Enhanced Recovery Programs in an Ambulatory Surgical Oncology Center.

BACKGROUND: We describe the implementation of enhanced recovery after surgery (ERAS) programs designed to minimize postoperative nausea and vomiting (PONV) and pain and reduce opioid use in patients undergoing selected procedures at an ambulatory cancer surgery center. Key components of the ERAS included preoperative patient education regarding the postoperative course, liberal preoperative hydration, standardized PONV prophylaxis, appropriate intraoperative fluid management, and multimodal analgesia at all stages. METHODS: We retrospectively reviewed data on patients who underwent mastectomy with or without immediate reconstruction, minimally invasive hysterectomy, thyroidectomy, or minimally invasive prostatectomy from the opening of our institution on January 2016 to December 2018. Data collected included use of total intravenous anesthesia (TIVA), rate of PONV rescue, time to first oral opioid, and total intraoperative and postoperative opioid consumption. Compliance with ERAS elements was determined for each service. Quality outcomes included time to first ambulation, postoperative length of stay (LOS), rate of reoperation, rate of transfer to acute care hospital, 30-day readmission, and urgent care visits ≤30 days. RESULTS: We analyzed 6781 ambulatory surgery cases (2965 mastectomies, 1099 hysterectomies, 680 thyroidectomies, and 1976 prostatectomies). PONV rescue decreased most appreciably for mastectomy (28% decrease; 95% confidence interval [CI], -36 to -22). TIVA use increased for both mastectomies (28%; 95% CI, 20-40) and hysterectomies (58%; 95% CI, 46-76). Total intraoperative opioid administration decreased over time across all procedures. Time to first oral opioid decreased for all surgeries; decreases ranged from 0.96 hours (95% CI, 2.1-1.4) for thyroidectomies to 3.3 hours (95% CI, 4.5 to -1.7) for hysterectomies. Total postoperative opioid consumption did not change by a clinically meaningful degree for any surgery. Compliance with ERAS measures was generally high but varied among surgeries. CONCLUSIONS: This quality improvement study demonstrates the feasibility of implementing ERAS at an ambulatory surgery center. However, the study did not include either a concurrent or preintervention control so that further studies are needed to assess whether there is an association between implementation of ERAS components and improvements in outcomes. Nevertheless, we provide benchmarking data on postoperative outcomes during the first 3 years of ERAS implementation. Our findings reflect progressive improvement achieved through continuous feedback and education of staff.

COVID-19 in the Cancer Patient.

The novel coronavirus disease 2019 (COVID-19) was first reported in China in December 2019. Since then, it has spread across the world to become one of the most serious life-threatening pandemics since the influenza pandemic of 1918. This review article will focus on the specific risks and nuanced considerations of COVID-19 in the cancer patient. Important perioperative management recommendations during this outbreak are emphasized, in addition to discussion of current treatment techniques and strategies available in the battle against COVID-19.

Impact of intraoperative remifentanil on postoperative pain and opioid use in thyroid surgery.

BACKGROUND AND OBJECTIVES: Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy. METHODS: Retrospective review of prospectively collected data from an outpatient surgery center. Primary analysis compared patients treated before and after remifentanil shortage. RESULTS: Median postoperative opioid consumption was 20 morphine milligram equivalents (MMEs) among those treated in the high-dose period and 15 MMEs in the low-dose period. Remifentanil/weight received was a significant predictor of requiring a postoperative narcotic (P = .006). Total non-remifentanil narcotics administered were equivalent but patients in the low dose period received higher amounts of intraoperative long-acting narcotics. CONCLUSIONS: Remifentanil infusion for thyroid surgery is associated with higher postoperative pain and postoperative narcotics requirement. While a hyperalgesia state is possible, shifting of longer-acting narcotics from intraoperative to postoperatively is also supported.

Organization of Multidisciplinary Cancer Care for the Surgical Patient: Role of Anesthesiologists.

PURPOSE OF REVIEW: The purpose of this review is to describe significant recent trends or developments regarding the role of anesthesiologists in a multidisciplinary team approach to cancer care for the surgical patient. We also discuss our own institutional multidisciplinary approach as a comprehensive cancer center with high surgical volume. RECENT FINDINGS: Beyond the multidisciplinary team meeting concept, and local, institution-specific, or national programs, more formalized concepts and models of perioperative care have evolved. These provide a framework for robust involvement of anesthesiologists in cancer care for the surgical patient, with the goal of allowing for optimal individualized cancer outcomes. SUMMARY: Because of the wide-ranging nature of their perioperative expertise, anesthesiologists play an important role in multidisciplinary team cancer care for surgical patients. This role has been seen in the recent trends toward clinical models, such as the perioperative surgical home and enhanced recovery programs. Areas for future research include multidisciplinary assessment of the impact of such models on perioperative cancer outcomes through integration of data from national outcomes groups.

Perioperative Care of the Breastfeeding Patient.

Nurses providing surgical care in nonobstetrical ambulatory surgery centers or specialty hospitals without traditional lactation resources may need to care for patients who are breastfeeding. Nurses in these settings play an important role in supporting and protecting the breastfeeding relationship for nursing mothers separated from their infants during illness or surgical procedures. It is important for care providers to understand how hospitalization and the medications administered before, during, and after a surgical procedure affect mothers who are breastfeeding their infants. This article examines the effects of hospitalization on breastfeeding and focuses on preoperative and postoperative care considerations, including medication use, radiology imaging, interrupting and resuming breastfeeding, breast assessment, and milk storage.

Implementation and Organization of a Perioperative Lactation Program: A Descriptive Study.

INTRODUCTION: As breastfeeding rates rise, perioperative care of lactating women is an increasingly important issue. There is a lack of reports describing the implementation of perioperative lactation programs. Beginning in 2014, Memorial Sloan Kettering Cancer Center developed a perioperative lactation program to address the comprehensive care of lactating patients. The aim of this study was to determine the incidence of lactation in our perioperative population, as well as to describe preliminary data and experiences during the implementation of our program. MATERIALS AND METHODS: This retrospective descriptive study included lactating patients who underwent procedures requiring anesthesia care at our institution from August 2014 to February 2017. This period coincided with implementation of the lactation program, which focused on patient identification, education, and support, as well as staff education and collaboration. Patient volume and characteristics, procedure types, and intraoperative non-narcotic analgesic use were analyzed. RESULTS: Over the 30-month study period, we identified 80 lactating perioperative patients, with ∼2-3 patients presenting monthly. The median (range) age of the child was 5 (0.6-24) months. Most of our lactating patients were American Society of Anesthesiologists class I-II patients (81%), who underwent general anesthesia (89%), and received at least one non-narcotic analgesic intraoperatively (89%). CONCLUSION: Our study showed that we cared for lactating patients undergoing a wide range of procedures on a regular basis. The results from this study are intended to inform the next phase of our research, which will focus on determining how this work impacts outcomes such as postoperative lactation complications, breastfeeding resumption, and overall patient satisfaction.

Bilateral Otorrhagia after Robotically Assisted Gynecologic Surgery in the Setting of a Reduced Trendelenburg Position and Low-Pressure Pneumoperitoneum: A Case Report and Review of the Literature.

Perioperative otorrhagia in association with nonotolaryngologic surgery is rare. The cause is typically attributed to the physiologic derangements associated with the Trendelenburg position and pneumoperitoneum during laparoscopic surgery. The most well-accepted etiology is an increase in arterial and venous pressures causing the rupture of subcutaneous capillaries, although the exact etiology remains unclear. We present the first reported case of bilateral spontaneous otorrhagia associated with robotically assisted laparoscopic surgery involving a reduced Trendelenburg position and low-pressure pneumoperitoneum. Perioperative hypertension, female gender, advanced age, and increased bleeding risk may contribute to the development of this rare complication.