Implementation of an enhanced recovery protocol for lung volume reduction surgery: an observational cohort study.

OBJECTIVES: Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP. METHODS: This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS. RESULTS: Seventy-six LVRS patients were included (pre-ERP: n=41, ERP: n=35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P=0.0002), shorter chest tube duration (4 vs 12 days, P<0.0001) with a lower incidence of PAL (21% vs 61%, P=0.0005) and shorter LOS (6 vs 14 days, P<0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l). CONCLUSIONS: Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months.

Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up.

OBJECTIVES: An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure. DESIGN: A retrospective cohort study. SETTING: A single academic center. PARTICIPANTS: Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019. INTERVENTION: The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients. MEASUREMENTS AND MAIN RESULTS: Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve = 0.676; 95% confidence interval, 0.611-0.741). CONCLUSION: Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.

Impact of Check of Medication Appropriateness (CMA) in optimizing analgesic prescribing: An interrupted time series analysis.

BACKGROUND: Pain therapy in inpatients is regularly suboptimal and might be improved by clinical pharmacy services. In our hospital, we have implemented a software-supported 'Check of Medication Appropriateness' (CMA), which is a centralized pharmacist-led service consisting of a clinical rule-based screening for potentially inappropriate prescriptions (PIPs), and a subsequent medication review by pharmacists. We aimed to investigate the impact of the CMA on pain-related prescribing. METHODS: A quasi-experimental study was performed in a large teaching hospital, using an interrupted time series design. Pre-implementation, patients were exposed to standard of care. Afterwards, a pain-focused CMA comprising 12 specific clinical rules pertaining to analgesic prescribing were implemented in the post-implementation period. A regression model was used to assess the impact of the intervention on the number of pain-related residual PIPs between both periods. The total number of recommendations and acceptance rate was recorded for the post-implementation period. RESULTS: At baseline, a median number of 13.1 (range: 9.5-15.8) residual PIPs per day was observed. After the CMA intervention, the number was reduced to 2.2 (range: 0-9.5) per day. Clinical rules showed an immediate relative reduction of 66% (p < .0001) in pain-related residual PIPs. A significant decreasing time trend was observed during the post-implementation period. Post-implementation, 1683 recommendations were given over 1 year with an acceptance rate of 74.3%. CONCLUSIONS: We proved that the CMA approach reduced the number of pain-related residual PIPs. More pharmacist involvement and the use of clinical rules during hospital stay should be further promoted to optimize appropriate prescribing of analgesics. SIGNIFICANCE: Prescribing of analgesics should be improved in inpatients to optimize pain control and to reduce iatrogenic harm. The Check of Medication Appropriateness (CMA) approach, comprising a clinical rule-based screening for patients at risk and a targeted medication review by pharmacists, reduced the number of pain-related potentially inappropriate prescriptions in a highly significant and sustained manner. This study presents the opportunities of a centralized clinical pharmacy service to help clinicians to further improve analgesic prescribing.

Quality Indicators in Vascular Surgery: Toward a National Consensus on 20 Quality Indicators in Belgium.

BACKGROUND: The aim of the present study is to develop relevant quality indicators (QI) to monitor and improve quality of care in vascular surgery. METHODS: The Delphi method was used to incorporate expert opinion to reach consensus on a set of QI. A national expert panel consisting of 52 vascular surgeons was installed on a voluntary basis and endorsed by the Belgian Society of Vascular Surgery and the Flemish Hospital Network KU Leuven. A task force team consisting of 12 surgeons was created to serve as a delegation of the expert panel to discuss and filter the obtained data from the different Delphi rounds. RESULTS: A total of 3 Delphi rounds were needed to reach consensus on a set of 20 QI. Each QI had a content validity index (using a 7-point Likert scale), a feasibility index, and a target level. Twelve outcome indicators and 8 process indicators on several vascular topics were selected: overall for all vascular treatments (n = 1), arterial occlusive disease in general (n = 3), arterial occlusive disease of the lower limbs (n = 4), arterial occlusive disease of the carotid arteries (n = 5), arterial aneurysm disease in general (n = 2), arterial aneurysm disease with endovascular treatment (n = 1), and venous disease (n = 4). CONCLUSIONS: This resulted in the successful identification of 20 validated and relevant vascular QI, focusing on arterial occlusive disease, arterial aneurysm disease, and venous disease. The next step in this project will be the performance of an implementation study.

Gastrocnemius fascia release under local anaesthesia as a treatment for neuropathic foot ulcers in diabetic patients: a short series.

BACKGROUND: Diabetic foot ulceration is the leading cause of major amputation in the developed world. Plantar neuropathic ulcers at the forefoot can be managed conservatively with off-loading, but treatment is not invariably successful. Achilles tendon lengthening procedures aim at increasing dorsiflexion and decreasing forefoot pressure but can be associated with complications and require prolonged postoperative immobilization to prevent tendon rupture. We assessed the feasibility and clinical outcome of a comparative minimal invasive procedure: the gastrocnemius fascia release. This technique targets the same goals but is performed under local anaesthesia and allows immediate postoperative weight bearing and ambulation. METHODS: Diabetic patients with plantar neuropathic ulcers Wagner grade 2 or 3 were recruited from our diabetic foot clinic. Patients with infected wounds or untreatable peripheral arterial disease were excluded from the study. Conservative treatment with off-loading and local wound care was attempted for six weeks and surgical procedure only contemplated upon failure. Primary end-points were improved range of dorsiflexion and time to healing. Secondary end-points were local ulcer recurrences, new plantar ulcers, and minor or major amputation. Post-operative follow-up was 12 months. RESULTS: Seven patients were included in the study. An improvement in dorsiflexion of 10.4° (mean) was recorded post-operatively (p < 0.01). After 30 days, complete healing was accomplished in six of the seven patients. Long-term results were excellent as no ulcer recurrence or amputation was noted. CONCLUSIONS: Gastrocnemius fascia release under local anaesthesia can be performed safely in diabetic patients with plantar neuropathic ulcers under the metatarsal heads. Clinical outcome is excellent and long-term results promising.

Breastfeeding and epidural analgesia during labour.

PURPOSE OF REVIEW: To evaluate the effect of epidural analgesia on breastfeeding. RECENT FINDINGS: Alarming messages were sent out following a retrospective study indicating that epidural analgesia caused more breastfeeding failures. The limitations of this study were reviewed as well as the critical importance of good lactation support. SUMMARY: There is no good evidence that epidural analgesia causes reduced breastfeeding success. Good lactation support is critical.