Perioperative care in adults

This guideline covers care for adults (aged 18 and over) having elective or emergency surgery, including dental surgery. It covers all phases of perioperative care, from the time people are booked for surgery until they are discharged afterward. The guideline includes recommendations on preparing for surgery, keeping people safe during surgery and pain relief during recovery.

[Fast-track rehabilitation for acute cholecystitis: intermediate outcomes of prospective randomized trial]. / Uskorennoe vyzdorovlenie pri ostrom kholetsistite: promezhutochnye rezul'taty prospektivnogo randomizirovannogo issledovaniia.

AIM: To analyze an efficacy of FT-protocol in patients with acute cholecystitis. MATERIAL AND METHODS: Prospective randomized study included 102 patients (45 of main group (FT) and 57 of control groups). Patients did not differ by TG13 severity index. The protocol included information, antibiotic prophylaxis, restriction of drainage, intraperitoneal anesthesia with long-term anesthetics, low pressure pneumoperitoneum, antiemetics in the presence of risk factors, early activation and feeding of the patient. Pain was assessed by VAS immediately after surgery, and 2, 6 and 12-24 hours postoperatively. RESULTS: Surgery time was similar in both groups. Need for anesthesia and pain severity were significantly lower in the FT group. A total absence of pain (VAS 0-1) on the 1st postoperative day was noted in 8 (17.7%) of the FT group and 2 (3.5%) patients of the control group (p=0.038). Shoulder pain developed in 4 (8.9%) cases of the main and 22 (38.6%) cases of the control group (p=0.001). Postoperative nausea developed in 13% of the FT group vs 40.5% in the control group (p=0.05). Hospital-stay was 1.29±0.7 days and 2.7±1.6 (p<0.0001), respectively. The time of the first stool was similar. Twenty-four (53.5%) patients of the FT group and 8,9% of the control group were discharged on 1st postoperative day. There were 2 (IIIA) complications in the main group and 3 - in the control group (IIIA, IIIB and IV). There were no mortality and readmissions. CONCLUSION: FT protocol in AC reduce postoperative pain, dyspepsia, shoulder pain and in-hospital stay with equal number of postoperative complications.

Multimodal Rehabilitation in Geriatric Emergency Surgery.

Introduction: Perioperative application of multimodal rehabilitation pathways represents the anticipated evolution of a concept that has arisen in recent decades, initially named fast-track surgery and known today as enhanced recovery after surgery (ERAS). This concept refers to the use of standardised perioperative care protocols that are supported by evidence-based medicine and aim to reduce surgical trauma and stress. Although application of such protocols to emergency surgery has produced favourable results, the use of ERAS in the geriatric emergency surgery setting has not been widely applied, and no studies have produced results that support its use in this setting. However, ERAS could help improve outcomes in this group of patients, who already have high surgical morbidity and mortality rates. Material and Methods: In preparation for a lecture presented at the 18th European Congress of Trauma and Emergency Surgery (Bucharest, May 2017), the authors performed a literature search using the terms "ERAS", "fast-track", "emergency surgery", "emergency medicine", "multimodal rehabilitation" and "elderly patient" to gather scientific evidence with which to present suggestions in support of their opinion that ERAS could be applied successfully to improve postoperative outcomes for geriatric emergency patients. CONCLUSION: Urgent surgical treatment of elderly patients is associated with morbidity and mortality rates higher than those of younger patients, and there is room for improvement. A multimodal rehabilitation program seems to be a good working model for achieving this goal.

Healthcare professionals' views of the enhanced recovery after surgery programme: a qualitative investigation.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) programme is an approach to the perioperative care of patients which aims to improve outcomes and speed up recovery after surgery. Although the evidence base appears strong for this programme, the implementation of ERAS has been slow. This study aimed to gain an understanding of the facilitating factors and challenges of implementing the programme with a view to providing additional contextual information to aid implementation. The study had a particular focus on the nutritional elements as these have been highlighted as important. METHODS: The study employed qualitative research methods, guided by the Normalisation Process Theory (NPT) to explore the experiences and opinions of 26 healthcare professionals from a range of disciplines implementing the programme. RESULTS: This study identified facilitating factors to the implementation of ERAS: alignment with evidence based practice, standardising practice, drawing on the evidence base of other specialties, leadership, teamwork, ERAS meetings, patient involvement and education, a pre-operative assessment unit, staff education, resources attached to obtaining The Commissioning for Quality and Innovation (CQUIN) money, the ward layout, data collection and feedback, and adapting the care pathway. A number of implementation challenges were also identified: resistance to change, standardisation affecting personalised patient care, the buy-in of relevant stakeholders, keeping ERAS visible, information provision to patients, resources, palatability of nutritional drinks, aligning different ward cultures, patients going to non-ERAS departments, spreading the programme within the hospital, differences in health issue, and utilising a segmental approach.  CONCLUSIONS: The findings presented here provide useful contextual information from diverse surgical specialties to inform healthcare providers when implementing ERAS in practice. Addressing the challenges and utilising the facilitating factors identified in this study, could speed up the rate at which ERAS is adopted, implemented and embedded.

[Improving pre- and perioperative hospital care : Major elective surgery]. / Verbesserung des prä- und postoperativen Behandlungskonzepts : Große elektiv-chirurgische Eingriffe.

Surgery is aimed at improving a patient's health. However, surgery is plagued with a risk of negative consequences, such as perioperative complications and prolonged hospitalization. Also, achieving preoperative levels of physical functionality may be delayed. Above all, the "waiting" period before the operation and the period of hospitalisation endanger the state of health, especially in frail patients.The Better in Better out™ (BiBo™) strategy is aimed at reducing the risk of a complicated postoperative course through the optimisation and professionalisation of perioperative treatment strategies in a physiotherapy activating context. BiBo™ includes four steps towards optimising personalised health care in patients scheduled for elective surgery: 1) preoperative risk assessment, 2) preoperative patient education, 3) preoperative exercise therapy for high-risk patients (prehabilitation) and 4) postoperative mobilisation and functional exercise therapy.Preoperative screening is aimed at identifying frail, high-risk patients at an early stage, and advising these high-risk patients to participate in outpatient exercise training (prehabilitation) as soon as possible. By improving preoperative physical fitness, a patient is able to better withstand the impact of major surgery and this will lead to both a reduced risk of negative side effects and better short-term outcomes as a result. Besides prehabilitation, treatment culture and infrastructure should be inherently changing in such a way that patients stay as active as they can, socially, mentally and physically after discharge.

Enhanced recovery after gastro-intestinal surgery: The scientific background.

Enhanced recovery programs (ERP) are without any doubt a major innovation in the care of surgical patients. This multimodal approach encompasses elements of both medical and surgical care. The goal of this in-depth review is to analyze the surgical aspects of ERP, underlining the scientific rationale behind each element of ERP after surgery and in particular, the role of mechanical bowel preparation before colorectal surgery, the place of minimal access surgery, the utility of nasogastric tube, abdominal drainage, bladder catheters and early re-feeding. Publication of factual data has allowed many dogmas to be discarded.

[Perioperative Rehabilitation for Patients with Esophageal Cancer].

Transthoracic esophagectomy for patients with esophageal cancer is one of the most invasive of all gastrointestinal surgery. Postoperative management and surgical techniques are improved. However, many patients are more elderly or suffering from comorbid diseases or in malnutrition status. In order to prevent for postoperative complications after esophagectomy, especially for respiratory complication and swallowing dysfunction, adequate rehabilitation approaches are necessary depending on the various conditions.

[Current Status of Perioperative Rehabilitation in Patients who Undergo Esophagectomy for Cancer].

The esophagectomy for esophageal cancer is major surgery and has the highest rate of postoperative pulmonary complications. Respiratory physiotherapy in patients undergoing esophagectomy has been applied to improve oxygenation and airway secretion clearance. Recently, the utility and effectiveness of enhanced recovery after surgery for gastroenterological surgery have been reported in Japan, and patients should be encouraged to participate in early mobilization. Perioperative rehabilitation which includes early mobilization reduces postoperative complications and improves fast-track recovery after esophagectomy. These interventions play important role in postoperative care.

Guía de práctica clínica sobre cuidados perioperatorios en cirugía mayor abdominal / Clinical practice guide on perioperative care in major abdominal surgery

El objetivo de esta Guía de Práctica Clínica (GPC) es servir de instrumento para mejorar la atención sanitaria de los pacientes a los que se les va a realizar un procedimiento de cirugía mayor electiva con abordaje abdominal. Ofrece un conjunto de recomendaciones relacionadas con el manejo del paciente antes, durante y después de la intervención con el fin de mejorar la calidad de los cuidados y de este modo optimizar la recuperación y rehabilitación postoperatorias. Asimismo la guía pretende unificar la diversidad de intervenciones relacionadas con los cuidados perioperatorios y disminuir la variabilidad no justificada de la práctica clínica. La población diana de la guía son todos los pacientes mayores de 18 años con un proceso patológico intraabdominal que requiere cirugía mayor no urgente (electiva). Esta indicación incluye algunos de los procedimientos que se enumeran a continuación: cirugía colorrectal, gastrectomía, by-pass gástrico, histerectomía, prostatectomía, cistectomía, otras cirugías oncológicas ginecológica y urológica, etc. En este sentido la guía engloba a pacientes de diversas especialidades quirúrgicas como son la cirugía general, urológica y ginecológica. Quedan fuera del alcance de la GPC la cirugía de urgencias, la cirugía ambulatoria y la cirugía vascular. Esta GPC va dirigida a todo profesional sanitario implicado en la atención del paciente candidato a cirugía mayor abdominal electiva, principalmente médicos especialistas en cirugía, anestesia, nutrición, urología, ginecología, y enfermería. La GPC también es de interés para administradores, gestores clínicos y coordinadores de calidad. Por último, teniendo presente que es necesaria la implicación y colaboración del paciente en el proceso de su tratamiento, la guía también se dirige a ellos y a sus familiares y cuidadores.

Prospective study of colorectal enhanced recovery after surgery in a community hospital.

IMPORTANCE: Enhanced recovery after surgery (ERAS) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers; however, their efficacy in a community hospital setting remains unclear. OBJECTIVE: To determine if favorable results could be reproduced in a community hospital setting using our ERAS program, which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of ERAS program, a multidisciplinary effort involving anesthesia, preadmission staff, nursing, and surgery staff at a community hospital. The program was initiated in 2010 and was in full practice by 2011. We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 (prior to ERAS implementation), 2011, and 2012. MAIN OUTCOMES AND MEASURES: Laparoscopic approach, narcotic use, length of stay, 30-day readmission, ileus (defined as reinsertion of nasogastric tube), and intra-abdominal infection and association between colorectal cancer (CRC) diagnosis and these outcomes. RESULTS: From 2009 to 2012, the use of laparoscopy increased from 57.4% to 88.8% (P < .001). Length of stay decreased significantly (6.7 days vs 3.7 days, P < .001), without an increase in 30-day readmission rate (17.6% vs 12.5%, P = .49). Use of patient-controlled narcotic analgesia and duration of use decreased (63.2% of patients vs 15%, P < .001; 67.8 hours vs 47.1 hours, P = .02). Ileus rate decreased from 13.2% to 2.5% (P = .02). Intra-abdominal infection decreased from 7.4% to 2.5% (P = .24). When comparing laparoscopic cases alone, similar results were observed. Following regression analysis, there were no statistically significant differences between CRC diagnosis and LOS, 30-day readmission rates, ileus, and intra-abdominal infection (all P's > .05). Length of stay reductions resulted in an estimated cost savings of $3202 per patient (2011) and $4803 per patient (2012). CONCLUSIONS AND RELEVANCE: Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting, and it is associated with decreased LOS without increased readmission or morbidity, as well as significant decreases in narcotic use and cost. Improved outcomes are independent of the laparoscopic approach and CRC diagnosis.

Perfil de pacientes ostomizados atendidos por la estrategia salud de la familia / Profile of ostomized patients assisted by family health strategy

Objetivo: analizar el perfil de pacientes ostomizados atendidos por la estrategia salud de la familia. Métodos: estudio exploratorio descriptivo, con abordaje cuantitativo, realizado con 45 pacientes ostomizados, de ambos sexos, cuya muestra se conformó con el 100 por ciento de estos pacientes. Los datos fueron recolectados por medio de un formulario en el período de julio a agosto de 2013, a través de técnica de entrevista y examen físico, categorizados en Microsoft Excel y procesados utilizando el paquete estadístico SPSS 16.0 por estadística descriptiva. Resultados: prevalecieron las mujeres (57,8 por ciento), predominantemente con edades entre 20-59 años (55,6 por ciento), en su mayoría con bajo nivel educativo (55,6 por ciento) y de bajos ingresos (75,6 por ciento). Como la causa subyacente de las ostomías, predominaron las enfermedades inflamatorias intestinales (40,0 por ciento); la mayoría eran colostomía (77,8 por ciento), temporales (66,7 por ciento), uso de dispositivo de una pieza (80 por ciento), del tipo drenable (60 por ciento) y con barrera de protección (62,2 por ciento). Conclusiones: el conocimiento del perfil de la persona ostomizada y las peculiaridades asociadas con el ostoma son esenciales para conducir la atención de enfermería, con vistas a la participación activa del cliente articulado con otros profesionales que participan en el cuidado perioperatorio y seguimiento del proceso de rehabilitación(AU)

Objective: To analyze the profile of ostomized patients assisted by family health strategy. Methods: Exploratory descriptive study with quantitative approach, performed with 45 ostomy patients of both sexes, whose sample covered 100 percent of patients. Data were collected through a form between July to August 2013, through technical interview and physical examination, categorization in Microsoft Excel and processed using the SPSS 16.0 by descriptive statistics. Results: Identified himself a predominance female (57,8 percent), predominantly aged 20-59 years (55,6 percent), mostly with low education (55,6 percent) and low family income (75,6 percent). As the underlying cause of ostomy predominant inflammatory bowel diseases (40,0 percent); most were colostomy (77,8 percent), temporary (66,7 percent), made use of a piece of scholarships (80,0 percent), drainable (60,0 percent) and protective barrier (62,2 percent). Conclusions: Knowledge of the profile of the person stoma and the peculiarities related to stoma shows is essential for directing nursing care, given the active participation of the client articulated with other professionals involved in the course of the perioperative and follow-up of rehabilitation process(AU)

Fast-track surgery combined with laparoscopy could improve postoperative recovery of low-risk rectal cancer patients: a randomized controlled clinical trial.

OBJECTIVE: In this study we aimed to assess the feasibility and safety of fast-track surgery (FTS) combined with laparoscopy for treating patients with rectal cancer and compare the results with those of the conventional perioperative intervention group. METHODS: A total of 120 patients with rectal cancer were prospectively randomly assigned to the FTS combined with laparoscopy group and the conventional perioperative intervention plus laparoscopy group from November 2011 to November 2012. All patients received radical anterior resection with total mesorectal excision. Their baseline characteristics and the perioperative outcomes were recorded for analyses. RESULTS: Compared with the conventional perioperative intervention group, the fast-track protocol combined with laparoscopy could shorten the time to the first flatus (53.44 ± 23.64 h vs 67.85 ± 20.12 h, P = 0.001) and first defecation (65.23 ± 22.24 h vs 86.98 ± 24.85 h, P = 0.000) after operation, accelerate the decrease of white blood cell count (P < 0.05), inhibit body temperature augmentation (P < 0.05) and reduce postoperative complication rate (16.9% vs 3.5%, P = 0.030). In addition, the length of postoperative stay was also shortened (5.05 ± 1.38 days vs 6.98 ± 2.26 days, P = 0.000). The medical cost of hospitalization was also reduced in the FTS group. CONCLUSION: FTS in combination with laparoscopy may accelerate the clinical recovery of patients with rectal cancer after surgery.

Orthogeriatrics moving forward.

The role of the orthogeriatrician has grown over the last few years. Orthogeriatrics was primarily involved in the care and management of fragility hip fractures, but has recently been expanded to provide specialist care to patients admitted with other various fractures, the spine, pelvis, appendicular, and those suffered from major trauma. There is also an increasing role for the orthogeriatrician to optimise the pre-operative care of patients undergoing elective joint and spine surgery. Much of what we do incorporates comprehensive geriatric assessment of the frail older person, and research into new and innovative ways of managing various types of fragility fractures such as the use of enhanced recovery after surgery (ERAS) pathways, regional anaesthesia, vertebral augmentation in spinal fractures, sacral augmentation and anabolic treatment in pelvic fractures. Ultimately, this reduces post-operative complication rates, improves outcomes and leads to better patient care and recovery.

Optimizing perioperative care in bariatric surgery patients.

Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.

Perioperative rehabilitation approaches in those over 75 years with respiratory dysfunction from chronic obstructive pulmonary disease undergoing abdominal tumor surgery.

PURPOSE: We report two cases of perioperative rehabilitation for abdominal cancer patients aged 75 years and older with severe chronic obstructive pulmonary disease (COPD). CASE DESCRIPTION: Case 1 was a 75-year-old man with COPD and 52-year history of smoking 30 cigarettes per day. The patient was diagnosed with gastric cancer and scheduled for laparoscopic total gastrectomy. Preoperative forced expiratory volume in 1 second (FEV1) was 0.64 L. He could walk with intermittent rest. Case 2 was an 81-year-old woman with COPD, bronchial asthma and 40-year history of smoking 20 cigarettes per day. She was diagnosed with transverse colon cancer and scheduled for laparoscopic-assisted partial transverse colectomy. Preoperative FEV1 was 0.70 L. She could walk indoors with T-cane. RESULTS: All staff started performing tasks simultaneously a week before surgery. Both patients were extubated soon after surgery; they could sit and take deep breaths soon after admission to intensive care unit. They could perform stepping movements early next morning, return to the general ward in the afternoon and started gait training. Because both patients could independently perform activities of daily living, they were discharged on postoperative day 13. CONCLUSION: Comprehensive perioperative rehabilitation appears to be effective in high-risk patients with severe COPD who need surgery for abdominal cancer.