve gastrectomies, oncological, and spine surgeries, and even arthroplasties are routinely performed as day cases or in a model of an ambulatory extended recovery. (2-5) The ambulatory surgery centers industry has grown since 2017 by 1.1% per year and reached a market size of $31.2 billion. According to the Ambulatory Surgery Center Association, there is a potential to save $57.6 billion in Medicare costs over the next decade (https://www.ibisworld.com/industry-statistics/market-size/ambulatory-surgery-centers-united-states/). These data suggest an expected rise in the volume of ambulatory (same day) or extended ambulatory (23 h) surgeries in coming years. Similar increases are also observed in other countries. For example, 75% of elective surgeries are performed as same-day surgery in the United Kingdom. (6) To reduce costs and improve the quality of care after those more complex procedures, ambulatory surgery centers have started implementing patient-centered, high-quality, value-based practices. To achieve those goals, Enhanced Recovery After Surgery (ERAS) protocols have been implemented to reduce the length of stay, decrease costs, increase patients' satisfaction, and transform clinical practices. The ERAS fundamentals for ambulatory surgery are based on five pillars, including (1) preoperative patient counseling, education, and optimization; (2) multimodal and opioid-sparing analgesia; (3) nausea and vomiting, wound infection, and venous thromboembolism prophylaxis; (4) maintenance of euvolemia; and (5) encouragement of early mobility. Those pillars rely on interdisciplinary teamwork led by anesthesiologists, surgery-specific workgroups, and safety culture. (2) Research shows that a team of ambulatory anesthesiologists is crucial in improving postoperative nausea and vomiting (PONV) and pain control. (7) This review will summarize the current evidence on the elements and clinical importance of implementing ERAS protocol for ambulatory surgery.
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Affiliation(s)
- Daniel S Cukierman
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA
| | - Tong Joo Gan
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.
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Close S, Blake SC, Davis TT, Balbale SN, Perry JE, Weingard R, Ingram MC, Schäfer W, Strople J, Raval MV. Implementation of Enhanced Recovery Protocols for Gastrointestinal Surgery in Children: Practical Tools From Key Stakeholders. J Surg Res 2023; 284:204-212. [PMID: 36586313 PMCID: PMC9911379 DOI: 10.1016/j.jss.2022.11.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/10/2022] [Accepted: 11/25/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION We explored patient, caregiver, and provider recommendations for development of a tool kit to implement enhanced recovery protocols (ERPs) for pediatric patients undergoing gastrointestinal surgery. ERPs are widely used for adults to decrease hospital length of stay, hospital costs, and complications while hastening patient recovery after surgery. With limited data available for ERPs among pediatric populations informed modification of adult ERPs is needed to facilitate successful implementation for pediatric surgery. METHODS Using a qualitative research design, semistructured interviews were conducted with hospital-based teams including surgeons, anesthesiologists, gastroenterologists, nursing, and physician assistants. Four in-person focus groups were held at two pediatric hospitals with patients and caregivers. Codes were developed and applied to interview and focus groups transcripts for structural content analysis. Thematic analysis guided by the Active Implementation Framework, included recommendations that informed ERP implementation tool kit development. RESULTS Key components of the ERP tool kit included the need for a structured and systematic approach, leadership support from key champions, and buy-in from surgical partners and hospital management. Providers identified the need for multimodal educational materials on ERP elements for staff and patients; use of uniform checklists, care sets and an electronic repository to collect outcome data for quality assurance assessment. Patients and caregivers endorsed expansion of the team to include child-life specialists, nutritionists, and patient-parent supporters to help navigate the surgical experience. CONCLUSIONS This study is the first to leverage key input from patients, caregivers, and providers to identify practical components for an ERP implementation tool kit for children undergoing gastrointestinal surgery.
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Affiliation(s)
- Sharron Close
- Department of Pediatric Advanced Practice Nursing, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia.
| | - Sarah C Blake
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Teaniese Tina Davis
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, Georgia
| | - Salva N Balbale
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joseph E Perry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Reed Weingard
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Martha-Conley Ingram
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Willemijn Schäfer
- Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Strople
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Center for Health Services and Outcomes Research, Institute of Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Principles of enhanced recovery in gastrointestinal surgery. Langenbecks Arch Surg 2022; 407:2619-2627. [PMID: 35861873 DOI: 10.1007/s00423-022-02602-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To reduce the impact of surgery-related stress, enhanced recovery after surgery (ERAS) pathways have been developed since over 15 years with subsequent improved postoperative outcome. This multimodal and evidence-based perioperative approach has spread to all fields of gastrointestinal surgery, from esophagus, stomach, duodenum and pancreas, liver, small intestine and colon, and rectum, as well as for other specialties like vascular and cardia surgeries or neurosurgery, among others. PURPOSE The aim of this state-of-the-art article is to assess current state of evidence on perioperative management specifically in gastrointestinal surgery, with a focus on surgery-related aspects, outcome benefit, and future directions. CONCLUSION The surgical team must promote continuous improvement of the patient's ERAS compliance to ensure optimal perioperative care. Everyday clinical practice should be performed according to latest evidence-based medicine and challenging surgical dogma. Moreover, the surgeon must lead and support a multidisciplinary and collaborative teamwork tailored to patient's need especially with anesthetists and nursing staff.
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Lee C, Mabeza RM, Verma A, Sakowitz S, Tran Z, Hadaya J, Lee H, Benharash P. Association of frailty with outcomes after elective colon resection for diverticular disease. Surgery 2022; 172:506-511. [PMID: 35513905 DOI: 10.1016/j.surg.2022.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Frailty has been associated with greater postoperative morbidity and mortality but its impact has not been investigated in patients with diverticulitis undergoing elective colon resection. Therefore, the present study examined the association of frailty with perioperative outcomes following elective colectomy for diverticular disease. METHODS The 2017-2019 American College of Surgeons-National Surgical Quality Improvement Program data registry was queried to identify patients (aged ≥18 years) undergoing elective colon resection for diverticular disease. The 5-factor modified frailty index (mFI-5) was used to stratify patients into non-frail (mFI 0), prefrail (mFI 1), and frail (mFI ≥2) cohorts. Major adverse events, surgical site infection, and postoperative ileus as well as prolonged length of stay, nonhome discharge, and unplanned readmission were evaluated using multivariable logistic models. RESULTS Of the 20,966 patients, 10.0% were frail. Compared to others, frail patients were generally older (non-frail: 55 years, [46-63], prefrail: 62, [54-70], frail: 64, [57-71]) and more commonly female (non-frail: 53.1%, prefrail: 58.6, frail: 64.4, P < .001). Frail patients more frequently underwent open colectomy and stoma creation compared with others. Frailty was associated with greater adjusted odds of major adverse event (adjusted odds ratio 1.25, 95% confidence interval 1.06-1.48), surgical site infection (adjusted odds ratio 1.28, 95% confidence interval 1.06-1.54), and postoperative ileus (adjusted odds ratio 1.59, 95% confidence interval 1.27-1.98). Similarly, frailty portended greater odds of prolonged length of stay, nonhome discharge, and unplanned readmission. CONCLUSION Frailty as defined by the mFI-5 was associated with greater morbidity and hospital resource use. Deployment of frailty instruments may augment traditional risk calculators and improve patient selection for elective colectomy.
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Affiliation(s)
- Cory Lee
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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McGinigle KL, Spangler EL, Pichel AC, Ayyash K, Arya S, Settembrini AM, Garg J, Thomas MM, Dell KE, Swiderski IJ, Lindo F, Davies MG, Setacci C, Urman RD, Howell SJ, Ljungqvist O, de Boer HD. Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2022; 75:1796-1820. [PMID: 35181517 DOI: 10.1016/j.jvs.2022.01.131] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adam C Pichel
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Fae Lindo
- Stanford University Hospital, Palo Alto, CA
| | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Parrish RH, Findley R, Elias KM, Kramer B, Johnson EG, Gramlich L, Nelson GS. Pharmacotherapeutic prophylaxis and post-operative outcomes within an Enhanced Recovery After Surgery (ERAS®) program: A randomized retrospective cohort study. Ann Med Surg (Lond) 2022; 73:103178. [PMID: 35003725 PMCID: PMC8717452 DOI: 10.1016/j.amsu.2021.103178] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 12/11/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Pharmacotherapy prophylaxis embedded in Enhanced Recovery After Surgery (ERAS®) protocols is largely unknown because data related to agent choice, dosing, timing, and duration of treatment currently are not collected in the ERAS Interactive Audit System (EIAS®). This exploratory retrospective randomized cohort study characterized pharmacologic regimens pertaining to prophylaxis of surgical site infections (SSI), venous thromboembolism (VTE), and post-operative nausea and vomiting (PONV). MATERIALS AND METHODS The records of 250 randomly-selected adult patients that underwent elective colorectal (CR) and gynecologic/oncology procedures (GO) at an ERAS® site in North America were abstracted using REDCap. In addition to descriptive statistics, bivariate associations between categorical variables were compared. RESULTS Rates of SSI, VTE, & PONV were 3.3%, 1.1%, and 53.6%, respectively. Mean length of stay (LOS) for CR was 6.9 days and for GO, 3.5 days (p < 0.001). The most common antibiotic prophylaxis was one-time combination cefazolin 2 g and metronidazole 500 mg between 16 and 30 min preoperatively after chlorhexidine skin preparation. The most frequent VTE prophylaxis was tinzaparin 4500 units SC daily continued for at least 7 days after hospital discharge in oncology patients. PONV was related to longer LOS in both groups. Total morphine milligram equivalents (MME) was positively related to PONV and LOS in both CR & GO groups. CONCLUSION Guideline-consistent pharmacologic prophylaxis for SSI and VTE for both CR and GO patients was associated with low complication, LOS, and readmission rates. LOS in both groups was highly influenced by total MME, incidence of PONV and multi-modal anesthesia.
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Affiliation(s)
- Richard H. Parrish
- Department of Biomedical Sciences, Mercer University School of Medicine, 633 First Street, Columbus, GA, 31901, USA
- Corresponding author.;
| | - Rachelle Findley
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 1N4, Canada
| | - Kevin M. Elias
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Brian Kramer
- Department of Pharmacy Services, 111 South Grant Avenue, Grant Medical Center, Columbus, OH, 43215, USA
| | - Eric G. Johnson
- Department of Pharmacy Services, University of Kentucky, 1000 S. Limestone, First Floor, Lexington, KY, 40536, USA
| | - Leah Gramlich
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Walter C Mackenzie Health Sciences Centre, 8440 112 Street NW, Edmonton, AB T6G 2R7, Canada
| | - Gregg S. Nelson
- Department of Obstetrics and Gynecology, University of Calgary Cumming School of Medicine, Tom Baker Cancer Centre, 1331 29 St NW, Calgary, AB T2N 1N4, Canada
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Xing J, Wang J, Liu G, Jia Y. Effects of enhanced recovery after surgery on robotic radical prostatectomy: a systematic review and meta-analysis. Gland Surg 2021; 10:3264-3271. [PMID: 35070886 PMCID: PMC8749100 DOI: 10.21037/gs-21-699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 11/04/2021] [Indexed: 04/06/2024]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has been shown to be an effective, reliable and practical clinical nursing method to support operations on a range of physiological systems, but its effects on robotic radical prostatectomy (RRP) are still unclear. This study assesses the clinical effects of ERAS in RRP. METHODS Various databases including PubMed, EMBASE, Web of Science and China National Knowledge were searched for relevant studies, in particular full-text articles comparing ERAS groups and conventional groups for RRP. All included articles were subject to a quality assessment, and the data analysis was conducted with Review Manager (5.3). Forest plots, sensitivity analyses, and bias analyses were also prepared based on the included articles. RESULTS In total, 8 studies were identified that met the inclusion criteria. The results showed that ERAS groups exhibited significantly reduced time of flatus [mean difference (MD) =-0.58; 95% confidence interval (CI): -0.88, -0.29; P=0.0001], time of catheter removal (MD =-1.65; 95% CI: -2.15, -1.16; P<0.00001), and length of stay (LOS) (MD =-1.49; 95% CI: -2.65, -0.34; P=0.01), and there was no significant difference in terms of postoperative complications between ERAS groups and conventional groups (P=0.07). DISCUSSION This study provides further evidence that ERAS improves postoperative recovery in patients undergoing RRP through reduced time of first flatus, time of catheter removal and LOS. Given the limited quality and quantity of the articles included in this study, further work is needed to validate these findings.
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Affiliation(s)
- Jiahui Xing
- Urology Department, Peking Union Medical College Hospital, Chinese Medical College of Medicine, Beijing, China
| | - Juan Wang
- Urology Department, Peking Union Medical College Hospital, Chinese Medical College of Medicine, Beijing, China
| | - Guanghua Liu
- Urology Department, Peking Union Medical College Hospital, Chinese Medical College of Medicine, Beijing, China
| | - Yujie Jia
- Urology Department, Peking Union Medical College Hospital, Chinese Medical College of Medicine, Beijing, China
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Thörn RMW, Stepniewski J, Hjelmqvist H, Forsberg A, Ahlstrand R, Ljungqvist O. Supervised Immediate Postoperative Mobilization After Elective Colorectal Surgery: A Feasibility Study. World J Surg 2021; 46:34-42. [PMID: 34668047 PMCID: PMC8677683 DOI: 10.1007/s00268-021-06347-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early mobilization is a significant part of the ERAS® Society guidelines, in which patients are recommended to spend 2 h out of bed on the day of surgery. However, it is not yet known how early patients can safely be mobilized after completion of colorectal surgery. The aim of this study was to evaluate the feasibility, and safety of providing almost immediate structured supervised mobilization starting 30 min post-surgery at the postoperative anesthesia care unit (PACU), and to describe reactions to this approach. METHODS This feasibility study includes 42 patients aged ≥18 years who received elective colorectal surgery at Örebro University Hospital. They underwent a structured mobilization performed by a specialized physiotherapist using a modified Surgical ICU Optimal Mobilization Score (SOMS). SOMS determines the level of mobilization at four levels from no activity to ambulating. Mobilization was considered successful at SOMS ≥ 2, corresponding to sitting on the edge of the bed as a proxy of sitting in a chair due to lack of space. RESULTS In all, 71% (n = 30) of the patients reached their highest level of mobilization between the second and third hour of arrival in the PACU. Before discharge to the ward, 43% (n = 18) could stand at the edge of the bed and 38% (n = 16) could ambulate. Symptoms that delayed advancement of mobilization were pain, somnolence, hypotension, nausea, and patient refusal. No serious adverse events occurred. CONCLUSIONS Supervised mobilization is feasible and can safely be initiated in the immediate postoperative care after colorectal surgery. Trial registration Clinical trials.gov identifier: NTC03357497.
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Affiliation(s)
- Rose-Marie W Thörn
- Department of Physiotherapy, Örebro University Hospital, Örebro, Sweden.
| | - Jan Stepniewski
- Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden
| | - Hans Hjelmqvist
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anette Forsberg
- Department of Physiotherapy, Örebro University Hospital, Örebro, Sweden
| | - Rebecca Ahlstrand
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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11
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de Boer HD, Fawcett WJ, Scott MJ. Enhanced recovery after surgery: The road to improve peri-operative care globally. Eur J Anaesthesiol 2021; 38:905-907. [PMID: 34397525 DOI: 10.1097/eja.0000000000001509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Hans D de Boer
- From the Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands (HDdeB), the Department of Anaesthesia and Pain Medicine, Royal Surrey NHS Foundation Trust, Guildford, UK (WJF), the Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA (MJS)
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Zorrilla-Vaca A, Stone AB, Ripolles-Melchor J, Abad-Motos A, Ramirez-Rodriguez JM, Galan-Menendez P, Mena GE, Grant MC. Institutional factors associated with adherence to enhanced recovery protocols for colorectal surgery: Secondary analysis of a multicenter study. J Clin Anesth 2021; 74:110378. [PMID: 34144497 DOI: 10.1016/j.jclinane.2021.110378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/20/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Adherence to Enhanced Recovery Protocols (ERPs) is associated with faster functional recovery, better patient satisfaction, lower complication rates and reduced length of hospital stay. Understanding institutional barriers and facilitators is essential for improving adherence to ERPs. The purpose of this study was to identify institutional factors associated with adherence to an ERP for colorectal surgery. METHODS A secondary analysis of a nationwide study was conducted including 686 patients who underwent colorectal surgery across twenty-one institutions in Spain. Adherence to ERPs was calculated based upon the components recommended by the Enhanced Recovery After Surgery (ERAS®) Society. Institutional characteristics (i.e., case volume, ERP duration, anesthesia staff size, multidisciplinary meetings, leadership discipline) were captured from each participating program. Multivariable regression was performed to determine characteristics associated with adherence. RESULTS The median adherence to ERAS was 68.2% (IQR 59.1%-81.8%). Multivariable linear regression revealed that anesthesiologist leadership (+5.49%, 95%CI +2.81% to +8.18%, P < 0.01), duration of ERAS implementation (+0.46% per year, 95%CI +0.06% to +0.86%, P < 0.01) and the use of regular multidisciplinary meetings (+4.66%, 95%CI +0.06 to +7.74%, P < 0.01) were independently associated with greater adherence. Case volume (-2.38% per 4 cases weekly, 95%CI -3.03 to -1.74, P < 0.01) and number of anesthesia providers (-1.19% per 10 providers, 95%CI +2.23 to -8.18%, P < 0.01) were negatively associated with adherence. CONCLUSION Adherence to ERPs is strongly associated with anesthesiology leadership, regular multidisciplinary meetings, and program duration, whereas case volume and the size of the anesthesia staff were potential barriers. These findings highlight the importance of strong leadership, experience and establishing a multidisciplinary team when developing an ERP for colorectal surgery.
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Affiliation(s)
- Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Alexander B Stone
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Javier Ripolles-Melchor
- Department of Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | - Ane Abad-Motos
- Department of Anesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
| | | | | | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital School of Medicine, Baltimore, MD, USA
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Book Review: Cohn, S.L. (Ed.). Decision Making in Perioperative Medicine: Clinical Pearls. (New York: McGraw-Hill), 2021. ISBN: 978-1-260-46810-6. Healthcare (Basel) 2021. [PMCID: PMC8229655 DOI: 10.3390/healthcare9060687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cohn’s work fills a void in the perioperative care literature by providing a concise, comprehensive, practical, and authoritative guide to the medical management of common periprocedural issues and scenarios [...]
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Enhanced Recovery: A Decade of Experience and Future Prospects at the Mayo Clinic. HEALTHCARE (BASEL, SWITZERLAND) 2021; 9:healthcare9050549. [PMID: 34066696 PMCID: PMC8150975 DOI: 10.3390/healthcare9050549] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023]
Abstract
This work aims to describe the implementation and subsequent learnings from the first decade after the full implementation of enhanced recovery pathway for colorectal surgery at a single institution. This paper will describe the diffusion efforts and plans through the Define, Measure, Analyze, Improve, Control (DMAIC) process of ongoing quality improvement and through research efforts. The information applies to all readers that provide surgical care within their organization as the fundamental principles of enhanced recovery for surgery are applicable regardless of the setting.
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15
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Debono B, Wainwright TW, Wang MY, Sigmundsson FG, Yang MMH, Smid-Nanninga H, Bonnal A, Le Huec JC, Fawcett WJ, Ljungqvist O, Lonjon G, de Boer HD. Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Spine J 2021; 21:729-752. [PMID: 33444664 DOI: 10.1016/j.spinee.2021.01.001] [Citation(s) in RCA: 145] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 12/02/2020] [Accepted: 01/04/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery. PURPOSE This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program. STUDY DESIGN This is a review article. METHODS Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature. RESULTS Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented. CONCLUSION Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.
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Affiliation(s)
- Bertrand Debono
- Paris-Versailles Spine Center (Centre Francilien du Dos), Paris, France; Ramsay Santé-Hôpital Privé de Versailles, Versailles, France.
| | - Thomas W Wainwright
- Research Institute, Bournemouth University, Bournemouth, UK; The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, Bournemouth, UK
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Freyr G Sigmundsson
- Department of Orthopedic Surgery, Örebro University Hospital, Södra Grev Rosengatan, Örebro, Sweden
| | - Michael M H Yang
- Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | | | - Aurélien Bonnal
- Department of Anesthesiology, Clinique St-Jean- Sud de France, Santécité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Jean-Charles Le Huec
- Department of Orthopedic Surgery - Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Olle Ljungqvist
- School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Guillaume Lonjon
- Department of Orthopedic Surgery, Orthosud, Clinique St-Jean- Sud de France, SantéCité Group. St Jean de Vedas, Montpellier Metropole, France
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, the Netherlands
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Xu Y, Udumyan R, Fall K, Ljungqvist O, Montgomery S, Gustafsson UO. Validity of Routinely Collected Swedish Data in the International Enhanced Recovery After Surgery (ERAS) Database. World J Surg 2021; 45:1622-1629. [PMID: 33825960 PMCID: PMC8093151 DOI: 10.1007/s00268-021-06094-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 11/12/2022]
Abstract
Background This study aims to assess patient coverage, validity and data quality in the Swedish part of the International Enhanced Recovery After Surgery (ERAS) Interactive Audit System (EIAS). Method All Swedish ERAS centers that recorded colorectal surgery data in EIAS between January 1, 2017, and December 31, 2017, were included (N = 12). Information registered in EIAS was compared with data from electronic medical records at each hospital to assess the overall coverage of EIAS. Twenty random-selected patients from each of the contributing centers were assessed for accuracy for a set of clinically relevant variables. All patients admitted to the contributing centers were included for the assessment of rate of missing on a selection of key clinical variables. Results Eight hospitals provided complete information for the evaluation, while four hospitals only allowed assessment of coverage and missing data. The eight hospitals had an overall coverage of 98.8% in EIAS (n = 1301) and the four 86.7% (n = 811). The average agreement for the assessed postoperative outcome variables was 96.5%. The accuracy was excellent for ‘length of hospital stay,’ ‘reoperation,’ and ‘any complications,’ but lower for other types of complications. Only a few variables had more than 5% missing data, and missingness was associated with hospital type and size. Conclusion This validation of the Swedish part of the international ERAS database suggests high patient coverage in EIAS and high agreement and limited missingness in clinically relevant variables. This validation approach or a modified version can be used for continued validation of the International ERAS database. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-021-06094-4.
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Affiliation(s)
- Yin Xu
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Ruzan Udumyan
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Katja Fall
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Örebro University and University Hospital, Stockholm, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, Örebro, Sweden.,Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Solna, Stockholm, Sweden.,Department of Epidemiology and Public Health, University College London, London, UK
| | - Ulf O Gustafsson
- Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 18288, Danderyd, Stockholm, Sweden.
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17
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Fawcett WJ, Mythen MG, Scott MJ. Enhanced recovery: joining the dots. Br J Anaesth 2021; 126:751-755. [PMID: 33516456 DOI: 10.1016/j.bja.2020.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/04/2020] [Accepted: 12/28/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey NHS Foundation Trust, Guildford, UK.
| | - Michael G Mythen
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - Michael J Scott
- Perelman School of Medicine, Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
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18
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Chu CE, Law L, Zuniga K, Lin TK, Tsourounis C, Rodriguez-Monguio R, Lazar A, Washington SL, Cooperberg MR, Greene KL, Carroll PR, Pruthi RS, Meng MV, Chen LL, Porten SP. Liposomal Bupivacaine Decreases Postoperative Length of Stay and Opioid Use in Patients Undergoing Radical Cystectomy. Urology 2020; 149:168-173. [PMID: 33278460 DOI: 10.1016/j.urology.2020.11.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/14/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To analyze differences in length of stay, opioid use, and other perioperative outcomes in patients undergoing radical cystectomy with urinary diversion who received either liposomal bupivacaine (LB) or epidural analgesia. METHODS This was a single center, retrospective cohort study of patients undergoing open radical cystectomy with urinary diversion from 2015-2019 in the early recovery after surgery (ERAS) pathway. Patients received either LB or epidural catheter analgesia for post-operative pain control. LB was injected at the time of fascial closure to provide up to 72 hours of local analgesia. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative opioid use, time to solid food, time to ambulation, and direct hospitalization costs. Multivariable Cox proportional hazards regression was used to determine associations between analgesia type and discharge. RESULTS LB use was independently associated with shorter post-operative length of stay compared to epidural use (median (IQR) 4.9 days (3.9-5.8) vs 5.9 days (4.9-7.9), P<.001), less total opioid use (mean 188.3 vs 612.2 OME, P <.001), earlier diet advancement (mean 1.6 vs 2.4 days, P <.001), and decreased overall direct costs ($23,188 vs $29,628, P <.001). 45% of patients who received LB were opioid-free after surgery, none in the epidural group. On multivariable Cox proportional hazards regression modeling, LB use was independently associated with earlier discharge (HR 2.1, IQR 1.0-4.5). CONCLUSION Use of LB in open radical cystectomy is associated with reduced LOS, less opioid exposure, and earlier diet advancement.
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Affiliation(s)
- Carissa E Chu
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA.
| | - Lauren Law
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Kyle Zuniga
- Department of Urology, University of California, Los Angeles, CA
| | - Tracy Kuo Lin
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Candy Tsourounis
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy, Medication Outcomes Center, University of California, San Francisco, CA
| | - Ann Lazar
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Samuel L Washington
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Matthew R Cooperberg
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Kirsten L Greene
- Department of Urology, University of Virginia, Charlottesville, VA
| | - Peter R Carroll
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Raj S Pruthi
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Maxwell V Meng
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
| | - Lee-Lynn Chen
- Department of Anesthesia, University of California, San Francisco, CA
| | - Sima P Porten
- Department of Urology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA
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19
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Impact of Multidisciplinary Audit of Enhanced Recovery After Surgery (ERAS)® Programs at a Single Institution. World J Surg 2020; 45:23-32. [DOI: 10.1007/s00268-020-05765-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 12/19/2022]
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20
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Vertical Compliance: A novel method of reporting patient specific ERAS compliance for real-time risk assessment. Int J Med Inform 2020; 141:104194. [DOI: 10.1016/j.ijmedinf.2020.104194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/17/2020] [Accepted: 05/21/2020] [Indexed: 11/20/2022]
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21
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Lyu HG, Saadat LV, Bertagnolli MM, Wang J, Baldini EH, Stopfkuchen-Evans M, Bleday R, Raut CP. Enhanced recovery after surgery pathway in patients with soft tissue sarcoma. Br J Surg 2020; 107:1667-1672. [PMID: 32618371 DOI: 10.1002/bjs.11758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/01/2020] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Patients undergoing surgery for soft tissue sarcoma have high morbidity rates, particularly after preoperative radiation therapy (RT). An enhanced recovery after surgery (ERAS) programme may improve perioperative outcomes in abdominal surgery. This study reported outcomes of an ERAS programme tailored to patients with soft tissue sarcoma. METHODS A prospective ERAS protocol was implemented in 2015 at a high-volume sarcoma centre. Patients treated within the ERAS programme from 2015 to 2018 were case-matched retrospectively with patients treated between 2012 and 2018 without use of the protocol, matched by surgical site, surgeon, sarcoma histology and preoperative RT treatment. Postoperative outcomes, specifically wound complications and duration of hospital stay, were reported. RESULTS In total, 234 patients treated within the ERAS programme were matched with 237 who were not. The ERAS group had lower wound dehiscence rates overall (2 of 234 (0·9 per cent) versus 31 of 237 (13·1 per cent); P < 0·001), after preoperative RT (0 of 41 versus 11 of 51; P = 0·004) and after extremity sarcoma surgery (0 of 54 versus 6 of 56; P = 0·040) compared with the non-ERAS group. Rates of postoperative ileus or obstruction were lower in the ERAS group (21 of 234 (9·9 per cent) versus 40 of 237 (16·9 per cent); P = 0·016) and in those with retroperitoneal sarcoma (4 of 36 versus 15 of 36; P = 0·007). Duration of hospital stay was shorter in the ERAS group (median 5 (range 0-36) versus 6 (0-67) days; P = 0·003). CONCLUSION Treatment within an ERAS protocol for patients with soft tissue sarcoma was associated with lower morbidity and shorter hospital stay.
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Affiliation(s)
- H G Lyu
- Departments of Surgery, Boston, Massachusetts, USA
| | - L V Saadat
- Departments of Surgery, Boston, Massachusetts, USA
| | - M M Bertagnolli
- Departments of Surgery, Boston, Massachusetts, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - J Wang
- Departments of Surgery, Boston, Massachusetts, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - E H Baldini
- Radiation Oncology, Boston, Massachusetts, USA.,Center for Sarcoma and Bone Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | | | - R Bleday
- Departments of Surgery, Boston, Massachusetts, USA.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - C P Raut
- Departments of Surgery, Boston, Massachusetts, USA.,Radiation Oncology, Boston, Massachusetts, USA
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22
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Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care. Clin Nutr 2020; 39:2014-2024. [DOI: 10.1016/j.clnu.2019.10.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/20/2019] [Indexed: 02/06/2023]
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Pickens RC, King L, Barrier M, Tezber K, Sulzer JK, Cochran A, Lyman WB, Mcclune G, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Hanley M, Vrochides D. Clinically Meaningful Laboratory Protocols Reduce Hospital Charges Based on Institutional and ACS-NSQIP® Risk Calculators in Hepatopancreatobiliary Surgery. Am Surg 2020. [DOI: 10.1177/000313481908500843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®–based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.
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Affiliation(s)
- Ryan C. Pickens
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lacey King
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Misty Barrier
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kendra Tezber
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Jesse K. Sulzer
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Allyson Cochran
- Carolinas Center for Surgical Outcomes Science, Carolinas Medical Center, Charlotte, North Carolina; and
| | - William B. Lyman
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Garth Mcclune
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin H. Baker
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee M. Ocuin
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | | | - Dionisios Vrochides
- Division ofHPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Dean HF, Carter F, Francis NK. Modern perioperative medicine - past, present, and future. Innov Surg Sci 2019; 4:123-131. [PMID: 33977121 PMCID: PMC8059350 DOI: 10.1515/iss-2019-0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/16/2019] [Indexed: 12/11/2022] Open
Abstract
Modern perioperative medicine has dramatically altered the care for patients undergoing major surgery. Anaesthetic and surgical practice has been directed at mitigating the surgical stress response and reducing physiological insult. The development of standardised enhanced recovery programmes combined with minimally invasive surgical techniques has lead to reduction in length of stay, morbidity, costs, and improved outcomes. The enhanced recovery after surgery (ERAS) society and its national chapters provide a means for sharing best practice in this field and developing evidence based guidelines. Research has highlighted persisting challenges with compliance as well as ensuring the effectiveness and sustainability of ERAS. There is also a growing need for increasingly personalised care programmes as well as complex geriatric assessment of frailer patients. Continuous collection of outcome and process data combined with machine learning, offers a potentially powerful solution to delivering bespoke care pathways and optimising individual management. Long-term data from ERAS programmes remain scarce and further evaluation of functional recovery and quality of life is required.
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Affiliation(s)
- Harry F. Dean
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK
| | - Fiona Carter
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil, UK
| | - Nader K. Francis
- Department of General Surgery, Yeovil District Hospital, Higher Kingston, Yeovil BA21 4AT, UK
- Enhanced Recovery after Surgery Society (UK) c.i.c., Yeovil BA20 2RH, UK
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK, Tel.: (01935) 384244
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25
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Reis PGDA, Polakowski C, Lopes M, Bussyguin DS, Ferreira RP, Preti VB, Tomasich FDS. Abbreviated preoperative fasting favours postoperative oral intake at lower hospital admission costs for cancer patients. Rev Col Bras Cir 2019; 46:e20192175. [PMID: 31389524 DOI: 10.1590/0100-6991e-20192175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/17/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate the feasibility of abbreviated fasting in oncologic colorectal surgeries, as well as the impact on the surgical outcome of the patients. METHODS prospective randomized comparative study with patients undergoing elective colorectal cancer surgeries from May to September 2017. Patients were randomized electronically into two groups according to the preoperative fast to be adopted: conventional or abbreviated. RESULTS of the 33 patients included, 15 followed the abbreviated fasting protocol and 18 the conventional fasting. Both groups had comparable profiles. No patient underwent mechanical preparation of the colon. In 69.7% of the cases, surgery involved low rectal dissection. The procedures were equivalent in relation to intraoperative variables and severe complications. The time to achieve complete oral intake was shorter for abbreviated fasting (10 versus 16 days, p=0.001), as well as the length of inhospital stay (2 versus 4 days, p=0.009). Hospital costs were lower in the abbreviated fasting (331 versus 682 reais, p<0.001). The univariable analysis revealed a correlation between complete oral intake and abbreviated fasting [HR 0.29 (IC95%: 0.12-0.68] and abdominal distension [HR 0.12 (IC95% 0.01-0.94)]. After multivariable analysis, abbreviated fasting presented a lower time for complete oral intake [HR 0.39 (IC95%: 0.16-0.92]. CONCLUSION the abbreviated preoperative fasting favors the metabolic-nutritional recovery, reducing the time for complete oral intake. The implementation of the abbreviation protocol reduces hospital admission costs.
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Affiliation(s)
| | - Camila Polakowski
- Hospital Erasto Gaertner, Serviço de Nutrição, Equipe Multidisciplinar de Terapia Nutricional (EMTN), Curitiba, PR, Brasil
| | - Marina Lopes
- Hospital Erasto Gaertner, Serviço de Nutrição, Equipe Multidisciplinar de Terapia Nutricional (EMTN), Curitiba, PR, Brasil
| | | | | | - Vinicius Basso Preti
- Hospital Erasto Gaertner, Serviço de Nutrição, Equipe Multidisciplinar de Terapia Nutricional (EMTN), Curitiba, PR, Brasil.,Hospital Erasto Gaertner, Serviço de Cirurgia Abdominal, Curitiba, PR, Brasil
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