An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients.

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

Safety guideline: neurological monitoring associated with obstetric neuraxial block 2020: A joint guideline by the Association of Anaesthetists and the Obstetric Anaesthetists' Association.

Serious neurological lesions such as vertebral canal haematoma are rare after obstetric regional analgesia/anaesthesia, but early detection may be crucial to avoid permanent damage. This may be hampered by the variable and sometimes prolonged recovery following 'normal' neuraxial block, such that an underlying lesion may easily be missed. These guidelines make recommendations for the monitoring of recovery from obstetric neuraxial block, and escalation should recovery be delayed or new symptoms develop, with the aim of preventing serious neurological morbidity.

Pre-operative fasting in adults and children: clinical practice and guidelines.

It is widely recognised that prolonged fasting for elective surgery in both children and adults serves no purpose, adversely affects patient well-being and can be detrimental. Although advised fasting times for solids remain unchanged, there is good evidence to support a 1-h fast for children, with no increase in risk of pulmonary aspiration. In adults, a major focus has been the introduction of carbohydrate loading before anaesthesia, so that patients arrive for surgery not only hydrated but also in a more normal metabolic state. The latter attenuates some of the physiological responses to surgery, such as insulin resistance. As in children, there is no increase in risk of pulmonary aspiration. Further data are required to guide best practice in patients with diabetes.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018.

BACKGROUND: This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS: A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS: All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS: The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Randomized clinical trial investigating the stress response from two different methods of analgesia after laparoscopic colorectal surgery.

BACKGROUND: One of the key elements of managed recovery is thought to be suppression of the neuroendocrine response using regional analgesics. This may be superfluous in laparoscopic colorectal surgery with small wounds. This trial assessed the effects of spinal analgesia versus intravenous patient-controlled analgesia (PCA) on neuroendocrine responses in that setting. METHODS: A randomized clinical trial was conducted with participation of patients undergoing laparoscopic colorectal surgery within a managed recovery programme. Consenting patients were allocated randomly to spinal analgesia or morphine PCA as primary postoperative analgesia. The primary outcome was interleukin (IL) 6 levels; secondary outcomes were levels of cortisol, glucose, insulin and other cytokines, pain scores, morphine use and length of hospital stay. Stress response analysis was conducted before operation, and 3, 6, 12, 24 and 48 h after surgery. RESULTS: Of 143 eligible patients, 133 were randomized and 120 completed the study. Baseline patient characteristics were similar in the two groups. There were no significant differences in median levels of insulin, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, interferon γ, tumour necrosis factor α or vascular endothelial growth factor between the spinal analgesia and PCA groups at any time point. Three hours after surgery (but at no other time point) median (i.q.r.) levels of cortisol (468 (329-678) versus 701 (429-820) nmol/l; P = 0.004) and glucose (6.1 (5.4-7.5) versus 7.0 (6.0-7.7) mmol/l; P = 0.012) were lower in the spinal analgesia group than in the PCA group. Median (i.q.r.) levels of total intravenous morphine were lower in the spinal analgesia group (10.0 (3.3-15.8) versus 45.5 (34.0-60.5) mg; P < 0.001). CONCLUSION: Spinal analgesia reduced early neuroendocrine responses and overall parenteral morphine use. REGISTRATION NUMBER: NCT01128088 (http://www.clinicaltrials.gov).

Intra-operative oxygen delivery in infusion volume-optimized patients undergoing laparoscopic colorectal surgery within an enhanced recovery programme: the effect of different analgesic modalities.

AIM: Patients undergoing major open surgery who have an indexed oxygen delivery (DO(2) I) > 600 ml/min/m(2) have been shown to have a lower incidence of morbidity and mortality compared with those whose DO(2) I is below this level. Laparoscopy and Trendelenburg positioning cause a reduction in DO(2) I. We aimed to quantify the effect of the type of analgesia on DO(2) I and to correlate the DO(2) I achieved with the incidence of anastomotic leakage in patients undergoing laparoscopic surgery. METHOD: Following ethical approval, patients were randomized to receive spinal anaesthesia (Group S), epidural analgesia (Group E) or intravenous morphine (Group P) followed by postoperative patient-controlled analgesia (PCA). In addition to standard monitoring, oesophageal Doppler monitoring of the stroke volume allowed directed intravenous fluid therapy. The mean DO(2) I was compared with the anastomotic leakage rate. RESULTS: Seventy-five patients were recruited (Group S, 27; Group E, 23; Group P, 25). The mean (range) DO(2) I for all patients was 490 (230-750) ml/min/m(2) . The analgesic modality had no effect on DO(2) I. Of the 18 patients with a DO(2) I of < 400 ml/min/m(2) , four (22%) developed anastomotic leakage compared with one (%) of the 57 patients with a DO(2) I of > 400 ml/min/m(2) (P = 0.01). CONCLUSION: The analgesic modality used had no effect on the DO(2) I achieved. Anastomotic leakage was significantly higher in patients with a DO(2) I of < 400 ml/min/m(2) . A further study assessing the outcome after raising the DO(2) I with inotropes is required.

Optimizing patient outcomes in laparoscopic surgery.

There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient's outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. 1 Analgesia - The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. There is a growing body of opinion that epidural analgesia may not be required for laparoscopic surgery. 2 Individualised goal directed therapy - It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. Analgesia and fluid therapy, together with the remaining enhanced recovery criteria have led to the development of the trimodal approach.

23-hour-stay laparoscopic colectomy.

PURPOSE: The combination of laparoscopic colorectal surgery together with an enhanced recovery program has resulted in short hospital stays. The purpose of this study was to assess the acceptability and safety of a 23-hour-stay protocol developed for patients undergoing laparoscopic colectomy. METHODS: Patients undergoing elective laparoscopic colorectal resection who met the inclusion criteria were invited to participate in the study. A specific preoperative, anesthetic, and postoperative protocol was used. Patients were discharged 23 hours after the start of surgery. Follow-up was by telephone contact on the evening of the day of discharge with outpatient follow-up at Day 3. RESULTS: Ten patients were included in the study. All patients were discharged within 23 hours from the commencement of surgery. There were no complications and no readmissions to the hospital. All patients were satisfied with the service; all ten would request to follow the same pathway again if required, and all would recommend it to other patients. CONCLUSION: A 23-hour-stay laparoscopic colectomy is possible with modification of the enhanced recovery program. Patients find it acceptable and it seems to be safe.