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Greig P, Sotiriou A, Kailainathan P, Carvalho CYM, Onwochei DN, Thurley N, Desai N. Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery. J Clin Anesth 2024; 95:111468. [PMID: 38599160 DOI: 10.1016/j.jclinane.2024.111468] [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: 01/15/2024] [Revised: 03/07/2024] [Accepted: 04/03/2024] [Indexed: 04/12/2024]
Abstract
STUDY OBJECTIVE Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery. DESIGN Systematic review. SETTINGS Robot assisted abdominal surgery. PATIENTS Adults. INTERVENTIONS Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials. MAIN RESULTS We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent. CONCLUSIONS Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.
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Affiliation(s)
- P Greig
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom
| | - A Sotiriou
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - P Kailainathan
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - C Y M Carvalho
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - D N Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom
| | - N Thurley
- Bodleian Health Care Libraries, University of Oxford, United Kingdom
| | - N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; King's College London, London, United Kingdom.
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Özbay T, Şanlı D, Springer JE. An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery. Acta Chir Belg 2024:1-10. [PMID: 38445819 DOI: 10.1080/00015458.2024.2327813] [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: 10/19/2023] [Accepted: 02/29/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Although ERAS protocols have many benefits, there are some deficiencies in their understanding and implementation by healthcare professionals. The present study was conducted to investigate the compliance of the current perioperative practices of healthcare professional with the ERAS protocols and to assess barriers to the implementation of ERAS protocols in colorectal surgery. METHODS This cross-sectional descriptive study conducted in the surgical clinics and operating rooms of a training and research hospital between January 2020 and September 2020 included 110 physician and nurse members of surgical teams. Data were collected using the Questionnaire for Evaluating the Use of the ERAS Protocol and Identifying Barriers to Implementation in Colorectal Surgery. RESULTS The compliance of the current perioperative practices by healthcare professionals with the ERAS protocols ranged between 15.5% (routinely leaving nasogastric tubes in situ following colorectal resection) and 61.8% (being aware of the concept of balanced analgesia). Variables such as the healthcare professional's profession, title, years in practice and colorectal surgery experience led to a difference between them in terms of their compliance of the practices with the ERAS protocols (p < 0.05). Based on the healthcare professionals' comments about barriers to the implementation of the ERAS protocol, themes such as education, teamwork, communication and lack of resources were created. CONCLUSION Healthcare professionals' compliance level of the current perioperative practices with the ERAS protocols was mostly low. Barriers to the implementation of the ERAS protocols had a multi-factor structure that concerns the multidisciplinary team.
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Affiliation(s)
- Turna Özbay
- Department of Nursing, Graduate School of Health Sciences, Izmir Katip Celebi University, Izmir, Türkiye
| | - Deniz Şanlı
- Department of Surgical Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Izmir, Türkiye
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Yim GH, Pikturnaite J, Harry L, Clement R, Pope-Jones S, Emam A, Marsden N. Enhanced recovery for acute open lower limb fracture 'fix and flap'. Injury 2024; 55:111234. [PMID: 38029681 DOI: 10.1016/j.injury.2023.111234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 10/10/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates. METHODS An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. RESULTS 161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. CONCLUSION In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.
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Affiliation(s)
- Guang Hua Yim
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Jurga Pikturnaite
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Lorraine Harry
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Rhys Clement
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Orthopaedic department, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom
| | - Sophie Pope-Jones
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Ahmed Emam
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom
| | - Nicholas Marsden
- The Welsh Centre for Burns & Plastics, Morriston Hospital, Heol Maes Eglwys, Morriston SA6 6NL, Swansea, United Kingdom; Major Trauma Centre, University Hospital of Wales, Cardiff CF14 4XW, United Kingdom.
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Heinrich S, Gratza S, Eckardt A, Ilchmann T. Stepwise implementation of an enhanced recovery pathway for elective total hip arthroplasty in a Swiss hospital: a cohort study. Swiss Med Wkly 2024; 154:3537. [PMID: 38579311 DOI: 10.57187/s.3537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Enhanced recovery programs after total hip arthroplasty have been shown to reduce hospital length of stay without compromising results, but yet there is a lack of data for the Swiss population. Therefore, this retrospective cohort study evaluated whether similar positive effects on clinical outcomes are present in the context of the Swiss healthcare system. METHODS Patients who underwent elective primary total hip arthroplasty were analysed. The baseline group comprised 50 patients treated consecutively by one surgeon in 2013 according to the clinical practice guidelines. Another surgeon implemented a new standardised treatment protocol in April 2014. In January 2018, this protocol was followed by an enhanced recovery program that integrated all care providers at the hospital. The data of the baseline group (series 0) and four series of 50 patients each, two treated with the standardised treatment protocol (series 1-2) and two treated with the enhanced recovery program (series 3-4), were analysed. All patients had follow-ups at 6 weeks and 3 months after surgery. The primary outcomes were length of stay and discharge destination; the secondary outcomes were admission on the day of surgery (instead of one day prior), the use of urinary catheters, the administration of opioids, the difference between pre- and postoperative haemoglobin, blood transfusions, and adverse events within 3 months of surgery. RESULTS The median length of stay was 10 days in the baseline group and only 5 days after the implementation of the standardised protocol and enhanced recovery program in series 4 (p <0.001). The percentage of patients discharged directly home was higher in series 4 than in the baseline group (84% vs. 66%, p = 0.085). Patients admitted to the hospital on the day of surgery increased from 2% in series 0 to 98% in series 4 (p <0.001). The use of urinary catheters was significantly higher in the baseline group (100% of patients) than in series 3 and 4 (0%) (p <0.001), and the number of patients who did not require opioids was significantly higher in series 4 than in series 0 (36% vs. 10%, p = 0.007). The median blood loss (500 ml vs. 300 ml, p <0.001), median difference in pre- and postoperative haemoglobin (29 g/dl vs. 25 g/dl, p = 0.145), and number of blood transfusions (5 vs. 2 p = 0.99) were higher in the baseline group than in series 4. The number of adverse events did not differ significantly between groups (p = 0.699). CONCLUSIONS Almost all parameters examined in this study showed improvement, whereas the rate of adverse events was not affected and remained low. The presented data can be used as a benchmark, but details of these findings need to be confirmed in larger cohorts.
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Affiliation(s)
| | - Simon Gratza
- University Hospital of Basel, Basel, Switzerland
| | - Anke Eckardt
- University Hospital of Basel, Basel, Switzerland
| | - Thomas Ilchmann
- Hirslanden Klinik Birshof, Endo Team, Münchenstein, Switzerland
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Enhanced Recovery after Uterine Corpus Cancer Surgery: A 10 Year Retrospective Cohort Study of Robotic Surgery in an NHS Cancer Centre. Cancers (Basel) 2022; 14:cancers14215463. [PMID: 36358881 PMCID: PMC9657636 DOI: 10.3390/cancers14215463] [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] [Received: 08/31/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/10/2022] Open
Abstract
Simple Summary Surgical and survival outcomes for uterine corpus cancer following the introduction of robotic surgery to Royal Surrey NHS Foundation Trust; a large volume United Kingdom teaching hospital and cancer centre. Introduction of the Da VinciTM robot was associated with enhanced recovery after surgery with low 30-day mortality (0.1%), low return to theatre (0.5%), a low use of blood transfusion and intensive care (1.8% & 7.2% respectively), low conversion to open surgery (0.5%) and a reduction in median length of stay, with comparable survival to published data, and a three to four fold increase in cases treated. This increased productivity was associated with a highly predicable patient pathway of care, for high-risk patients, with reduced demands on health services. Abstract Royal Surrey NHS Foundation Trust introduced robotic surgery for uterine corpus cancer in 2010 to support increased access to minimally invasive surgery, a central element of an enhanced recovery after surgery (ERAS) pathway. More than 1750 gynaecological oncology robotic procedures have now been performed at Royal Surrey NHS Foundation Trust. A retrospective cohort study was performed of patients undergoing surgery for uterine corpus cancer between the 1 January 2010 and the 31 December 2019 to evaluate its success. Data was extracted from the dedicated gynaecological oncology database and a detailed notes review performed. During this time; 952 patients received primary surgery for uterine corpus cancer; robotic: n = 734; open: n = 164; other minimally invasive surgery: n = 54. The introduction of the Da VinciTM robot to Royal Surrey NHS Foundation Trust was associated with an increase in the minimally invasive surgery rate. Prior to the introduction of robotic surgery in 2008 the minimally invasive surgery (MIS) rate was 33% for women with uterine corpus cancer undergoing full surgical staging. In 2019, 10 years after the start of the robotic surgery program 91.3% of women with uterine corpus cancer received robotic surgery. Overall the MIS rate increased from 33% in 2008 to 92.9% in 2019. Robotic surgery is associated with a low 30-day mortality (0.1%), low return to theatre (0.5%), a low use of blood transfusion and intensive care (1.8% & 7.2% respectively), low conversion to open surgery (0.5%) and a reduction in median length of stay from 6 days (in 2008) to 1 day, regardless of age/BMI. Robotic survival is consistent with published data. Introduction of the robotic program for the treatment of uterine cancer increased productivity and was associated with a highly predicable patient pathway of care, for high-risk patients, with reduced demands on health services. Future health care commissioning should further expand access to robotic surgery nationally for women with uterine corpus cancer.
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Wall J, Dhesi J, Snowden C, Swart M. Perioperative medicine. Future Healthc J 2022; 9:138-143. [DOI: 10.7861/fhj.2022-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Garipov MR, Moskalenko AN, Cherepanova EV, Ayupov RT, Feoktistov DV, Tarasov NA, Lyadov VK, Galkin VN. [Fast track recovery protocols for extended pelvic surgery]. Khirurgiia (Mosk) 2022:59-65. [PMID: 36562674 DOI: 10.17116/hirurgia202212259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare the immediate results of extended pelvic surgery before and after introduction of standardized fast track surgery (FTS) protocol into routine clinical practice. MATERIAL AND METHODS The study included 111 patients with pelvic tumors who underwent extended pelvic surgery. The control group included 59 patients whose perioperative management implied traditional approaches (2018-2019), the main group - 52 patients with FTS protocol (2020-2021). Age, BMI and ECOG status were similar. In the main group, females (90.4% vs. 74.6%; p=0.046), patients with recurrent (46.2% vs. 22.0%; p=0.009) and complicated tumors (26.9% vs. 11.9%; p=0.054) prevailed. Obstructive resection without anastomosis was less common in the main group (28.8% vs. 47.5%; p=0.068). RESULTS Surgery time was higher (319±125 min vs. 236±79 min, p<0.001) in the main group, but blood loss (238±154 ml vs. 282±150 ml, p=0.029) and incidence of blood transfusions (23.1% vs. 42.4%, p=0.043) were lower. Moreover, complications (36.6% vs. 54.3%; p=0.086), mild complications (Clavien-Dindo class I-II) (11.6% vs. 28.8%; p=0.034) and local infectious complications (19.2% vs. 42.4%; p=0.009) were less common in the main group. Two patients died in the control group due to sepsis following colonic anastomosis and bladder suture failure, respectively. Postoperative hospital-stay was similar (14±9.1 days vs. 14.4±9 days; p=0.89). CONCLUSION FTS protocol is possible and safe in patients with locally advanced and recurrent malignant pelvic tumors. This approach reduces blood loss, the number of blood transfusions and risk of postoperative infections.
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Affiliation(s)
- M R Garipov
- City Clinical Oncology Hospital No. 1, Moscow, Russia
| | | | | | - R T Ayupov
- Republican Clinical Oncology Dispensary, Ufa, Russia
| | | | - N A Tarasov
- Republican Clinical Oncology Dispensary, Ufa, Russia
| | - V K Lyadov
- City Clinical Oncology Hospital No. 1, Moscow, Russia
| | - V N Galkin
- City Clinical Oncology Hospital No. 1, Moscow, Russia
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Morrell AT, Layon DR, Scott MJ, Kates SL, Golladay GJ, Patel NK. Enhanced Recovery After Primary Total Hip and Knee Arthroplasty: A Systematic Review. J Bone Joint Surg Am 2021; 103:1938-1947. [PMID: 34166275 DOI: 10.2106/jbjs.20.02169] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) has become increasingly implemented to reduce costs, to increase efficiency, and to optimize patient outcomes after a surgical procedure. This study aimed to systematically review the effect of ERAS after primary elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) on hospital length of stay, total procedure-related morbidity, and readmission. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and with guidance from the Cochrane Handbook for Systematic Reviews of Interventions. MEDLINE, Embase, and Cochrane databases were searched from inception (1946 for MEDLINE and 1974 for Embase; Cochrane is a composite of multiple databases and thus does not report a standard inception date) until January 15, 2020. Prospective nonrandomized cohort studies and randomized controlled trials comparing adult patients undergoing elective primary THA or TKA with ERAS or traditional protocols were included. Articles examining outpatient, nonelective, or revision surgical procedures were excluded. Two reviewers independently assessed the risk of bias and extracted data. The primary outcome was length of stay. The secondary outcomes included total procedure-related morbidity and readmission. RESULTS Of the 1,018 references identified (1,017 identified through an electronic search and 1 identified through a manual search), 9 individual studies met inclusion criteria. Data were reported from 7,789 participants, with 2,428 receiving ERAS and 5,361 receiving traditional care. Narrative synthesis was performed instead of meta-analysis, given the presence of moderate to high risk of bias, wide variation of ERAS interventions, and inconsistent methods for assessing and reporting outcomes among included studies. Adherence to ERAS protocols consistently reduced hospital length of stay. Few studies demonstrated reduced total procedure-related morbidity, and there was no significant effect on readmission rates. CONCLUSIONS ERAS likely reduced the length of stay after primary elective THA and TKA, with a more pronounced effect in selected healthier patient populations. We found minimal to no impact on perioperative morbidity or readmission. The quality of existing evidence was limited because of study heterogeneity and a significant risk of bias. Further high-quality research is needed to definitively assess the impact of ERAS on total joint arthroplasty. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Aidan T Morrell
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel R Layon
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Michael J Scott
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Nirav K Patel
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, Virginia
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Grass F, Hübner M, Behm KT, Mathis KL, Hahnloser D, Day CN, Harmsen WS, Demartines N, Larson DW. Development and validation of a prediction score for safe outpatient colorectal resections. Surgery 2021; 171:336-341. [PMID: 34503851 DOI: 10.1016/j.surg.2021.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections. METHODS This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit. RESULTS Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort. CONCLUSION The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN; Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Kevin T Behm
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
| | - Dieter Hahnloser
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - Courtney N Day
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
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van den Broek RJC, van de Geer R, Schepel NC, Liu WY, Bouwman RA, Versyck B. Evaluation of adding the Erector spinae plane block to standard anesthetic care in patients undergoing posterior lumbar interbody fusion surgery. Sci Rep 2021; 11:7631. [PMID: 33828209 PMCID: PMC8027195 DOI: 10.1038/s41598-021-87374-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Postoperative analgesia in patients undergoing spinal fusion surgery is challenging due to the invasiveness of the surgical procedure and the frequent use of opioids preoperatively by many patients. Recently, the erector spinae plane (ESP) block has been introduced in our clinical practice as part of a multimodal pain strategy after posterior lumbar interbody fusion surgery. This is a retrospective case–control study evaluating the analgesic efficacy of the ESP block when added to our standard analgesic regimen for posterior lumbar interbody fusion surgery. Twenty patients who received an erector spinae plane block were compared with 20 controls. The primary endpoint was postoperative pain, measured by the numeric rating scale. Secondary outcome measures were opioid use, postoperative nausea and vomiting, and length of stay. Postoperative pain scores in the PACU were lower in patients who received an erector spinae plane block (p = 0.041). Opioid consumption during surgery and in the PACU was not significantly different. Need for patient-controlled analgesia postoperatively was significantly lower in the group receiving an ESP block (p = 0.010). Length of stay in hospital was reduced from 3.23 days (IQR 1.1) in the control group to 2.74 days (IQR 1.6) in the study group (p = 0.012). Adding an erector spinae plane block to the analgesic regimen for posterior lumbar interbody fusion surgery seemed to reduce postoperative pain and length of hospital stay.
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Affiliation(s)
- Renee J C van den Broek
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Robbin van de Geer
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Niek C Schepel
- Department of Orthopedic Surgery and Trauma, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Wai-Yan Liu
- Department of Orthopedic Surgery and Trauma, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Barbara Versyck
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.,Department of Anesthesiology, AZ Turnhout, Campus St Jozef, Steenweg op Merksplas 44, 2300, Turnhout, Belgium
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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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Dumitrascu CI, Warner NS, Stewart TM, Amundson AW, Bruns DL, Hanson AC, Schulte PJ, Smith MM, Brown MJ, Niesen AD, Mantilla CB, Warner MA. Peripheral Nerve Blockade with Combined Standard and Liposomal Bupivacaine in Major Lower-Extremity Amputation. Pain Pract 2020; 21:299-307. [PMID: 33058387 DOI: 10.1111/papr.12959] [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: 07/17/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Optimizing perioperative analgesia for patients undergoing major lower-extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower-extremity amputation is unknown. METHODS We conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower-extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression. RESULTS A total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59). CONCLUSIONS Peripheral nerve blockade is associated with reduced opioid requirements after lower-extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.
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Affiliation(s)
- Catalina I Dumitrascu
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nafisseh S Warner
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.,Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Thomas M Stewart
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam W Amundson
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Danette L Bruns
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Andrew C Hanson
- Division of Biomedical Statistics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Phillip J Schulte
- Division of Biomedical Statistics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Brown
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam D Niesen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Carlos B Mantilla
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Matthew A Warner
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.,Division of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Witcher A, Axley J, Novak Z, Laygo-Prickett M, Guthrie M, Xhaja A, Chu DI, Brokus SD, Spangler EL, Passman MA, McGinigle KL, Pearce BJ, Schlitz R, Short RT, Simmons JW, Cross RC, McFarland GE, Beck AW. Implementation of an enhanced recovery program for lower extremity bypass. J Vasc Surg 2020; 73:554-563. [PMID: 32682069 DOI: 10.1016/j.jvs.2020.06.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 06/12/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Enhanced recovery programs (ERPs) have gained wide acceptance across multiple surgical disciplines to improve postoperative outcomes and to decrease hospital length of stay (LOS). However, there is limited information in the existing literature for vascular patients. We describe the implementation and early results of an ERP and barriers to its implementation for lower extremity bypass surgery. Our intention is to provide a framework to assist with implementation of similar ERPs. METHODS Using the plan, do, check, adjust methodology, a multidisciplinary team was assembled. A database was used to collect information on patient-, procedure-, and ERP-specific metrics. We then retrospectively analyzed patients' demographics and outcomes. RESULTS During 9 months, an ERP (n = 57) was successfully developed and implemented spanning preoperative, intraoperative, and postoperative phases. ERP and non-ERP patient demographics were statistically similar. Early successes include 97% use of fascia iliaca block and multimodal analgesia administration in 81%. Barriers included only 47% of patients achieving day of surgery mobilization and 19% receiving celecoxib preoperatively. ERP patients had decreased total and postoperative LOS compared with non-ERP patients (n = 190) with a mean (standard deviation) total LOS of 8.32 (8.4) days vs 11.14 (10.1) days (P = .056) and postoperative LOS of 6.12 (6.02) days vs 7.98 (7.52) days (P = .089). There was significant decrease in observed to expected postoperative LOS (1.28 [0.66] vs 1.82 [1.38]; P = .005). Variable and total costs for ERP patients were significantly reduced ($13,208 [$9930] vs $18,777 [$19,118; P < .01] and $29,865 [$22,110] vs $40,328 [$37,820; P = .01], respectively). CONCLUSIONS Successful implementation of ERP for lower extremity bypass carries notable challenges but can have a significant impact on practice patterns. Further adjustment of our current protocol is anticipated, but early results are promising. Implementation of a vascular surgery ERP reduced variable and total costs and decreased total and postoperative LOS. We believe this protocol can easily be implemented at other institutions using the pathway outlined.
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Affiliation(s)
- Adam Witcher
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - John Axley
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Maria Laygo-Prickett
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Meredith Guthrie
- UAB Clinical Effectiveness, University of Alabama at Birmingham, Birmingham, Ala
| | - Anisa Xhaja
- UAB Clinical Effectiveness, University of Alabama at Birmingham, Birmingham, Ala
| | - Daniel I Chu
- Division of Gastrointestinal Surgery, Section of Colorectal Surgery, University of Alabama at Birmingham, Birmingham, Ala
| | - S Danielle Brokus
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | | | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Ryne Schlitz
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Roland T Short
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Jeffrey W Simmons
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Richard C Cross
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, Ala.
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14
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Savikko J, Vikatmaa L, Hiltunen AM, Mallat N, Tukiainen E, Salonen SM, Nordin A. Enhanced recovery protocol in laparoscopic liver surgery. Surg Endosc 2020; 35:1058-1066. [PMID: 32107630 PMCID: PMC7886749 DOI: 10.1007/s00464-020-07470-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/19/2020] [Indexed: 01/22/2023]
Abstract
Introduction Enhanced recovery protocols (ERP) accelerate recovery and shorten postoperative hospital stay. This increased knowledge of ERPs has also gradually implemented into liver surgery. However, in laparoscopic liver surgery (LLS), the experience of optimized perioperative care protocols is still limited. Methods We prospectively studied the implementation of multimodal ERP principles to LLS in the first 100 consecutive patients. Opioid-sparing multimodal pain management was applied together with early mobilization already in the postoperative care unit (PACU). Drains and catheters were avoided and per oral intake was initiated promptly. Primary pain control was achieved with iv NSAIDS, low-dose opioid and corticosteroids. Combination of per oral ibuprofen and long-acting tramadol was routinely administered shortly after operation. The multiprofessional adherence to the protocol was also evaluated. Results Investigated LLS was performed during Aug 2016–Apr 2019. Operations were done due to malignancy in 83 (83%) of cases, mostly for colorectal liver metastases (n = 52, 52%). Forty-eight (48%) of the operated patients were female. Median age was 65 years (range 17–91). The American Society of Anaesthesiologists Physical Status (ASA) classification median was three. Median postoperative hospital stay was 2 days (range 1–8 days). More than seventy percent of patients were discharged by the second postoperative day and nearly ninety percent by the third postoperative day. Complications after surgery were few. The new ERP elements were adopted in most of the cases. Conclusions ERP was introduced safely and effectively after LLS. The adherence to the ERP was good. Routine discharge 1–2 days after LLS is realistic and achievable.
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Affiliation(s)
- Johanna Savikko
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland.
| | - Leena Vikatmaa
- Department of Anesthesiology and Intensive Care Medicine, HUS Helsinki University Hospital, Helsinki, Finland
| | - Anna-Maria Hiltunen
- Department of Industrial Engineering and Management, HEMA Institute, Aalto University, Helsinki, Finland.,Nordic Healthcare Group, Helsinki, Finland
| | - Noora Mallat
- Department of Anesthesiology and Intensive Care Medicine, HUS Helsinki University Hospital, Helsinki, Finland
| | - Eija Tukiainen
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland
| | - Sari-Mari Salonen
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, HUS Helsinki University Hospital, Haartmaninkatu 4, P.O. Box 340, 00029, Helsinki, Finland
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15
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Elderly patients over 70 years benefit from enhanced recovery programme after colorectal surgery as much as younger patients. J Visc Surg 2020; 157:23-31. [DOI: 10.1016/j.jviscsurg.2019.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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16
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Zaouter C, Oses P, Assatourian S, Labrousse L, Rémy A, Ouattara A. Reduced Length of Hospital Stay for Cardiac Surgery—Implementing an Optimized Perioperative Pathway: Prospective Evaluation of an Enhanced Recovery After Surgery Program Designed for Mini-Invasive Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2019; 33:3010-3019. [DOI: 10.1053/j.jvca.2019.05.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 05/02/2019] [Accepted: 05/04/2019] [Indexed: 12/21/2022]
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17
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Ribeiro D, Cimino SR, Mayo AL, Ratto M, Hitzig SL. 3D printing and amputation: a scoping review. Disabil Rehabil Assist Technol 2019; 16:221-240. [PMID: 31418306 DOI: 10.1080/17483107.2019.1646825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Three-dimensional (3D) printing is an innovative technology being utilized to create prostheses for individuals with limb loss. However, there is a paucity of research on the feasibility of using this technology to fabricate prostheses. A scoping review was conducted to map the literature on 3D printing and its applications in the field of amputation. MATERIALS AND METHODS Using a scoping review framework, a systematic literature search was conducted in three electronic databases (MEDLINE, EMBASE and CINAHL) for all indexed literature up to 29 June 2018. RESULTS Twenty-eight articles met the inclusion criteria. The majority of studies had small sample sizes (five participants or less; n = 20) and used a case study design (n = 17). The benefits of 3D printing technology include higher levels of customization and lower production costs. However, the functionality of 3D printed prostheses is lacking. There is also a need for more robust research designs to obtain a better understanding of the advantages and disadvantages of 3D printed prostheses and its impact on end-user outcomes. CONCLUSIONS The use of 3D printing technology has a number of benefits for improving the manufacturing process of devices for people with lower and upper limb loss. However, more research and technological advancements are required to fully understand the impact of this technology on patients and how it will affect their daily life. The long-term effects of this technology will also need to be investigated in order to produce a more sustainable alternative to traditional prostheses.IMPLICATIONS FOR REHABILITATIONThe use of 3D printing technology for the fabrication of prosthetics for persons with limb-loss has a number of promising features to improve the fitting and customization of these devices for this patient population.Although the costs of producing 3D printed devices is less expensive and burdensome than traditional approaches to manufacturing techniques, there is a need for additional technological advancements to improve the functionality of these devices.Future research needs to adopt more robust research designs with larger sample sizes to provide a better understanding of the viability of using 3D printing technology to improve patient outcomes.
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Affiliation(s)
- Danielle Ribeiro
- Department of Electrical, Computer and Biomedical Engineering, Faculty of Engineering and Architectural Science, Ryerson University, Toronto, Canada
| | - Stephanie R Cimino
- St. John's Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Amanda L Mayo
- St. John's Rehabilitation Hospital, Sunnybrook Health Sciences Centre, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Matt Ratto
- Faculty of Information, University of Toronto, Toronto, Canada
| | - Sander L Hitzig
- St. John's Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada.,Faculty of Information, University of Toronto, Toronto, Canada.,Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada
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18
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Fawcett W. Outcome following surgery. Anaesthesia 2019; 74:1204. [PMID: 31386182 DOI: 10.1111/anae.14766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- W Fawcett
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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19
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20
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Fawcett WJ. Enhanced recovery after surgery pathways in gynecologic surgery: great strides already, but more still to come. Int J Gynecol Cancer 2019; 29:649-650. [PMID: 31064861 DOI: 10.1136/ijgc-2019-000395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 11/03/2022] Open
Affiliation(s)
- William J Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford GU2 7XX, UK
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21
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Elias KM, Stone AB, McGinigle K, Tankou JI, Scott MJ, Fawcett WJ, Demartines N, Lobo DN, Ljungqvist O, Urman RD. The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS ® and ERAS ® USA Societies. World J Surg 2019; 43:1-8. [PMID: 30116862 PMCID: PMC6313353 DOI: 10.1007/s00268-018-4753-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programs are multimodal care pathways designed to minimize the physiological and psychological impact of surgery for patients. Increased compliance with ERAS guidelines is associated with improved patient outcomes across surgical types. As ERAS programs have proliferated, an unintentional effect has been significant variation in how ERAS-related studies are reported in the literature. METHODS To improve the quality of ERAS reporting, ERAS® USA and the ERAS® Society launched an effort to create an instrument to assist authors in manuscript preparation. Criteria to include were selected by a combination of literature review and expert opinion. The final checklist was refined by group consensus. RESULTS The Societies present the Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist. The tool contains 20 items including best practices for reporting clinical pathways, compliance auditing, and formatting guidelines. CONCLUSIONS The RECOvER Checklist is intended to provide a standardized framework for the reporting of ERAS-related studies. The checklist can also assist reviewers in evaluating the quality of ERAS-related manuscripts. Authors are encouraged to include the RECOvER Checklist when submitting ERAS-related studies to peer-reviewed journals.
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Affiliation(s)
- Kevin M Elias
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Alexander B Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katharine McGinigle
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jo'An I Tankou
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, Richmond, VA, USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital and University of Surrey, Guilford, UK
| | - Nicolas Demartines
- Department of Visceral Surgery, Lausanne University Hospital CHUV, Lausanne, Switzerland
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Daenen C, Coimbra C, Hans G, Joris J. Labelling as reference Centre of GRACE (Groupe francophone de Réhabilitation Améliorée après ChirurgiE) for colorectal surgery: its impact on the implementation of enhanced recovery programme at the University Hospital of Liège. Acta Chir Belg 2018; 118:294-298. [PMID: 29334872 DOI: 10.1080/00015458.2018.1427837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Enhanced recovery programme (ERP) has been used in our hospital since 2005 for selected colorectal surgeries. Since October 2015, after labelling as GRACE reference centre, we included all patients scheduled for elective colorectal surgery in this programme. We assessed the impact of our labelling on the implementation of ERP. METHODS Results of our first 100 patients entered in the GRACE database were analyzed: length of stay, complications, readmission, adherence to the protocol. These results are compared to those of the last 100 patients undergoing colorectal surgery before our labelling. RESULTS Patients' characteristics in both groups were similar. The complications rate was similar in both groups. The global length of hospital stay was 4 [5] days vs. 8.5 [8] (median [IQR]), respectively after and before labelling; p < .001. The duration of hospitalization for the different subgroups (age, surgical approach, types of surgery) were significantly shorter after our labelling (respectively: p < .001, p < .01, and p < .05). CONCLUSIONS Our results demonstrate that labelling as reference centre increases the efficiency of the implementation of ERP. The fact that all subgroups of patients benefit from ERP must encourage inclusion of all patients undergoing elective colorectal surgery in ERP.
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Affiliation(s)
- Coralie Daenen
- Department of Anaesthesiology, CHU Liège, University of Liège, Liège, Belgium
| | - Carla Coimbra
- Service of Abdominal Surgery, CHU Liège, University of Liège, Liège, Belgium
| | - Grégory Hans
- Department of Anaesthesiology, CHU Liège, University of Liège, Liège, Belgium
| | - Jean Joris
- Department of Anaesthesiology, CHU Liège, University of Liège, Liège, Belgium
- GRACE3 (Groupe francophone de Réhabilitation Après ChirurgiE), Baumont, France
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Berg U, BüLow E, Sundberg M, Rolfson O. No increase in readmissions or adverse events after implementation of fast-track program in total hip and knee replacement at 8 Swedish hospitals: An observational before-and-after study of 14,148 total joint replacements 2011-2015. Acta Orthop 2018; 89:522-527. [PMID: 29985681 PMCID: PMC6202734 DOI: 10.1080/17453674.2018.1492507] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - Fast-track care programs in elective total hip and knee replacement (THR/TKR) have been introduced in several countries during the last decade resulting in a significant reduction of hospital stay without any rise in readmissions or early adverse events (AE). We evaluated the risk of readmissions and AE within 30 and 90 days after surgery when a fast-track program was introduced in routine care of joint replacement at 8 Swedish hospitals. Patients and methods - Fast-track care programs were introduced at 8 public hospitals in Västra Götaland region from 2012 to 2014. We obtained data from the Swedish Hip and Knee Arthroplasty Registers for patients operated with THR and TKR in 2011-2015. All readmissions and new contacts with the health care system within 3 months with a possible connection to the surgical intervention were requested from the regional patient register. We compared patients operated before and after the introduction of the fast-track program. Results - Implementation of the fast-track program resulted in a decrease in median hospital length of stay (LOS) from 5 to 3 days in both THR and TKR. The total readmission rate <90 days for THR was 7.2% with fast-track compared with 6.7% in the previous program, and for TKR 8.4% in both groups. Almost half of the readmissions occurred without any AE identified. There was no statistically significant difference concerning readmissions or AE when comparing the programs. Interpretation - Implementation of a fast-track care program in routine care of elective hip and knee replacement is effective in reducing hospital stay without increasing the risk of readmissions or adverse events within 90 days after surgery.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Critical Pathways/organization & administration
- Female
- Hospitalization/statistics & numerical data
- Humans
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Patient Readmission/statistics & numerical data
- Postoperative Complications/epidemiology
- Registries
- Sweden/epidemiology
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Affiliation(s)
- Urban Berg
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg;
- Department of Surgery and Orthopaedics, Kungälv Hospital;
- Correspondence:
| | - Erik BüLow
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg;
- The Swedish Hip Arthroplasty Register;
| | - Martin Sundberg
- Department of Orthopedics, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden;
- The Swedish Knee Arthroplasty Register
| | - Ola Rolfson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg;
- The Swedish Hip Arthroplasty Register;
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Gan TJ, Scott M, Thacker J, Hedrick T, Thiele RH, Miller TE. American Society for Enhanced Recovery. Anesth Analg 2018; 126:1870-1873. [DOI: 10.1213/ane.0000000000002925] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Joris J, Léonard D, Slim K. How to implement an enhanced recovery programme after colorectal surgery? Acta Chir Belg 2018; 118:73-77. [PMID: 29334849 DOI: 10.1080/00015458.2018.1427841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Although the concept of enhanced recovery after surgery was introduced more than 20 years ago, its implementation in daily practice still remains difficult. RESULTS This article addresses bottlenecks and barriers to the development of enhanced recovery programme (ERP). Barriers to the implementation are multifactorial and are raised by the different actors of these programmes: surgeons, anaesthetists, nurses, patients. Solutions and steps that must be respected to succeed in introducing ERP in an hospital are proposed. CONCLUSIONS Large-scale implementation of ERP continues to face mainly lack of trust and communication. Solutions exist and are based particularly on team work and interdisciplinary collaboration.
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Affiliation(s)
- Jean Joris
- Department of Anaesthesiology, Anaesthesia and Intensive Care, CHU Liège, ULiège, Liège, Belgium
- GRACE: Groupe francophone de Réhabilitation Améliorée après ChirurgiE, Beaumont, France
| | - Daniel Léonard
- GRACE: Groupe francophone de Réhabilitation Améliorée après ChirurgiE, Beaumont, France
- Colorectal Surgery Unit, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - Karem Slim
- GRACE: Groupe francophone de Réhabilitation Améliorée après ChirurgiE, Beaumont, France
- Service of Digestive Surgery, University Hospital Estaing, Clermont-Ferrand, France
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26
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Enhanced recovery care versus traditional care after laparoscopic liver resections: a randomized controlled trial. Surg Endosc 2017; 32:2746-2757. [DOI: 10.1007/s00464-017-5973-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
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27
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Partoune A, Coimbra C, Brichant JF, Joris J. Quality of life at home and satisfaction of patients after enhanced recovery protocol for colorectal surgery. Acta Chir Belg 2017; 117:176-180. [PMID: 28103758 DOI: 10.1080/00015458.2017.1279871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Quality of life of patients at home after an enhanced recovery protocol (ERP) for surgery has been least studied especially in elderly patients. METHODS Our first 41 patients entered in the colorectal GRACE database were interviewed through telephone about their postoperative stress, fatigue, pain, difficulty in feeding, home autonomy, and satisfaction. We compared the responses of the elderly patients (>70 years, n = 19) with those of the younger patients. RESULTS The time between the surgery and the questionnaire was 79 ± 48 days. Early return was experienced as stressful by ±20% of the patients. Fatigue and pain were low (respectively: simple numerical scale [SNS] = 4.2 ± 3.2 and 2.5 ± 2.9). When present, pain was relieved by the prescribed treatment. One-third of the patients described some difficulty in feeding. Fifty percent of the patients felt completely autonomous when returned at home, 80% attributed the rapid recovery of autonomy to the ERP. Finally, 87% were globally satisfied (SNS: 8.5 ± 1.0). The characteristics of the 'elderly' group (77 ± 6 years) and their questionnaire responses were similar to those of the younger patients. CONCLUSIONS Despite some limitations (retrospective, different time between surgery and the telephone survey), our study suggests that quality of life at home after ERP for colorectal surgery is very satisfactory for over 80% of patients. Furthermore, this study confirms that elderly patients benefit from an ERP for colorectal surgery like younger patients.
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Affiliation(s)
- Aurélien Partoune
- Department of anaesthesia reanimation, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
| | - Carla Coimbra
- Service of digestive surgery, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
- GRACE (Groupe francophone de Réhabilitation Après ChirurgiE), Baumont, France
| | - Jean-François Brichant
- Department of anaesthesia reanimation, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
| | - Jean Joris
- Department of anaesthesia reanimation, CHU Liège, domaine du Sart Tilman, University of Liège, Liège, Belgium
- GRACE (Groupe francophone de Réhabilitation Après ChirurgiE), Baumont, France
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Evolving healthcare delivery paradigms and the optimization of ‘value’ in anesthesiology. Curr Opin Anaesthesiol 2017; 30:223-229. [DOI: 10.1097/aco.0000000000000430] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 375] [Impact Index Per Article: 46.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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Scott MJ, Miller TE. Pathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes. Anesthesiol Clin 2015; 33:79-91. [PMID: 25701930 DOI: 10.1016/j.anclin.2014.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Enhanced recovery pathways have been increasingly adopted into surgical specialties with the aim of reducing the stress response and improving the metabolic response to surgical insult. Enhanced recovery pathways encompass a large range of perioperative elements that together aim to restore a patient's gut function, mobility, function and well-being to preoperative levels as soon as feasible after major surgery. There is increasing evidence that rapid recovery and return to normal function reduces complications. This may not just have a benefit by reducing morbidity and mortality but also have an effect on long-term survival. There also may be additional benefits for patients with cancer.
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Affiliation(s)
- Michael J Scott
- Department of Anesthesia and Perioperative Medicine, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Surrey, Guildford GU1 7XX, United Kingdom; Surrey Perioperative Anesthesia Critical Care Research Group (SPACeR), University of Surrey, Surrey, Guildford GU2 7XH, United Kingdom.
| | - Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, BOX 3094, HAFS 5677, Durham, NC 27710, USA
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Columb M, Hopkins P. Programmes, guidelines and protocols – the antithesis of precision medicine? Br J Anaesth 2015; 115:485-7. [DOI: 10.1093/bja/aev295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Savikko J, Ilmakunnas M, Mäkisalo H, Nordin A, Isoniemi H. Enhanced recovery protocol after liver resection. Br J Surg 2015; 102:1526-32. [PMID: 26331595 DOI: 10.1002/bjs.9912] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/23/2015] [Accepted: 07/08/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Enhanced recovery protocols (ERPs) accelerate patient recovery and shorten hospital stay by optimization of perioperative care. However, experience with ERPs is still limited in liver surgery. METHODS The implementation of a multimodal ERP was studied in patients who underwent open and laparoscopic liver surgery. An opioid-sparing pain treatment was chosen together with early mobilization and oral feeding, as well as restricted use of abdominal drains and catheters. Date to discharge, postoperative complications and patient satisfaction were assessed. A historical cohort of patients who underwent liver resection served as a control group. RESULTS Some 134 liver resections (126 open, 8 laparoscopic) were performed between April 2013 and March 2014. Operations were carried out mostly for malignant liver tumours. One hundred and six (79.1 per cent) of the 134 patients were discharged by the fifth postoperative day. The median (range) postoperative hospital stay was 4 (2-11) days, compared with 6 (4-16) days for the control group (P < 0.001). Only four patients in the ERP group were readmitted and the 30-day mortality rate was zero. CONCLUSION An ERP for perioperative care after liver surgery was introduced safely and effectively. Discharge within 4 days is achievable with no increase in adverse events and good patient satisfaction.
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Affiliation(s)
- J Savikko
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - M Ilmakunnas
- Departments of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland
| | - H Mäkisalo
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - A Nordin
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
| | - H Isoniemi
- Departments of Transplantation and Liver Surgery, Helsinki University Hospital, Helsinki, Finland
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Abstract
Optimal analgesia is a key element of enhanced recovery after surgery (ERAS), not only for humanitarian reasons but also because poorly relieved surgical pain contributes to surgical stress and impairs recovery. A multimodal analgesic approach is advised in order to provide adequate analgesia, reduce opioid consumption, reduce side effects and facilitate the achievement of ERAS milestones. For open surgery, a thoracic epidural for 48 to 72 hours, with regular acetaminophen and antiinflammatories is probably the treatment of choice. For laparoscopic surgery, intrathecal or local anesthesia in the wound combined with regular acetaminophen and antiinflammatory drugs is effective.
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Affiliation(s)
- William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Egerton Road, Guildford GU2 7XX, UK; Faculty of Health and Medical Sciences, Duke of Kent Building, University of Surrey, Guildford GU2 7TE, UK.
| | - Gabriele Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, 1650 Avenue Cedar, Montreal, Quebec H3G 1A4, Canada
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Minto G, Scott MJ, Miller TE. Monitoring needs and goal-directed fluid therapy within an enhanced recovery program. Anesthesiol Clin 2015; 33:35-49. [PMID: 25701927 DOI: 10.1016/j.anclin.2014.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Patients having major abdominal surgery need perioperative fluid supplementation; however, enhanced recovery principles mitigate against many of the factors that traditionally led to relative hypovolemia in the perioperative period. An estimate of fluid requirements for abdominal surgery can be made but individualization of fluid prescription requires consideration of clinical signs and hemodynamic variables. The literature supports goal-directed fluid therapy. Application of this evidence to justify stroke volume optimization in the setting of major surgery within an enhanced recovery program is controversial. This article places the evidence in context, reviews controversies, and suggests implications for current practice and future research.
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Affiliation(s)
- Gary Minto
- Department of Anaesthesia & Perioperative Medicine, Plymouth Hospitals NHS Trust, Plymouth University Peninsula School of Medicine, Plymouth PL6 8DH, UK.
| | - Michael J Scott
- Department of Anaesthesia and Intensive Care Medicine, Royal Surrey County Hospital, University of Surrey, Guildford GU1 7XX, UK
| | - Timothy E Miller
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
INTRODUCTION The application of a fast-track recovery program after surgery can decrease the physiological impact of surgery and reduce the duration of hospitalisation compared to conventional care. This program has permitted us to consider the performance of colectomy on an outpatient basis. METHOD After analyzing the recommendations for fast-track recovery, we developed and validated a specific protocol. Drawing on extensive experience in ambulatory surgery (inguinal hernia, cholecystectomy, adjustable gastric-banding), we formalized a protocol for outpatient colectomy. Patient selection criteria were the absence of serious or decompensated comorbidity, very good general condition, and full patient understanding of the procedure. Discharge was authorized if the patient met the exit criteria according to the Chung score. Postoperative surveillance was provided by regular home visits of a nurse trained in enhanced recovery, every afternoon until day 10. RESULTS Five patients underwent this management strategy (4 men and 1 woman, mean age 64 years, range: 59-69), for indications including cancer of the rectosigmoid junction (1 case), sigmoid diverticulitis (3 cases), and volvulus. The postoperative course was simple and uncomplicated except for two patients who had dysuria and an incisional hematoma, respectively. CONCLUSION To our knowledge, these are the first cases of colectomy performed strictly on an outpatient basis (i.e., stay<12h). We demonstrated the feasibility of outpatient colectomy when integrated into a protocol of enhanced recovery for selected patients provided that at-home monitoring was available.
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Affiliation(s)
- B Gignoux
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France.
| | - A Pasquer
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France
| | - A Vulliez
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France
| | - T Lanz
- General surgery unit, visceral and endocrine, Clinic Backup, Ben-Gurion avenue, 69009 Lyon, France
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Sunitha Suresh BS, De Oliveira GS, Suresh S. The effect of audio therapy to treat postoperative pain in children undergoing major surgery: a randomized controlled trial. Pediatr Surg Int 2015; 31:197-201. [PMID: 25555856 DOI: 10.1007/s00383-014-3649-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 02/01/2023]
Abstract
PURPOSE To evaluate the analgesic effect of music and audiobooks in children undergoing major surgical procedures when compared to a control (silence) group. METHODS The study was a prospective and randomized trial. Children undergoing major surgeries were randomized to one of the three groups: music, audiobook or control (silence). The primary outcome was the pain burden reduction by two treatments within 48 h postoperatively. Pain burden was measured using the area under the pain scale versus the 30 min interval for each treatment. RESULTS 60 patients were recruited and 56 completed the study. Pain burden was reduced in the music and audiobook groups compared to control, median (IQR) of -60 (-90 to 0), -45 (-90 to 0) and 0 (-30 to 90) (min × pain score), respectively, P = 0.04. A linear regression analysis demonstrated an independent group effect on pain reduction even after adjusting for the mean pain scores recorded at the beginning of the treatment, slope of regression line -56.8 ± 24 goodness of fit r (2) = 0.25 and slope significantly different from 0 (P = 0.02). CONCLUSIONS Audio therapy is an efficacious adjunct method to decrease post-surgical pain in children undergoing major surgeries. Audio therapy should be considered as an important strategy to minimize pain in children undergoing major surgery.
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Affiliation(s)
- B S Sunitha Suresh
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Spread and adoption of enhanced recovery from elective surgery in the English National Health Service. Can J Anaesth 2014; 62:105-9. [PMID: 25391730 PMCID: PMC4315473 DOI: 10.1007/s12630-014-0260-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 10/22/2014] [Indexed: 11/19/2022] Open
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The national variation in peri-operative anaesthetic technique for breast free flap reconstruction in the UK: is it time to define best practice? EUROPEAN JOURNAL OF PLASTIC SURGERY 2014. [DOI: 10.1007/s00238-014-1011-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Smart NJ, Daniels IR. Beyond enhanced recovery: authors' reply. Colorectal Dis 2014; 16:317-8. [PMID: 24629006 DOI: 10.1111/codi.12583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 01/19/2014] [Indexed: 02/08/2023]
Affiliation(s)
- N J Smart
- Exeter Surgical Health Services Research Unit, Royal Devon & Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.
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Jr GSDO, Fitzgerald P, Ahmad S, Kim J, Rahangdale R, McCarthy R. Transversus abdominis plane infiltration for laparoscopic gastric banding: A pilot study. World J Gastrointest Surg 2014; 6:27-32. [PMID: 24600508 PMCID: PMC3942536 DOI: 10.4240/wjgs.v6.i2.27] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 10/29/2013] [Accepted: 01/14/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To estimate an effect size for the transversus abdominis plane (TAP) infiltration on quality of recovery in patients undergoing laparoscopic gastric band surgery.
METHODS: The pilot study was a randomized, double blinded, placebo controlled trial. Patients undergoing laparoscopic gastric band surgery were randomized to receive a bilateral TAP infiltration with 20 mL of 0.5% ropivacaine or saline. The evaluated outcomes included quality of recovery-40 (QoR-40) at 24 h, postoperative opioid consumption and pain. Data was examined using the Mann-Whitney U test.
RESULTS: Nineteen subjects were recruited. There was a positive trend favoring the TAP infiltration group in global QoR-40 scores at 24 h after surgery, median [interquartile range (IQR)] of 175.5 (170-189) compared to 170 (160-175) in the control group (P = 0.06). There also a positive trend toward a lower cumulative opioid consumption in the TAP infiltration group, median (IQR) of 7.5 (2.5-11.5) mg iv morphine equivalents compared to 13 (7-21.5) in the control group (P = 0.07). Correlation analysis (Spearman’s Rho) demonstrated an inverse relationship between 24 h cumulative opioid consumption and global QoR-40 scores, -0.49 (P = 0.03).
CONCLUSION: The use of multimodal analgesic techniques to reduce opioid related side effects is particularly desirable in morbidly obese patients undergoing gastric reduction surgery. The TAP infiltration seems to have a clinically important effect in reducing postoperative opioid consumption and improve quality of recovery after laparoscopic gastric band surgery in morbid obese patients. Future studies to confirm the beneficial effects of the TAP infiltration in these patients are warranted.
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Jones C, Kelliher L, Dickinson M, Riga A, Worthington T, Scott MJ, Vandrevala T, Fry CH, Karanjia N, Quiney N. Randomized clinical trial on enhanced recovery versus standard care following open liver resection. Br J Surg 2013; 100:1015-24. [PMID: 23696477 DOI: 10.1002/bjs.9165] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Enhanced recovery programmes (ERPs) have been shown to reduce length of hospital stay (LOS) and complications in colorectal surgery. Whether ERPs have the same benefits in open liver resection surgery is unclear, and randomized clinical trials are lacking. METHODS Consecutive patients scheduled for open liver resection were randomized to an ERP group or standard care. Primary endpoints were time until medically fit for discharge (MFD) and LOS. Secondary endpoints were postoperative morbidity, pain scores, readmission rate, mortality, quality of life (QoL) and patient satisfaction. ERP elements included greater preoperative education, preoperative oral carbohydrate loading, postoperative goal-directed fluid therapy, early mobilization and physiotherapy. Both groups received standardized anaesthesia with epidural analgesia. RESULTS The analysis included 46 patients in the ERP group and 45 in the standard care group. Median MFD time was reduced in the ERP group (3 days versus 6 days with standard care; P < 0·001), as was LOS (4 days versus 7 days; P < 0·001). The ERP significantly reduced the rate of medical complications (7 versus 27 per cent; P = 0·020), but not surgical complications (15 versus 11 per cent; P = 0·612), readmissions (4 versus 0 per cent; P = 0·153) or mortality (both 2 per cent; P = 0·987). QoL over 28 days was significantly better in the ERP group (P = 0·002). There was no difference in patient satisfaction. CONCLUSION ERPs for open liver resection surgery are safe and effective. Patients treated in the ERP recovered faster, were discharged sooner, and had fewer medical-related complications and improved QoL. REGISTRATION NUMBER ISRCTN03274575 (http://www.controlled-trials.com).
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Affiliation(s)
- C Jones
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK.
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