Enhanced recovery after surgery program for elective abdominal surgery at three Victorian hospitals.

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

Postoperative analgesia using epidural infusions of fentanyl with bupivacaine. A prospective analysis of 1,014 patients.

BACKGROUND: Epidural fentanyl/bupivacaine infusions often are limited to high dependency units or intensive care units. One thousand fourteen patients receiving epidural fentanyl/bupivacaine infusions for analgesia after major surgery who were managed in the general surgical ward were prospectively surveyed. METHODS: Patients leaving the recovery room with an epidural catheter in situ were assessed three times a day by acute pain service personnel for quality of pain relief, using a rating scale that accounted for pain on movement. The presence of side effects and complications was assessed. RESULTS: Data were collected from February 1990 to May 1993. The average duration of infusion was 3 days. A patient's pain relief was rated as good to excellent on 82.6% of visits. Side effects possibly attributable to fentanyl included sedation (7.4%), pruritus (10.2%), nausea and vomiting (3.1%), and respiratory depression (1.2%). Respiratory depression commonly was associated with sedation and was detected easily on the postsurgical ward, with only four patients requiring naloxone (0.4%). Side effects possibly related to bupivacaine included unpleasant sensory block (2.6%), significant lower limb motor block (3.0%), and hypotension (6.6%). There were two cases of epidural hematoma. Inflammation at the epidural catheter insertion site occurred in 3.8% (38), of which 42% (16) had some cutaneous purulence detected. There were no epidural space infections. Mechanical problems, including dislodgment of the catheter, accounted for 18.7% of infusion discontinuations within the first 72 h. CONCLUSIONS: Postoperative epidural fentanyl/bupivacaine infusions are effective and can be managed readily in general postsurgical wards with minimal complications provided that appropriate patient observations are performed.

Epidural catheter insertion: the effect of saline prior to threading in non-obstetric patients.

The effects of injecting normal saline 4 ml through the epidural needle before catheter passage on ease of catheterisation and incidence of certain complications were investigated in 189 non-obstetric patients. The use of saline had no effect on ease of catheterisation, with 84.2% of Group S patients (saline, n = 95) and 88.3% of Group C patients (control, n = 94) having the difficulty of passing the catheter rated as "easy" (P = 0.31). The incidence of complications was not affected by the use of saline. Paraesthesia occurred in 27.4% of Group S patients compared with 16.0% of Group C patients (P = 0.08). Epidural venous cannulation occurred in 6.3% of Group S patients versus 11.7% of Group C patients (P = 0.30). We conclude that the use of 5 ml of normal saline prior to catheter threading provides no significant benefit in improving the ease of catheterisation or decreasing the incidence of catheter complications.

A double-blind assessment of segmental sensory changes with epidural fentanyl versus epidural saline in patients undergoing extracorporeal shock-wave lithotripsy.

Segmental changes to pin prick and cold stimuli were tested in a double-blind manner in pain-free patients scheduled for extracorporeal shockwave lithotripsy (ESWL). Fifty patients were randomly allocated to receive either epidural fentanyl (100 micrograms in 10 ml normal saline) or 10 ml epidural normal saline. In a further 25 patients an epidural catheter was inserted but no solution injected. In contrast to this latter group, epidural fentanyl and normal saline both produced segmental sensory changes. There were no significant differences between fentanyl and normal saline groups in the number of patients reporting sensory changes to pin prick, rate of onset of these changes, or segmental level. For cold stimuli, more patients in the fentanyl group than in the normal saline group reported a change (16 vs. 8; P = 0.02) but the segmental level was similar. The effect of normal saline as a diluent in epidurally administered opioids may be of clinical importance.

In-vivo modification of angiotensin II pressor responsiveness in sheep by indomethacin.

1. Sodium (Na) depletion, due to uncompensated loss of parotid saliva, reduces the pressor responsiveness to angiotensin II (AII) in intact conscious sheep. 2. Inhibition of prostaglandin synthesis by indomethacin restored AII pressor responsiveness in Na-deplete sheep. 3. Indomethacin infusion also increased the pressor responsiveness to AII in the Na-replete sheep. 4. These findings suggest that in vivo prostaglandins may play a role in modulating the pressor responsiveness to angiotensin II in sheep.