Implementation of a multidisciplinary perioperative protocol in major emergency abdominal surgery.

PURPOSE: Enhanced recovery after surgery programs is widely implemented in elective settings, however, until recently, rarely in emergency surgery. The purpose of this study was to present detailed contents and data on implementation of an emergency abdominal perioperative protocol on the basis of compliance. METHODS: A multidisciplinary perioperative bundle for major emergency abdominal surgery was developed and implemented in March 2017 covering surgical, emergency, anesthesiological, radiological, physiotherapy, and nutritional support. The bundle consisted of preoperative-, intraoperative-, and postoperative initiatives. Fifteen core protocol items were identified for audit and compliance rates for each protocol item and overall compliance rates were evaluated and quarterly stratified throughout the first year of implementation. RESULTS: A total of 227 consecutive patients underwent major emergency abdominal surgery from March 2017 throughout February 2018. The specific protocol items showed high individual compliance rates throughout all quarters of the first year. Time to suspicion of diagnosis at the emergency department, rate of perioperative thoracic epidural, and postoperative referral to physiotherapy showed the lowest compliance rates. The overall compliance rate of all 15 protocol items was 83% (min-max 71.4-100%). CONCLUSION: We found it possible to implement a comprehensive detailed perioperative protocol in emergency abdominal surgery across multiple specialties with an overall good compliance of protocol items.

Extracranial internal carotid artery tortuosity may cause vocal cord palsy.

BACKGROUND: Clinical practice made us suspect that vocal cord palsy (VCP) can be associated with extracranial internal carotid artery (ICA) tortuosity. OBJECTIVES: To find evidence for a causative relation between ICA tortuosity and VCP. METHODS: This single-center, retrospective study comprised 66 patients with VCP. A total of 45 patients without VCP served as control group. Patient charts were reviewed for etiology and side of VCP. CT scans were reviewed independently by two radiologists for imprint in the jugular vein (JV) caused by a tortuous ICA, considered an indirect sign of potential vagus nerve affection. RESULTS: A total of 33 patients had idiopathic VCP. ICA tortuosity causing a JV imprint with >10% JV lumen reduction was found more frequently on the paretic sides of patients with idiopathic VCP (15-24%) than in controls (3-9%), with p<.05 for observer 2 and p=.07 for observer 1. In patients with idiopathic VCP and JV imprint with >10% JV lumen reduction on one or both sides (n = 9), both observers found JV imprint with >10% JV lumen reduction more frequently on the side of VCP (p<.05). CONCLUSIONS: ICA tortuosity causing a JV imprint may be the cause of VCP in some of the cases of VCP currently regarded as idiopathic.