Perioperative anaemia and iron deficiency.

Anaemia affects a third of surgical patients and is associated with increased morbidity and mortality. Iron deficiency is the most common cause of anaemia and can be absolute or functional. Patients may require treatment with oral or intravenous iron.

Patient-reported outcomes for ambulatory surgery.

PURPOSE OF REVIEW: To discuss the importance of validated tools that measure patient-reported outcomes and their use in ambulatory surgery. RECENT FINDINGS: Sustained increases in ambulatory surgical care reflect advances in surgical techniques and perioperative anaesthetic care. Use of patient-reported outcomes allows identification of minor adverse events that are more common in this population compared with traditional endpoints such as mortality. Variability in reported outcomes restricts research potential and limits the ability to benchmark providers. The standardized endpoints in perioperative medicine initiative's recommendations on patient-reported outcomes and patient comfort measures are relevant to evaluating ambulatory care. Combining validated generic and disease-specific patient-reported outcome measures (PROMs) examines the widest spectrum of outcomes. Technological advances can be used to facilitate outcome measurement in ambulatory surgery with digital integration optimizing accurate real-time data collection. Telephone or web-based applications for reviewing ambulatory patients were found to be acceptable in multiple international settings and should be harnessed to allow remote follow-up. SUMMARY: Use of validated tools to measure patient-reported outcomes allows internal and external quality comparison. Tools can be combined to measure objective outcomes and patient satisfaction. These are both key factors in driving forward improvements in perioperative ambulatory surgical care.

Translation of national guidelines into local practice.

BACKGROUND: Addressing themes raised by the Royal College of Anaesthetists National Audit Project 4, we introduced new training programmes to improve the knowledge and skills necessary for the management of airway crises. A further large-scale multimodal training programme was introduced to implement guidelines published in 2015 by the Difficult Airway Society (DAS). METHODS: In 2014, questionnaires were used to assess the knowledge necessary to manage the unanticipated difficult airway before and after high-fidelity simulation sessions. In 2016, surveys assessed knowledge of new DAS guidelines before and 5 months after the implementation of a large-scale targeted teaching programme to educate staff. RESULTS: In 2014, 20 anaesthetic teams (75 delegates) attended high-fidelity simulations and demonstrated a significant immediate improvement in knowledge. In 2016, 185 participants attended a targeted teaching programme. Although after the teaching programme an increased number of anaesthetists reported having accessed training, there was a persistent knowledge gap, with some details retained by as few as 15% of participants. DISCUSSION: Whereas the knowledge of these important guidelines was improved in the immediate aftermath of high-fidelity simulation training, the knowledge retention was disappointing, raising questions as to why knowledge of highly important techniques used in crises was so poor. We ask whether training should be compulsory and how knowledge retention might be improved across all health care disciplines that rely on guidelines for the effective management of rarely occurring but safety-critical events.

Cardiopulmonary Exercise Testing Has no Additive Incremental Value to Standard Scoring Systems when Risk Stratifying for Bariatric Surgery.

BACKGROUND: Cardiopulmonary exercise testing (CPET) can identify patients at risk of adverse post-operative outcomes following major abdominal surgery including bariatric surgery. Scoring systems that also aim to predict post-operative outcome in this group include the validated obesity surgery mortality risk score (OSMRS). This study aims to investigate if CPET has additive value to other scoring systems in predicting post-operative outcomes following bariatric surgery. METHODS: Data was collected retrospectively on 398 patients who underwent CPET between October 2008 and April 2013. CPET data, medical history, complication rates and length of stay (LOS) were obtained from patient records. Data was analysed to investigate the relationship between CPET and other scoring systems with post-operative outcome. RESULTS: Two hundred and fifty patients underwent Roux-en-Y gastric bypass or sleeve gastrectomy. Median LOS was 4 days (IQR 4-6 days) and 41 patients (16.4 %) developed a complication. Adjusted data showed a risk difference for complications of 17 % (95 % CI 9-25 %) between high- and low-risk patients stratified by OSMRS alongside a 27 % (95 % CI 12-45 %) longer LOS. Variation in AT or peak VO2 showed no significant relationship with complications or LOS. Amongst high OSMRS risk patients, there was no significant difference in complications or LOS when CPET data was added to this analysis. CONCLUSIONS: Cardiopulmonary exercise testing adds no incremental value in predicting post-operative outcomes in the bariatric population compared to the OSMRS, which is strongly predictive of length of stay and complication following bariatric surgery.

Comparison of esophageal Doppler and plethysmographic variability index to guide intraoperative fluid therapy for low-risk patients undergoing colorectal surgery.

STUDY OBJECTIVE: This study aims to investigate if there is equivalence in volumes of fluid administered when intravenous fluid therapy is guided by Pleth Variability Index (PVI) compared to the established technology of esophageal Doppler in low-risk patients undergoing major colorectal surgery. DESIGN: Randomized controlled trial. SETTING: Operating room. PATIENTS: Forty low-risk patients undergoing elective colorectal surgery. INTERVENTION: Patients were monitored by esophageal Doppler and PVI probes and were randomized to have fluid therapy directed by using one of these technologies, with 250 mL boluses of colloid to maintain a maximal stroke volume, or a PVI of less than 14%. MEASUREMENTS: Absolute volumes of fluid volumes given intraoperatively were measured as were 24 hours fluid volumes. Perioperative measurements of lactate and base excess were recorded as were postoperative complications. MAIN RESULT: There was no significant difference between PVI and esophageal Doppler groups in mean total fluid administered (1286 vs 1520 mL, P=.300) or mean intraoperative fluid balance (+839 v+1145 mL, P=.150). CONCLUSIONS: PVI offers an entirely non-invasive alternative for goal-directed fluid therapy in this group of patients.