Pre-operative triAge proCedure to streaMline elective surgicAl patieNts (PACMAN) improves efficiency by selecting patients eligible for phone consultation: A retrospective cohort study.

BACKGROUND: Pre-operative screening is a high volume task consuming time and resource. Streamlining patient flow by gathering information in advance reduces costs, optimises resources and diminishes patient burden whilst maintaining safety of care. OBJECTIVE: To evaluate whether 'Pre-operative triAge proCedure to streaMline elective surgicAl patieNts' (PACMAN) is able to improve pre-operative screening by selecting patients eligible for evaluation by telephone. DESIGN: A single-centre, retrospective, observational cohort analysis. SETTING: A tertiary medical teaching hospital in 's-Hertogenbosch, The Netherlands. PATIENTS AND METHODS: Adults scheduled for clinical interventions under procedural sedation and all types of elective medium or low risk surgery with anaesthetic guidance were eligible. Patients answered a questionnaire to calculate the PACMAN score. This score combined with risk factors related to surgery determines suitability for phone consultation (PhC) or the need for an in-person consultation (in-PC). INTERVENTION: Evaluation of standard care. MAIN OUTCOME MEASURES: Primary outcome was the reduction in number of in-PCs. Secondary outcomes included reliability of PACMAN, peri-operative patient outcomes and cost-effectiveness. RESULTS: Of 965 patients triaged by PACMAN, 705 (73.1%) were identified as suitable for a PhC. Of those, 688 (97.6%) were classified American Society of Anesthesiologists Physical Status (ASA-PS) I to II or III with stable comorbidities. Of the 260 in-PC patients, 47.4% were classified ASA-PS III with unstable comorbidities or ASA-PS IV. The overall incidence of unanticipated adverse peri-operative events was 1.3%. Finally, implementation of PACMAN led to a 20% increase in pre-operative department efficiency due to better deployment of personnel and resources. CONCLUSION: Implementation of PACMAN resulted in a 73.1% reduction in pre-operative in-PCs at our hospital. Given the increasing pressure on healthcare systems globally, we suggest developing further optimisation and integration of smart triage solutions into the pre-operative process. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06148701.

Comparison of three perioperative fluid regimes for laparoscopic donor nephrectomy : A prospective randomized dose-finding study.

BACKGROUND: Pneumoperitoneum (PP), as used for laparoscopic procedures, impairs stroke volume, renal blood flow, glomerular filtration rate and urine output. This study investigated whether perioperative fluid management can abolish these negative effects of PP on hemodynamics. METHODS: Twenty-one patients undergoing laparoscopic donor nephrectomy (LDN) were randomized into three groups: group 1 received overnight infusion and received a bolus of colloid before induction of anesthesia, followed by a bolus just before PP; group 2 received overnight infusion and a colloid bolus before anesthesia; group 3 served as controls and received only infusion during operation. All three groups received the same total amount of crystalloids and colloids until nephrectomy. Data analysis of the donor included; mean arterial pressure (MAP), stroke volume (SV), left ventricular ejection time (LVETc), perioperative urine output and renal function measured as the creatinine clearance (CrCl) until one-year post-operative. RESULTS: SV was significantly higher in group 1 compared to controls for all measurements. In the control group SV significantly decreased after changing from the supine to lateral position whereas there was no change in SV in both pre-hydrated groups. In all groups, MAP decreased after induction of anesthesia, and restored to pre-anesthetic values during PP. CrCl decreased in the control group during PP, but not in the other groups. From two days postoperative, CrCl was comparable between the three study groups. CONCLUSION: Overnight infusion and a bolus of colloid just before PP attenuate hemodynamic compromise from PP.