Perioperative optimisation in low- and middle-income countries (LMICs): A systematic review and meta-analysis of enhanced recovery after surgery (ERAS).

Background: Enhanced recovery after surgery (ERAS) protocols have largely been incorporated into practice in high-income settings due to proven improvement in perioperative outcomes. We aimed to review the implementation of ERAS protocols and other perioperative optimisation strategies in low- and middle-income countries (LMICs) and their impact on length of hospital stay (LOS). Methods: We searched MEDLINE, PubMed, Global Health (CABI), WHO Global Index Medicus, Index Medicus, and Latin American and Caribbean Health Sciences Literature (LILACS) for studies incorporating ERAS or other prehabilitation approaches in LMICs. We conducted a pooled analysis of LOS using a random-effects model to evaluate the impact of such programs. This systematic review was pre-registered on PROSPERO. Results: We screened 1205 studies and included 70 for a full-text review; six were eligible for inclusion and five for quantitative analysis, two of which were randomised controlled trials. ERAS was compared to routine practice in all included studies, while none implemented prehabilitation or other preoperative optimisation strategies. Pooled analysis of 290 patients showed reduced LOS in the ERAS group with a standardised mean difference of -2.18 (95% confidence interval (CI) = -4.13, -.0.05, P < 0.01). The prediction interval was wide (95% CI = -7.85, 3.48) with substantial heterogeneity (I2 = 94%). Conclusions: Perioperative optimisation is feasible in LMICs and appears to reduce LOS, despite high levels of between-study heterogeneity. There is a need for high-quality data on perioperative practice in LMICs and supplementary qualitative analysis to further understand barriers to perioperative optimisation implementation. Registration: PROSPERO: CRD42021279053.

Does an alcolmeter in the hands of an anesthesiologist make TURP safer? - Results from a case-control study.

BACKGROUND: This hospital-based, prospective, case-controlled study was carried out to monitor fluid absorption during transurethral resection of the prostrate (TURP) by marking the irrigating fluid with ethanol for signs of TURP syndrome. Addition of ethanol allows early detection and prevention of full blown TURP syndrome as also the volume of fluid absorbed can be measured. SUBJECTS AND METHODS: Patients were divided into two groups of 50 each, taking males undergoing TURP belonging to ASA (American Society of Anesthesiologists) I and II. Group 1 received irrigation with 1.5% glycine alone and group 2 received irrigation with 1.5% glycine along with ethanol during TURP. The primary outcome measure was the detection of TURP syndrome using end expiratory ethanol levels and comparing with serum electrolytes and clinical manifestations. The secondary outcome measures, the hemodynamic parameters such as heart rate, systolic and diastolic pressures, and oxygen saturation were recorded during the intraoperative period after spinal anesthesia and then postoperatively till the end of the first hour in the recovery room. STATISTICAL ANALYSIS: Chi-square test, Student's t-test and Pearson's correlation coefficient 'r'. RESULTS: Mean resection time in the ethanol positive patients (36.36 min) was significantly higher than that in the ethanol negative patients (22.08 min) (P < 0.01). The estimated fluid absorbed was statistically significant in 45 minutes of resection in three patients with positive ethanol readings (P < 0.05). Resection was temporally stopped in 16 patients (32%) and permanently in 1 patient (2%), whose resection time reached 60 min. A positive correlation was found between total fall in serum sodium and maximum expiratory ethanol concentration. There was a significant difference in the heart rate between the two groups in the 40(th) minute (P < 0.05). CONCLUSION: Ethanol is a noninvasive, easy-to-use marker in irrigating fluid for assessing fluid absorption. It forewarns to take corrective measures earlier than both fall in sodium and manifestations of TURP syndrome, allowing successful completion of TURP.