Evidence-based prescribing of opioids after laparotomy: A quality-improvement initiative in gynecologic oncology.

Introduction: Across specialties, surgeons over-prescribe opioids to patients after surgery. We aimed to develop and implement an evidence-based calculator to inform post-discharge opioid prescription size for gynecologic oncology patients after laparotomy. Methods: In 2021, open surgical gynecologic oncology patients were called 2-4 weeks after surgery to ask about their home opioid use. This data was used to develop a calculator for post-discharge opioid prescription size using two factors: 1) age of the patient, 2) oral morphine equivalents (OME) used by patients the day before hospital discharge. The calculator was implemented on the inpatient service from 8/21/22 and patients were contacted 2-4 weeks after surgery to again assess their opioid use at home. Results: Data from 95 surveys were used to develop the opioid prescription size calculator and are compared to 95 post-intervention surveys. There was no difference pre- to post-intervention in demographic data, surgical procedure, or immediate postoperative recovery. The median opioid prescription size decreased from 150 to 37.5 OME (p < 0.01) and self-reported use of opioids at home decreased from 22.5 to 7.5 OME (p = 0.05). The refill rate did not differ (12.6 % pre- and 11.6 % post-intervention, p = 0.82). The surplus of opioids our patients reported having at home decreased from 1264 doses of 5 mg oxycodone tabs in the pre-intervention cohort, to 490 doses in the post-intervention cohort, a 61 % reduction. Conclusions: An evidence-based approach for prescribing opioids to patients after laparotomy decreased the surplus of opioids we introduced into our patients' communities without impacting refill rates.

Perioperative care of the patient with a periodic fever syndrome.

Periodic fever syndromes are autoinflammatory disorders associated with recurrent fevers unrelated to infection. Little is known about the perioperative management of patients with these syndromes, and existing literature consists primarily of case reports and occasional case series. This narrative review discusses background information and diagnostic criteria for the three most common periodic fever syndromes: periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA), familial Mediterranean fever (FMF), and TNF receptor-associated periodic syndrome (TRAPS), and describes perioperative considerations for anesthesia providers when caring for the patient with a periodic fever syndrome. We include a systems-based framework in which to organize these considerations.

Feasibility of the ERAS (Enhanced Recovery After Surgery) Protocol in Patients Undergoing Gastrointestinal Cancer Surgeries in a Tertiary Care Hospital-A Prospective Interventional Study.

Enhanced Recovery After Surgery (ERAS) protocols have emerged as a promising approach to optimize perioperative care and improve outcomes in various surgical specialties. Despite feasibility studies on ERAS in various surgeries, there remains a paucity of research focusing on gastrointestinal cancer surgeries in the Indian context. The primary objective is to evaluate the compliance rate of the ERAS protocol and secondary objectives include the compliance rate of individual components of the protocol, the complications, the length of hospital stay, and the challenges faced during implementation in patients undergoing gastrointestinal cancer surgeries in our tertiary care cancer center. In this prospective interventional study (CTRI/2022/04/041657; registered on 05/04/2022), we evaluated 50 patients aged 18 to 70 years undergoing surgery for gastrointestinal malignancies and implemented a refined ERAS protocol tailored to our institutional resources and conditions based on standard ERAS society recommendations for gastrointestinal surgeries and specific recommendations for colorectal, pancreatic, and esophageal surgeries.Our study's mean overall compliance rate with the ERAS protocol was 88.54%. We achieved a compliance rate of 91.98%, 81.66%, and 92.00% for pre-operative, intraoperative, and post-operative components respectively. Fourteen (28%) patients experienced complications during the study. The median length of stay was 6.5 days (5.25-8). Challenges were encountered during the preoperative, intraoperative, and postoperative phases. The study highlighted the feasibility of implementing the ERAS protocol in a cancer institute, but specific challenges need to be addressed for its optimal success in gastrointestinal cancer surgeries. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-024-01897-y.

Time-to-surgery paradigms: wait time and surgical outcomes in critically Ill patients who underwent emergency surgery for gastrointestinal perforation.

BACKGROUND: Waiting time for emergency abdominal surgery have been known to be linked to mortality. However, there is no clear consensus on the appropriated timing of surgery for gastrointestinal perforation. We investigated association between wait time and surgical outcomes in emergency abdominal surgery. METHODS: This single-center retrospective cohort study evaluated adult patients who underwent emergency surgery for gastrointestinal perforations between January 2003 and September 2021. Risk-adjusted restricted cubic splines modeled the probability of each mortality according to wait time. The inflection point when mortality began to increase was used to define early and late surgery. Outcomes among propensity-score matched early and late surgical patients were compared using percent absolute risk differences (RDs, with 95% CIs). RESULTS: Mortality rates began to rise after 16 h of waiting. However, early and late surgery groups showed no significant differences in 30-day mortality (11.4% vs. 5.7%), ICU stay duration (4.3 ± 7.5 vs. 4.3 ± 5.2 days), or total hospital stay (17.4 ± 17.0 vs. 24.7 ± 23.4 days). Notably, patients waiting over 16 h had a significantly higher ICU readmission rate (8.6% vs. 31.4%). The APACHE II score was a significant predictor of 30-day mortality. CONCLUSIONS: Although we were unable to reveal significant differences in mortality in the subgroup analysis, we were able to find an inflection point of 16 h through the RCS curve technique. TRIAL REGISTRATION: Formal consent was waived due to the retrospective nature of the study, and ethical approval was obtained from the institutional research committee of our institution (B-2110-714-107) on 6 October 2021.

Perioperative adverse cardiac events in maxillofacial surgery: A systematic review and meta-analysis.

Background and Aims: Maxillofacial surgeries, including procedures to the face, oral cavity, jaw, and head and neck, are common in adults. However, they impose a risk of adverse cardiac events (ACEs). While ACEs are well understood for other non-cardiac surgeries, there is a paucity of data about maxillofacial surgeries. This systematic review and meta-analysis report the incidence and presentation of perioperative ACEs during maxillofacial surgery. Methods: We included primary studies that reported on perioperative ACEs in adults. To standardise reporting, ACEs were categorised as 1. heart rate and rhythm disturbances, 2. blood pressure disturbances, 3. ischaemic heart disease and 4. heart failure and other complications. The primary outcome was ACE presentation and incidence during the perioperative period. Secondary outcomes included the surgical outcome according to the Clavien-Dindo classification and trigeminocardiac reflex involvement. STATA version 17.0 and MetaProp were used to delineate proportion as effect size with a 95% confidence interval (CI). Results: Twelve studies (34,227 patients) were included. The incidence of perioperative ACEs was 2.58% (95% CI 1.70, 3.45, I2 = 96.17%, P = 0.001). Heart rate and rhythm disturbances resulted in the greatest incidence at 3.84% among the four categories. Most commonly, these ACEs resulted in intensive care unit admission (i.e. Clavien-Dindo score of 4). Conclusion: Despite an incidence of 2.58%, ACEs can disproportionately impact surgical outcomes. Future research should include large-scale prospective studies that may provide a better understanding of the contributory factors and long-term effects of ACEs in patients during maxillofacial surgery.

Beyond measurement: a deep dive into the commonly used pain scales for postoperative pain assessment.

This review explores the essential methodologies for effective postoperative pain management, focusing on the need for thorough pain assessment tools, as underscored in various existing guidelines. Herein, the strengths and weaknesses of commonly used pain scales for postoperative pain-the Visual Analog Scale, Numeric Rating Scale, Verbal Rating Scale, and Faces Pain Scale-are evaluated, highlighting the importance of selecting appropriate assessment tools based on factors influencing their effectiveness in surgical contexts. By emphasizing the need to comprehend the minimal clinically important difference (MCID) for these scales in evaluating new analgesic interventions and monitoring pain trajectories over time, this review advocates recognizing the limitations of common pain scales to improve pain assessment strategies, ultimately enhancing postoperative pain management. Finally, five recommendations for pain assessment in research on postoperative pain are provided: first, selecting an appropriate pain scale tailored to the patient group, considering the strengths and weaknesses of each scale; second, simultaneously assessing the intensity of postoperative pain at rest and during movement; third, conducting evaluations at specific time points and monitoring trends over time; fourth, extending the focus beyond the intensity of postoperative pain to include its impact on postoperative functional recovery; and lastly, interpreting the findings while considering the MCID, ensuring that it is clinically significant for the chosen pain scale. These recommendations broaden our understanding of postoperative pain and provide insights that contribute to more effective pain management strategies, thereby enhancing patient care outcomes.

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery. METHODS: PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness. DISCUSSION: This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients. TRIAL REGISTRATION: This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Perioperative Management in Patients with Atrial Fibrillation Treated with Non-Vitamin K Antagonist Oral Anticoagulants Undergoing Minor Bleeding Risk Procedure: Rationale and Protocol for the PERIXa Study.

Background: While treatment interruption of non-vitamin K antagonist oral anticoagulants (NOACs) for elective surgery or procedures among patients with atrial fibrillation (AF) is becoming more prevalent, there remains insufficient evidence regarding the optimal perioperative management of NOACs, particularly procedures with minor bleeding risks. Objective: This study aims to evaluate the safety and effectiveness of a simplified, standardized protocol for perioperative management of direct factor Xa inhibitors in patients, with AF undergoing procedures associated with minor bleeding risk. Methods: This multicenter, prospective single-arm registry study plans to enroll patients undergoing procedures with minor bleeding risk who were prescribed direct factor Xa inhibitors for AF. The procedures with minor bleeding risk will include gastrointestinal endoscopy for diagnostic purposes, selected dental procedures, and ocular surgery for cataracts or glaucoma. For apixaban, patients will withhold the last evening dose and resume either from the evening dose of the procedure day or the following morning, depending on the bleeding risk of the patient. For edoxaban or rivaroxaban, patients will withhold only a single dose on the procedure day. The primary outcome is the occurrence of major bleeding events within 30 days. Secondary outcomes include systemic thromboembolism, all-cause mortality, and a composite of major and clinically relevant non-major bleeding events. Conclusion: This study has the potential to generate evidence regarding the safety of perioperative management for patients, with AF undergoing procedures associated with minor bleeding risk. Trial Registration: Clinicaltrials.gov: NCT05801068.

Comparison of the Outcomes of Enhanced Recovery After Surgery and Traditional Recovery Pathway in Robotic Hysterectomy for Benign Indications: A Randomized Controlled Trial.

STUDY OBJECTIVE: The present study aimed to evaluate the impact of the implementation of the enhanced recovery after surgery (ERAS) program in patients undergoing robotic hysterectomy for benign indications in comparison with conventional management. DESIGN: Randomized controlled trial. SETTING: North Indian tertiary care hospital. PARTICIPANTS: Patients aged 40 to 60 years willing to sign the informed written consent were included, whereas cases with contraindications for neuraxial anesthesia were excluded. A total of 130 subjects undergoing robotic hysterectomy were divided into ERAS (n = 65) and conventional (non-ERAS) (n = 65) groups. INTERVENTIONS: Components of the ERAS protocol included preoperative counseling, carbohydrate loading, early removal of catheter, and early ambulation. Both groups underwent optimization of medical conditions, standardized anesthesia, and venous thromboembolism prophylaxis. MEASUREMENTS AND MAIN RESULTS: Outcome measures included length of hospital stay (LOHS), time to tolerance of diet, postoperative complications, readmission rates, and quality of life assessed by WHO-QOL BREF. Baseline characteristics were comparable between groups. ERAS group showed significantly lower docking time (4.82 ± 0.73 vs 5.31 ± 0.92 minutes), faster tolerance of diet (0.14 ± 0.35 vs 1.14 ± 0.35 days), and earlier resumption of ambulation (0.42 ± 0.5 vs 1.26 ± 0.44 days). Time for "fit for discharge" (1.43 ± 0.61 vs 2.97 ± 1.1 days) and LOHS (2.85 ± 1.09 vs 3.78 ± 1.29 days) were significantly lower in the ERAS group. Postoperative complications and readmission rates were comparable. Quality-of-life scores favored the ERAS group at postoperative days 1 and 30. CONCLUSION: The combination of ERAS and robotic surgery improves patient outcomes, shortens hospital stays, and enhances postoperative recovery without increasing complications. This research serves as a pioneering effort in assessing the impact of ERAS on robotic hysterectomy for benign indications, providing valuable insights for future multicentric studies and supporting the integration of ERAS protocols to enhance patient outcomes and quality of life.

Perioperative patient safety indicators-A Delphi study.

AIM: To identify, define and achieve consensus on perioperative patient safety indicators within a Swedish context. DESIGN: A modified Delphi method. METHODS: A purposeful sample of 22 experts, all experienced operating room nurse specialists, was recruited for this study. A questionnaire was constructed incorporating statements derived from a preceding study. The experts were asked to rate the importance of each statement concerning patient safety during the perioperative phase. The data collection occurred through an online survey platform between November 2022 and April 2023. The CREDES checklist guided the reporting of this study. RESULTS: The three-round Delphi study resulted in consensus on 73 statements out of 103, encompassing 74% process indicators and 26% structure indicators. Key areas of consensus included the use of the Surgical Safety Checklist and optimizing the operating room environment. CONCLUSION: Consensus was reached on perioperative safety indicators, underscoring the intricate challenges involved in ensuring patient safety in the operating room. It emphasizes the important integration of both structure and process indicators for comprehensive safety assessment during surgical procedures. Recognizing the difficulty in measuring factors like teamwork and communication, essential for patient safety, the study offers practical guidance. It underlines a balanced approach and specific consensus areas applicable in clinical practice to enhance perioperative patient safety. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: This study provides concrete practice guidance and establishes a structured framework for evaluating perioperative care processes. It emphasizes the critical role of professionals having the necessary skills and being present during surgical procedures. Additionally, the study underscores the paramount importance of effective communication and teamwork within the operating room team, substantively contributing to overall patient safety enhancement. IMPACT: The study focused on addressing the challenge of ensuring patient safety in operating rooms, acknowledging the persistent complications related to surgery despite global efforts to eliminate avoidable harm in healthcare. Consensus was reached on 73 crucial indicators for perioperative patient safety, emphasizing a balanced approach integrating both process and structure indicators for a comprehensive assessment of safety during surgical procedures. The study has a broad impact on professionals and healthcare systems, providing concrete guidance for practice and offering a structured process for evaluating perioperative care. REPORTING METHOD: The study is reported informed by 'Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations derived from a methodological systematic review'. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Patient-reported outcomes after oncologic hepatic resection predict the risk of delayed readiness to return to intended oncologic therapy (RIOT).

BACKGROUND: Optimal surgical recovery is critical to readiness to return to intended oncologic therapy (RIOT). The current study defined the value of patient-reported outcomes (PROs) in predicting the risk for delayed RIOT after oncologic hepatic resection. METHODS: In a prospective longitudinal study, perioperative symptoms were assessed using a valid PRO assessment tool, the MD Anderson Symptom Inventory module for hepatectomy perioperative care (MDASI-PeriOp-Hep), for 4 weeks after surgery. The timed up and go test (TUGT) was administered before surgery, by discharge day, and at the first postoperative follow-up visit. Multivariate logistic regression analysis assessed the predictive value of PROs for delayed RIOT. RESULTS: We enrolled 210 patients and analyzed 148 patients who received adjuvant chemotherapy and contributed more than 3 PRO assessments postoperatively. About 36 percent of the patients had delayed RIOT (>5 weeks, range 1-14 weeks). MDASI scores for drowsiness, fatigue, dry mouth, and interference with general activity, walking, and work on day 7 after discharge and MDASI scores for incisional tightness, fatigue, dry mouth, shortness of breath, and interference with work on day 14 after discharge were associated with delayed RIOT (all P < 0.05). Walking and general activity items on the MDASI-Interference subscale on day 7 after discharge were highly correlated with prolonged TUGT scores at discharge (P < 0.01). CONCLUSION: We defined clinically meaningful PROs on MDASI-PeriOp-Hep after hepatic resection that predicted increased risk of delayed RIOT. These findings highlight the importance PROs for monitoring symptoms and functioning 1-2 weeks after discharge to be implementing into perioperative care.

Development of a minimum clinical dataset for preoperative comprehensive geriatric assessment using a modified Delphi technique.

OBJECTIVE: To construct a standardised, consensus-guided minimum clinical dataset (MCDS) for preoperative comprehensive geriatric assessment and optimisation (CGA) in Australia and Aotearoa New Zealand. METHODS: We conducted a review of the international perioperative literature to identify CGA domains and tools for potential inclusion in the MCDS. We invited members of the Australian and New Zealand Society for Geriatric Medicine to participate in a Delphi study to obtain consensus on MCDS tools. Participants were asked to rate proposed tools using Likert scales (when >2 tools) or make a binary choice between two proposed tools. Consensus was considered to be achieved when there was at least 75% concordance between the two rounds amongst the participants, and at least one variable attaining over 50% of participants' votes. Domains that did not achieve consensus in Round 1 were carried over to Round 2. RESULTS: There were 73 participants in Round 1 of the Delphi study and 47 participants in Round 2. Consensus was achieved on tool/s recommended for every MCDS domain: Clinical Frailty Scale (frailty); sMMSE, RUDAS, MoCA (cognition); 4AT (delirium); timed-up-and-go (physical function); GDS-15 (mood); Barthel Index (functional status); and MUST (malnutrition). CONCLUSIONS: We recommend clinicians delivering preoperative CGA consider the use of the MCDS we have constructed when assessing older people contemplating surgery, as part of a multicomponent and multidisciplinary approach to optimising perioperative outcomes.

Sedation for Colonoscopy Procedures Using Dexmedetomidine Versus Propofol-Fentanyl Infusions: A Prospective Randomized Controlled Trial.

Objective: Different anaesthetists for sedation or monitored anaesthesia care have been used for colonoscopy. The target of this research was the ability to perform colonoscopy under a painless degree of sedation and the prevalence of undesired proceedings. Methods: A total of 60 patients were randomly divided into two groups: Group D received dexmedetomidine and Group PF received propofol-fentanyl. Patients in both groups received the same infusion ratio. The minimum infusion amount of dexmetatomidine is (0.1 to 0.4 µg kg-1 h-1) in Group D, whereas fentanyl is administered at a rate of 0.01 to 0.05 µg kg-1 min-1 in the PF group during the approximately 45-min colonoscopy. Results: Group D exhibited significantly lower modified Observer's Assessment of Alertness/Sedation (OAA/S) scores at intraoperative time points T1-T12. Group D also exhibited significantly lower visual analog scale scores for pain at intraoperative time points T4 and T7. The mean arterial pressure was significantly lower in Group D at intraoperative times T6-T8 and T11-T12, as well as upon admission to the post-anaesthesia care unit (PACU) and 30 min after admission to the PACU. The results of the ANOVA tests revealed a significantly lower heart rate in Group D. The respiratory rate exhibited a notable decrease during time intervals T8 and T10 in the PF group. Conclusion: The administration of dexmetatomidine and propofol-fentanyl during colonoscopy was found to be safe. In addition, dexmetatomidine may present significant benefits in this context because of its lower occurrence of adverse respiratory events.

Enhanced Recovery After Surgery Cardiac Society turnkey order set for prevention and management of postoperative atrial fibrillation after cardiac surgery: Proceedings from the American Association for Thoracic Surgery ERAS Conclave 2023.

Background: Postoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery. Methods: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type. Results: Preoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery. Conclusions: Despite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.

Patients' perioperative experiences of an opioid-free versus opioid-based care pathway for laparoscopic bariatric surgery: A qualitative study.

Background: Despite recent evidence supporting the adoption of opioid-free anaesthetic and analgesic alternatives in the perioperative context, opioid-based regimens remain standard of care. There is limited knowledge about the patients' perioperative experiences of bariatric surgery, with no study yet investigating their experiences within an opioid-free care pathway. Objective: We aimed to describe similarities and differences in patients' perioperative experiences of undergoing bariatric surgery with either an opioid-free or opioid-based care pathway. Design: A qualitative interview study. Setting: A strategic sample of patients enrolled in an ongoing randomized controlled trial investigating the effects of opioid-free anaesthesia for bariatric surgery were recruited. In the randomized controlled trial, participants were randomized to either opioid-based anaesthesia or opioid-free anaesthesia, including transcutaneous electrical nerve stimulation as primary postoperative pain management. Participants: Twenty patients were interviewed 3 months after surgery: 10 participants in the opioid-free group versus 10 in the opioid-based group. Methods: Semi-structured interviews were conducted between December 2020 and February 2022 and analysed with qualitative content analysis. Results: The analysis yielded four categories and 12 subcategories. In Category 1, participants shared diverse emotions before surgery, including anticipation of a healthier life, but also apprehensions and feelings of failure. In Category 2, describing liminality of general anaesthesia, there were similar descriptions of struggling to remember the anaesthesia induction and struggling to surface when recovering from anaesthesia. However, some participants in the opioid-free group shared descriptions of struggling to keep control, describing accentuated memories of the anaesthesia induction. Category 3, managing your pain, showed similar experiences and strategies but different narrations of pain management, with the opioid-free group stating that transcutaneous electrical nerve stimulation works but not when it really hurts, and the opioid-based group describing confidence in but awareness of opioids. Throughout the overall perioperative time period, participants acknowledged Category 4, a patient-professional presence, stating that preparations boost the feeling of confidence before surgery and that they felt confidence in a vulnerable situation although vulnerability challenges communication. Conclusions: We highlighted the overall similarities in perioperative experiences of patients undergoing bariatric surgery. However, the differences in experiences during opioid-free anaesthesia induction need to be addressed in further implementation and research studies investigating strategies to reduce the sense of loss of control. More research is needed to facilitate the implementation of opioid-free treatment strategies into clinical practice and improve the patient care experience.

ERAS® Cardiac Society Turnkey Order Set for Surgical Site Infection Prevention: Proceedings from the AATS ERAS Conclave 2023.

OBJECTIVES: Surgical site infections (SSIs) after cardiac surgery increase morbidity and mortality, consume healthcare resources, impair recovery, and diminish patients' quality of life. Numerous guidelines and expert consensus documents have been published to address the prevention and management of SSIs. Our objective is to integrate these documents into an order set that will facilitate the adoption and implementation of evidence-based best practices for preventing and managing SSIs following cardiac surgery. METHODS: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for SSI reduction. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistent Class I or IIA, Class IIB or otherwise supported by published evidence, were also included in italicized type. RESULTS: Preventative care begins with the preoperative identification of both modifiable and non-modifiable SSI risks by healthcare providers. Assessment tools can be utilized to assist in identifying patients at a high risk of SSI. Preoperative recommendations include screening for and treating Staphylococcus aureus nasal carriage. Intraoperatively, tailored prophylactic intravenous antibiotics and maintaining blood glucose levels below 180 mg/dL are essential elements. Postoperative care includes maintaining normothermia, glucose control and patient engagement. CONCLUSION: Despite the well-documented advantages of a multidisciplinary care pathway for SSI in cardiac surgery, there are inconsistencies in its adoption and implementation. This manuscript provides an order set that incorporates recommendations from existing guidelines to prevent SSI in the cardiac surgical population.

Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis.

BACKGROUND: Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care. METHODS: A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates. RESULTS: After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure. CONCLUSION: In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.