Rapid Discharge Protocol Reduces Length of Stay and Eliminates Postoperative Nausea and Vomiting After Surgery for Adolescent Idiopathic Scoliosis.

BACKGROUND: Implementing standardized pathways following adolescent idiopathic scoliosis surgery have been shown to reduce length of stay (LOS). However, controversies still exist. This applies especially to the transition to solid foods, postoperative pruritus, and postoperative nausea and vomiting (PONV). The aim of this proposed protocol is to present an option to reduce these factors while reducing the LOS. METHODS: The protocol was designed with reduction of morphine. One-hundred and eight patients were included in this study, including 66 controls before intervention. All patients underwent posterior scoliosis surgery. All patients were scored daily using a numeric rating scale, and they noted if any nausea, vomiting, or pruritus was present. All medications were recorded. For every 20 patients included, the steering committee met to identify any implementation issues. RESULTS: LOS was reduced from 6.3 to 3.6 days (43% reduction, P = 0.003). PONV was reduced from affecting 82% to 9% of patients (P < 0.0001). The number of patients experiencing postoperative pruritus was reduced from 40% to 2% (P < 0.001). Time spent in postoperative recovery was reduced from 278 (117 - 470) minutes to 199 (128 - 643), P < 0.001. Patients' pain scores remained unchanged compared with controls (mean 4 [3 - 8]). We found no adverse effects of solid food intake from postoperative day 0. CONCLUSIONS: We found a significant reduction in length of stay, PONV, and pruritus after implementation of the protocol. This allowed for no restrictions in regards to solid food intake postoperatively.

Waking Up in Pain: a prospective unselected cohort study of pain in 3702 patients immediately after surgery in the Danish Realm.

BACKGROUND: Acute and persistent pain after surgery is well described. However, no large-scale studies on immediate postoperative pain in the operating room (OR) exist, hindering potential areas of research to improve clinical outcomes. Thus, we aimed to describe the occurrence and severity of immediate postoperative pain in a large, unselected cohort. METHODS: This was a prospective cohort study, encompassing all procedures in 31 public hospitals in the Danish Realm, during a 5-day period including the weekend. Data on procedures and anesthesia were collected and the main outcome was occurrence of moderate or severe pain in the OR. Secondary outcomes included pain, sedation and nausea in the OR or during the first 15 min in the postanesthesia care unit (PACU) including relevant risk factors. Descriptive and logistic regression statistics were used. RESULTS: A total of 3675 procedures were included for analysis (87% inclusion rate). Moderate or severe pain occurred in 7.4% (95% CI 6.5% to 8.3%) of cases in the OR immediately after awakening, rising to 20.2% in the OR and/or PACU. Large intraprocedure and interprocedure variations occurred (0.0%-37.5%), and in 20% of cases with epidural-general anesthesia patients experienced moderate or severe pain. Independent risk factors were female sex, younger age, preoperative pain, daily opioid use and major surgical procedures. CONCLUSION: Moderate or severe pain in the immediate postoperative phase occurred in 20% of all cases with procedure and anesthesiological technique variations, suggesting a need for identification of relevant procedure-specific risk factors and development of preventive treatments. TRIAL REGISTRATION NUMBER: RoPR ID 43191.

Is there a diurnal difference in mortality of severely injured trauma patients?

BACKGROUND: Mortality may be higher for admissions at odd hours than during daytime, although for trauma patients results are conflicting. The objective of this study was to assess whether diurnal differences in mortality among severely injured trauma patients in Denmark were present. METHODS: This observational cohort study was conducted between 1 December 2009 and 30 April 2011 involving one level 1 trauma centre and seven local emergency departments in eastern Denmark. Patients were consecutively included if received by a designated trauma team. Night-time patients (20:00-07:59) were compared with daytime patients (20:00-07:59). An injury severity score (ISS) >15 defined severe injury. Patients with burns and patients who upon arrival were declared non-trauma patients were not included. The primary outcome measure was 30-day mortality. RESULTS: A total of 1985 patients were recorded, of whom 576 were admitted at night-time, 1369 at daytime and 40 not included due to missing data. There were 142 patients with ISS >15 in the daytime group and 64 at night-time. The 30-day mortality was 14.1% for admittance at night-time versus 21.3% at daytime (p=0.22). Logistic regression analysis revealed that odd-hour admission was not a significant predictor of mortality for patients with ISS >15 when adjusted for age, ISS and initial treatment facility (OR 0.71 (95% CI 0.27 to 1.90); p=0.50). CONCLUSIONS: In conclusion, we found no diurnal differences in 30-day mortality for severely injured trauma patients.