A distractions capture tool for cardiac surgery and lung transplantation: impact on outcomes.

OBJECTIVES: Surgical distractions are associated with worse patient outcomes. Lung transplantation and cardiac surgery's multi-disciplinary nature, and their inherent complexities render them more vulnerable to distractions. We aim to use a novel distractions capture tool to evaluate the severity of distractions during cardiac surgery (CS) and lung transplantation (LTx) and assess its impact on post-operative complications. METHODS: A prospective 'blinded' study was undertaken by direct observation of distractions during CS and LTx. Events were identified using the Imperial College Error Capture tool (ICECAP). Number and severity of distractions were correlated with post-operative outcomes (ICU & hospital stay, bleeding and anastomotic complications). RESULTS: In LTx, we observed 2059 distractions within 287 h across 41 surgeries. In CS, we observed 1089 distractions within 192 h across 62 surgeries. Surgeons were consciously aware of 19.2% (LTx) and 21.3% (CS) of recorded events. Distractions consisted of procedure-independent pressures (61% LTx vs 56% CS), equipment problems (15% LTx vs 23%CS), communication (12% LTx vs 12% CS), technical problems or patient safety concerns (12% LTx vs 9% CS). In CS, 91% of procedure-independent pressures were non-operative distractions whilst LTx recorded 83%. Staff absences at a critical moment of surgery were recorded at 9% (LTx) and 7% (CS). The number and severity of distractions correlated with bleeding (CS p < 0.001, LTx p < 0.01), prolonged ICU stay (CS p = 0.002, LTx p = 0.002), hospital stay (CS p < 0.001) and anastomotic complications(LTx p < 0.03). CONCLUSIONS: ICECAP as a novel surgical distractions capture tool was effective & applicable to both elective cardiac and urgent transplant surgeries. Surgeons were unaware of a large number of distractions & interruptions. Distractions were associated with longer ICU stay and higher rate of bleeding.

Too Cool? Hip Fracture Care and Maintaining Body Temperature.

INTRODUCTION: Patients with hip fractures can become cold during the perioperative period despite measures applied to maintain warmth. Poor temperature control is linked with increasing complications and poorer functional outcomes. There is generic evidence for the benefits of maintaining normothermia, however this is sparse where specifically concerning hip fracture. We provide the first comprehensive review in this population. SIGNIFICANCE: Large studies have revealed dramatic impact on wound infection, transfusion rates, increased morbidity and mortality. With very few studies relating to hip fracture patients, this review aimed to capture an overview of available literature regarding hypothermia and its impact on outcomes. RESULTS: Increased mortality, readmission rates and surgical site infections are all associated with poor temperature control. This is more profound, and more common, in older frail patients. Increasing age and lower BMI were recognized as demographic factors that increase risk of hypothermia, which was routinely identified within modern day practice despite the use of active warming. CONCLUSION: There is a gap in research related to fragility fractures and how hypothermia impacts outcomes. Inadvertent intraoperative hypothermia still occurs routinely, even when active warming and cotton blankets are applied. No studies documented temperature readings postoperatively once patients had been returned to the ward. This is a point in the timeline where patients could be hypothermic. More studies need to be performed relating to this area of surgery.

Assessment of Nutrition and Supplementation in Patients With Hip Fractures.

INTRODUCTION: Malnutrition is common in older people, is known to interact with frailty, and is a risk factor for wound complications and poor functional outcomes postoperatively. Sustaining a hip fracture is a significant life event, often resulting in a decline in mobility and functional ability. A poor nutritional state may further impede recovery and rehabilitation, so strategies to improve perioperative nutrition are of considerable importance. We provide a review of nutritional supplement practices in this vulnerable and growing population. METHOD: Systematic review of preoperative oral nutritional supplementation (ONS) in hip fracture patients. RESULTS: We identified 12 articles pertaining to this important area of perioperative care. The findings suggest postoperative ONS can improve postoperative outcomes in hip fracture patients, especially in terms of increasing total serum protein, improving nutritional status to near-optimum levels, and decreasing postoperative complications. DISCUSSION: There is an absence of evidence specific to preoperative ONS in patients admitted following hip fracture. Literature relating to other populations is encouraging but is yet to be robustly studied. It is unclear whether these results are generalizable to the frailer hip fracture population. There is a need for studies clearly defining outcome measurement and complication assessment pertaining to preoperative ONS. The potential benefit is considerable, and this review will provide a means to inform the construction of meaningful trials in preoperative ONS of patients sustaining hip fracture. CONCLUSION: Oral nutritional supplementation in hip fracture patients may decrease postoperative complications while increasing elderly patient's nutritional state to a near-optimum level. This is extrapolated from postoperative literature, however with a clear gap in research pertaining specifically to preoperative care. The need for well-constructed studies focused on the impact and assessment of early ONS in this population is transparent.

Nutrition in Hip Fracture Units: Contemporary Practices in Preoperative Supplementation.

INTRODUCTION: Patients with hip fractures pose a significant burden on health services. Malnutrition, frailty, and cognitive impairment are common, and key to addressing the needs of this vulnerable patient group is nutrition optimization, including reduction in arbitrary nil by mouth (NBM) perioperative regimens. In order to understand current practices, we characterize preoperative nutrition in a regional hip fracture population. METHODS: Prospective data were submitted to the National Hip Fracture Database by 6 hospitals in the north east of England over a 6-month period. Patients were stratified by preoperative nutritional intake, frailty, and cognitive function. RESULTS: In all, 24.2% (n = 205) patients received no oral intake at all preoperatively; 15.3% of NBM patients were at risk of malnutrition; and 6.9% were malnourished at the time of assessment. Median time to surgery for NBM patients was 16.75 hours, and 6.34% of patients were fasted with no intake for >36 hours. In all, 6.5% (n = 44) of patients with an Abbreviated Mental Test Score (AMTS) of 8 or above were deemed to be at risk of malnutrition at admission, compared to 11.3% (n = 50) of patients with an AMTS of 7 or below. The NBM patients had similar mean Rockwood (4.97) and AMTS (6.51) scores to patients given oral nutrition. CONCLUSION: We have demonstrated contemporary preoperative nutritional practices in the management of over 800 hip fracture patients. Contrary to perception, nutrition practices vary little when stratified for age, cognition frailty, or comorbid burden. We have identified widespread prolonged NBM fasting and undersupplementation in patients sustaining hip fracture across a region. This work suggests a need to focus less on patient factors and more on systematic practices.