Identifying risk factors for poor multidimensional recovery after major surgery: A systematic review

Traditional risk factors used for predicting poor postoperative recovery have focused on postoperative complications, adverse symptoms (nausea, pain), length of hospital stay, and patient quality of life. Despite these being traditional performance indicators of patient postoperative "status," they may not fully define the multidimensional nature of patient recovery. The definition of postoperative recovery is thus evolving to include patient-reported outcomes that are important to the patient. Previous reviews have focused on risk factors for the above traditional outcomes after major surgery. Yet, there remains a need for further study of risk factors predicting multidimensional patient-focused recovery, and investigation beyond the immediate postoperative period after patients are discharged from the hospital. This review aimed to appraise the current literature identifying risk factors for multidimensional patient recovery.

METHODS

A systematic review without meta-analysis was performed to qualitatively summarize preoperative risk factors for multidimensional recovery 4-6 weeks after major surgery (PROSPERO, CRD42022321626). We reviewed three electronic databases between January 2012 and April 2022. The primary outcome was risk factors for multidimensional recovery at 4-6 weeks. A GRADE quality appraisal and a risk of bias assessment were completed.

RESULTS

In total, 5150 studies were identified, after which 1506 duplicates were removed. After the primary and secondary screening, nine articles were included in the final review. Interrater agreements between the two assessors for the primary and secondary screening process were 86% (k = 0.47) and 94% (k = 0.70), respectively. Factors associated with poor recovery were found to include ASA grade, recovery tool baseline score, physical function, number of co-morbidities, previous surgery, and psychological well-being. Mixed results were reported for age, BMI, and preoperative pain. Due to the observational nature, heterogeneity, multiple definitions of recovery, and moderate risk of bias of the primary studies, the quality of evidence was rated from very low to low.

CONCLUSION

Our review found that there were few studies assessing preoperative risk factors as predictors for poor postoperative multidimensional recovery. This confirms the need for higher quality studies assessing risk for poor recovery, ideally with a consistent and multi-dimensional definition of recovery.

Evaluation of Complication Development in General Surgery Patients Admitted to the Post Anesthesia Care Unit

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Effect of Postoperative Adverse Events on Hospitalization Expenditures and Length of Stay Among Surgery Patients in Taiwan: A Nationwide Population-Based Case-Control Study

Background: The current study sought to determine the incidence of postoperative adverse events (AEs) based on data from the 2006 Taiwan National Health Insurance Research Database (NHIRD).

Methods: This retrospective case-control study included patients who experienced postoperative AEs in 387 hospitals throughout Taiwan in 2006. The independent variable was the presence or absence of 10 possible postoperative AEs, as identified by patient safety indicators (PSIs).

Results: A total of 17,517 postoperative AEs were identified during the study year. PSI incidence ranged from 0.1/1,000 admissions (obstetric trauma-cesarean section) to 132.6/1,000 admissions (obstetric trauma with instrument). Length of stay (LOS) associated with postoperative AEs ranged from 0.10 days (obstetric trauma with instrument) to 14.06 days (postoperative respiratory failure). Total hospitalization expenditures (THEs) ranged from 363.7 New Taiwan Dollars (obstetric trauma without instrument) to 263,732 NTD (postoperative respiratory failure). Compared to patients without AEs, we determined that the THEs were 2.13 times in cases of postoperative AE and LOS was 1.72 times higher.

Conclusions: AEs that occur during hospitalization have a major impact on THEs and LOS.

The effect of advanced recovery room care on postoperative outcomes in moderate-risk surgical patients: a multicentre feasibility study

Postoperative complications are common and may be under-recognised. It has been suggested that enhanced postoperative care in the recovery room may reduce in-hospital complications in moderate- and high-risk surgical patients. We investigated the feasibility of providing advanced recovery room care for 12-18 h postoperatively in the post-anaesthesia care unit. The primary hypothesis was that a clinical trial of advanced recovery room care was feasible. The secondary hypothesis was that this model may have a sustained impact on postoperative in-hospital and post-discharge events. This was a multicentre, prospective, feasibility before-and-after trial of moderate-risk patients (predicted 30-day mortality of 1-4%) undergoing non-cardiac surgery and who were scheduled for postoperative ward care. Patients were managed using defined assessment checklists and goals of care in an advanced recovery room care setting in the immediate postoperative period. This utilised existing post-anaesthesia care unit infrastructure and staffing, but extended care until the morning of the first postoperative day. The advanced recovery room care trial was deemed feasible, as defined by the recruitment and per protocol management of > 120 patients. However, in a specialised cancer centre, recruitment was slow due to low rates of eligibility according to narrow inclusion criteria. At a rural site, advanced recovery room care could not be commenced due to logistical issues in establishing a new model of care. A definitive randomised controlled trial of advanced recovery room care appears feasible and, based on the indicative data on outcomes, we believe this is warranted.

Experiences of Post Anaesthetic Unit Recovery Nurse facilitating Advanced Directives in the immediate postanaesthetic period: A phenomenological study

AIMS

The aims of this study were to develop an understanding of the lived experience of the Post Anaesthetic Unit Recovery Nurse facilitating Advanced Directives and implications for patient-centred care.

DESIGN

Interpretive phenomenological analysis.

METHODS

Homogenized purposive sampling of six Registered Nurses using in-depth semi-structured interviews. Interviews were conducted between June-July 2018. Analysis was performed using interpretive phenomenology analysis.

RESULTS

Post Anaesthetic Recovery Nurses experienced a 'Grey Zone' when facilitating Advanced Directives postanaesthetic. The 'Grey Zone' is defined through four themes; The 'Trigger' of the anaesthetic characterized by physiological instability; 'Confusion and Frustration' featuring balancing of roles as a clinician and advocate during patient decline; 'Consistent Paternalism' by medical staff in the consideration of Advanced Directives; and 'Disempowerment' where nurses faced issues of advocacy, personal distress, a lack of literature or protocols, and handover of information.

CONCLUSION

The lived experience of nurses facilitating Advanced Directives postanaesthetic may be distressing. Further research is required to understand the implications of Advanced Directives following an anaesthetic. Education and development of protocols are recommended to optimize patient-centred care.

IMPACT

Post Anaesthetic Unit Recovery Nurses experienced a 'Grey Zone' when facilitating Advanced Directives, defined through four themes. Advanced Directives may appear to be clear, however, the anaesthetic may trigger physiological instability leading to confusion and frustration in interpretation and application of Advanced Directives. Confusion and Frustration were experienced while the attitudes of Consistent Paternalism were encountered when advocating for patient wishes, resulting in Disempowerment. Post Anaesthetic Unit Recovery Nurses may become empowered through acknowledging and describing the 'Grey Zone'.

A retrospective analysis of 62,571 cases of perioperative adverse events in thoracic surgery at a tertiary care teaching hospital in a developing country

Objectives

Despite a long history of concerns regarding patient safety during clinical care, some patients undergoing thoracic surgery continue to experience adverse events (AEs). AEs are a major significant source of perioperative morbidity and mortality following thoracic surgery. This study analysed the causes, treatment and prognosis of perioperative AEs to provide a reference for further surgical safety.

Methods

The authors collected a total of 62,571 thoracic surgery anaesthesia records via the Anaesthesia Information Management System (AIMS) from 14 August 2006 to 14 August 2017 and obtained 150 cases of perioperative serious AEs from the “adverse events registration” subsystem. The related hospitalization data of the 150 patients were analysed, including anaesthesia, recovery room time, ICU records and follow-up outcomes. The causes of these AEs were classified as follows: events related to the patients’ pathogenic conditions(P); surgery-related factors(S); anaesthesia-related factors(A); and interactions between pathogenic, surgical and anaesthesia factors (P&S&A). We then analysed the main clinical manifestations, causes and treatment of these events.

Results

The overall rate of perioperative AEs in thoracic surgery (n = 62,571) was 0.2%. Of these, 10.7% were.

caused by P and 23.3% by A; neither cause led to patient death. S and P&S&A accounted for 55.3 and 10.7% of AEs, respectively; together, they accounted for 66%. Twelve patients with postoperative AEs caused by S or P&S&A died within 3 days (8% of 150 cases). A total of 33%(50/150) of patients experienced sudden cardiac arrest (SCA) and recovered successfully. Surgical massive haemorrhage (22%, 33/150) was reported as a predominant mortality-related outcome in this group, and 8 of the 12 deaths were caused by massive haemorrhage.

Conclusions

The rate of perioperative AEs after thoracic surgery was 0.2%. AEs must be identified and treated immediately. An important factor in anaesthesia-related events was respiratory management. Two major clinical manifestations of surgery-related events were cardiac arrest and massive haemorrhage. Cardiac arrest was the major factor contributing to AEs, but its adverse consequences could be avoided with timely discovery and proper treatment. Massive haemorrhage is a significant cause of mortality that can be prevented with a surgeon’s early diagnosis and appropriate interventions.

Venous Thromboembolism in Podiatric Foot and Ankle Surgery

BACKGROUND

The extent to which podiatric surgeons follow venous thromboembolism guidelines is unknown. The aim of this study therefore, was 2-fold: (a) to determine the rate of venous thromboembolism following podiatric surgery and (b) to investigate the factors that influence the use of thromboprophylaxis.

METHODS

Data from 4238 patients who underwent foot and ankle surgery over 2 years were analyzed. Venous thromboembolism within the first 30 days following surgery was recorded using the Australasian College of Podiatric Surgeons surgical audit tool. Logistic regression analyses were undertaken to determine the factors that influenced thromboprophylaxis.

RESULTS

Of the 4238 patient records, 3677 records (87%) provided complete data (age range 2-94 years; mean ± SD, 49.1 ± 19.7 years; 2693 females). A total of 7 venous thromboembolic events (0.2% rate) were reported. Operative duration and age (OR 12.63, 95% CI 9.47 to 16.84, P < 0.01), postoperative immobilization (OR 6.94, 95% CI 3.95 to 12.20, P < 0.01), and a prior history of VTE (OR 3.41, 95% CI 1.01 to 11.04, P = 0.04) were the strongest predictors of thromboprophylaxis.

CONCLUSION

Podiatric foot and ankle surgery is associated with a low rate of venous thromboembolism. This may be due in part to the thromboprophylaxis regime implemented by podiatric surgeons, which closely aligns with current evidence-based guidelines.

LEVELS OF EVIDENCE

Level II: Prospective cohort study.

Managing Postoperative Analgesic Failure: Tramadol Versus Morphine for Refractory Pain in the Post-Operative Recovery Unit

Objective

This study aimed to discover whether co-analgesia with tramadol or additional morphine was more effective for patients who still had severe pain despite being given 10 mg intravenous morphine in the post-anesthesia care unit (PACU).

Methods

All eligible patients were consented and recruited to the trial pre-operatively, but only a small subgroup – whose pain was not successfully controlled (pain score 6/10 or more) after receiving 10 mg of morphine in the PACU—were then randomized to enter the trial and receive, in a double blinded fashion, the analgesic study drug; which consisted of either a further 10 mg of morphine, or 100 mg of tramadol, titrated intravenously to control their pain. The groups were compared as to: the time to readiness for discharge, the patient’s pain scores over time, and the presence of side effects.

Results

There was no statistically significant difference in any of the outcomes measured. The time to readiness for discharge from PACU was 119 minutes in the morphine group and 120 minutes in the tramadol group. However in approximately half the cases who entered the trial (i.e., where pain had not been controlled with the pre-enrollment baseline 10 mg of morphine in PACU) neither a further 10 mg of morphine nor 100 mg of tramadol effectively relieved the patient’s pain.

Conclusions

We found no difference between additional morphine and co-analgesia with tramadol in this study. Patients who don’t respond to reasonable doses of opioids in PACU are very likely to be unresponsive to further opioids, and other non-opioid analgesic techniques (such as regional anesthesia) should be considered early in this group of patients.

Effect of a newly designed observation, response and discharge chart in the Post Anaesthesia Care Unit on patient outcomes: a quasi-expermental study in Australia

OBJECTIVES

This study aimed to evaluate whether use of a discharge criteria tool for nursing assessment of patients in Post Anaesthesia Care Unit (PACU) would enhance nurses' recognition and response to patients at-risk of deterioration and improve patient outcomes.

METHODS

A prospective non-randomised pre-post intervention study was conducted in three hospitals in Australia. Participants were adults undergoing elective surgery before (n=723) and after (n=694) implementation of the Post-Anaesthetic Care Tool (PACT).

RESULTS

Nursing response to patients at-risk of deterioration was higher using PACT, with more medical consultations initiated by PACU nurses (19% vs 30%, P<0.001) and more patients with Medical Emergency Team activation criteria modified by an anaesthetist while in PACU (6.5% vs 13.8%, P<0.001). There were higher rates of analgesia administration (37.3% vs 54.2%, P=0.001), nursing assessment of pain and documentation of ongoing analgesia prior to discharge (55% vs 85%, P<0.001). More adverse events were recorded in PACU after introduction of the PACT (8.3% vs 16.7%, P<0.001). The rate of adverse events after discharge from PACU remained constant (16.5%), but the rate of cardiac events (5.1% vs 2.6%, P=0.021) and clinical deterioration (8.7% vs 4.3%, P=0.001) following PACU discharge significantly decreased, using the PACT. Despite the increased number of patients with adverse events in phase 2, healthcare costs did not increase significantly. Length of stay in PACU and length of hospital admission for those patients who had an adverse event in PACU were significantly reduced after implementation of the PACT.

CONCLUSION

This study found that using a structured discharge criteria tool, the PACT, enhanced nurses' recognition and response to patients who experienced clinical deterioration, reduced length of stay for patients who experienced an adverse event in PACU and was cost-effective.

Factors Associated with a Short (<2 Days) or Long (>10 Days) Length of Stay after Colectomy: A Multivariate Analysis of over 400 Patients

A prospectively maintained database of 415 patients undergoing colectomy was evaluated. We performed a logistic regression analysis to identify factors associated with 1) length of stay (LOS) of 2 days or less and 2) LOS of 10 days or more. Investigated variables included demographics, American Society of Anesthesiology (ASA) score, diagnosis, operative procedure, approach and time, transfusion requirements, and occurrence of any complications. Factors associated with a LOS of two days or less included ASA [odds ratio (OR): 0.34, 95% confidence interval (CI): 0.208–0.576], use of transversus abdominis plane block (OR: 5.259, 95% CI: 2.825–9.791), and operative time (OR: 0.98, 95% CI: 0.974–0.986). Age >65 had an OR of 1.73, though this did not reach statistical significance. Factors associated with LOS >10 days included ASA (OR: 2.152, 95% CI: 1.245–3.721), anastomotic leak (OR: 2.163, 95% CI: 1.486–3.148), ileus (OR: 8.790, 95% CI: 4.501–17.165), and surgical site infection (OR: 5.846, 95% CI: 2.764–12.362). Cancer and transfusion status were associated but did not reach statistical significance. Although operative time was longer in left-sided resections, no differences in LOS were observed. In conclusion, numerous factors are associated with short or long LOS and may help stratify resource utilization after colectomy. Further study is needed to confirm our findings.

A call centre and extended checklist for pre-screening elective surgical patients – a pilot study

Background

Novel approaches to preoperative assessment and management before elective surgery are warranted to ensure that a sustainable high quality service is provided. The benefits of a call centre incorporating an extended preoperative electronic checklist and phone follow-up as an alternative to a clinic attendance were examined.

Methods

This was a pilot study of a new method of patient assessment in patients scheduled for elective non-cardiac surgery and who attended a conventional preoperative clinic. A call centre assessment, using a Computer-assisted Health Assessment by Telephone (CHAT), paper review by an anaesthetist, and a follow-up phone call if the anaesthetist wished more information, preceded the conventional preoperative clinic. Summaries from the call centre and clinic assessments were independently produced.

The times spent by call centre staff were recorded. The ‘procedural anaesthetist’ (who provided anaesthesia for each patient’s actual surgery/procedure) documented an opinion on whether the call centre assessment alone would have been sufficient to bypass the preoperative clinic if the patient were hypothetically undergoing laparoscopic cholecystectomy. This opinion was also sought from a panel of four senior anaesthetists, based on patient summaries from both the call centre and preoperative clinic, but expanded to three hypothetical operations of different complexity – cataract removal, laparoscopic cholecystectomy, and total hip replacement.

Results

Call centre assessment followed by clinic attendance was studied in 193 patients. The mean time for CHAT was 19.8 (SD 7.5) minutes and, after review of CHAT summaries, anaesthetists telephoned 45.6 % of cases for follow-up information. The mean time spent by anaesthetists on summary review and phone calls was 3.8 (SD 3.9) minutes. Procedural anaesthetists considered 89 % of the patients under their care suitable to have bypassed the preoperative clinic if they were to have undergone cholecystectomy. The panel of senior anaesthetists judged 95-97 % of patients suitable to have bypassed preoperative clinic for cataract surgery, 81-85 % for cholecystectomy and 79-82 % for hip replacement.

Conclusions

A call centre to pre-screen elective surgical patients might substantially reduce patient numbers attending preoperative anaesthetic assessment clinics. Further studies to assess the quality of such an approach are indicated.

Trial registration

ANZCTRACTRN12614000199617.