Groh, J; Van Aken, H; Peter, K
Due to the recent development in operative medicine medical and organizational demands on perioperative patient care have changed significantly. Corresponding to the responsibility of the operative colleagues for therapy of the primary disease, anesthesiologists have to account for monitoring and treatment of vital functions throughout the perioperative period, starting from preoperative evaluation until postoperative care. The postanesthesia recovery unit has a key role in perioperative management. Beyond post-operative monitoring and stabilization of vital parameters it is increasingly used as a buffer and switch operating station, where patients are prepared and allocated to a normal ward, an observation or intensive care unit for subsequent postoperative care. The recovery unit has developed to a "multitasking" care center, which should be operational 24 h a day with an anesthesiologist present during working hours. The terminology should be changed in the future in order to better characterize the new task spectrum, e.g. in perioperative anaesthetic care unit (PACU) for medical and medicolegal reasons patient security must have absolute priority above economic aspects. Effective postoperative pain control using epidural or patient-controlled intravenous analgesia may increase patient comfort and reduce postoperative complications caused by sympathoadrenergic activation. Both method can be safely used on normal wards provided that close cooperation and training of ward personnel is guaranteed as well as continuous supervision by a specialized acute pain service.
Smith, Francis Duval
Correctional nurses are trained to care for prisoners in a controlled security environment; however, when a convict is transferred to a noncorrectional health care facility, the nurses there are often unfamiliar with custody requirements or how to safely care for these patients. The care of prisoners outside of prison has not been adequately investigated, and a gap exists between research and nursing education and practice. Nurses rarely have to consider how providing care for a prisoner in custody affects their practice, the potential dissonance between routine nursing care and the requirements to maintain security, or that care of prisoners in unsecured clinical areas places the nurse and other personnel at risk for physical assault or prisoner escape. Educating perioperative nurses in the care of prisoners in a public hospital environment is important for the provision of safe care and prevention of physical and emotional repercussions to personnel. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
According to the U.S. Food and Drug Administration 'the broad scope of digital health includes categories such as mobile health (mHealth), health information technology (IT), wearable devices, telehealth and telemedicine, and personalised medicine, and is used by providers and other stakeholders in their efforts to reduce inefficiencies, improve access, reduce costs, increase quality, and make medicine more personalised for patients (FDA 2016). More recently, Paul Sonier, a digital health strategist and founder of the Linkedin digital health group with more than 40,000 members, defined digital health as 'the convergence of the digital and genomic revolutions with health, healthcare, living, and society' (storyofdigitalhealth.com 2016). Copyright the Association for Perioperative Practice.
McNamara, S A
This study was designed to determine how caring is practiced in perioperative nursing. The theory of nursing by M. Jean Watson, RN, PhD, FAAN, provided the conceptual framework for the study. The researcher used a qualitative, descriptive methodology to analyze data collected in audiotaped interviews with five perioperative nurses and used standard qualitative research procedures for transcribing and analyzing the interview data. The five study participants identified their perceptions of caring behaviors with conscious and unconscious patients in the preoperative, intraoperative, and postoperative periods. They described the essential structure of caring as the establishment of a human care relationship and provision of a supportive, protective, and/or corrective psychological, physical, and spiritual environment.
Carla Monique Lopes Mourão
Full Text Available This study aimed to evaluate the evidence available in the literature about the perioperative care provided to women submitted to mastectomy. An integrative review of scientific literature conducted in MEDLINE, CINAHL, LILACS, and SciELO databases, published from 2000 to 2011, using the controlled descriptors: preoperative care; preoperative period; intraoperative care; intraoperative period; postoperative care; postoperative period; perioperative care; perioperative period; and mastectomy. The sample of this review consisted of seven articles. The evidence pointed as perioperative care of mastectomy the pharmacological management of pain in different surgical periods. Despite the difficulty in presenting a consensus of evidence for perioperative care of mastectomy, there was concern on the part of professionals to minimize/prevent pre-, intra- and post-operative pain. Nursing should be aware, both of the update of pharmacological treatments in pain management and the development of future research related to nursing care in the perioperative period of mastectomy.
Kucewicz-Czech, Ewa; Kiecak, Katarzyna; Urbańska, Ewa; Maciejewski, Tomasz; Kaliś, Robert; Pakosiewicz, Waldemar; Kołodziej, Tadeusz; Knapik, Piotr; Przybylski, Roman; Zembala, Marian
Surgery is an extreme physiological stress for the elderly. Aging is inevitably associated with irreversible and progressive cellular degeneration. Patients above 75 years of age are characterized by impaired responses to operative stress and a very narrow safety margin. To evaluate perioperative complications in patients aged ≥ 75 years who underwent cardiac surgery in comparison to outcomes in younger patients. The study was conducted at the Silesian Centre for Heart Diseases in Zabrze in 2009-2014 after a standard of perioperative care in seniors was implemented to reduce complications, in particular to decrease the duration of mechanical ventilation and reduce postoperative delirium. The study group included 1446 patients. The mean duration of mechanical ventilation was 13.8 h in patients aged ≥ 75 years and did not differ significantly compared to younger patients. In-hospital mortality among seniors was 3.8%, a value significantly higher than that observed among patients younger than 75 years of age. Patients aged ≥ 75 years undergoing cardiac surgery have significantly more concomitant conditions involving other organs, which affects treatment outcomes (duration of hospital stay, mortality). The implementation of a standard of perioperative care in this age group reduced the duration of mechanical ventilation and lowered the rate of postoperative delirium.
Grifasi, Carlo; Calogero, Armando; Esposito, Anna; Dodaro, Concetta
Epidemiological data show a continuous expansion of elderly population in Europe. Older individuals require more medical services relative to their younger counterparts. The aim of this review was to summarize the most recent considerations in regards to preoperative assessment, postoperative outcomes, patient satisfaction and cost-effectiveness analysis of day surgery in the elderly. This review considered studies that included older patients who were undergoing day surgery general procedures (such as inguinal hernia repair, excision of breast lump, haemorrhoidectomy). The interventions of interest to this review included selection criteria, perioperative care, management of postoperative pain. According to a large number of studies, old age does not constitute a contraindication for elderly to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management. Hospitalization of older patients is frequently associated with postoperative cognitive dysfunction (POCD). Management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease-drug and drug-drug interactions. Early studies evaluating approaches to facilitating the recovery process have demonstrated the benefits of multimodal analgesic techniques. A lot of studies show that even elderly patients can successfully undergo day surgery procedures by implementing evidence-based perioperative care programs, minimizing operative duration and tissue trauma and providing a comfortable setting.
Grifasi, Carlo; Calogero, Armando; Esposito, Anna; Dodaro, Concetta
Epidemiological data show a continuous expansion of elderly population in Europe. Older individuals require more medical services relative to their younger counterparts. The aim of this review was to summarize the most recent considerations in regards to preoperative assessment, postoperative outcomes, patient satisfaction and cost-effectiveness analysis of day surgery in the elderly. This review considered studies that included older patients who were undergoing day surgery general procedures (such as inguinal hernia repair, excision of breast lump, haemorrhoidectomy). The interventions of interest to this review included selection criteria, perioperative care, management of postoperative pain. According to a large number of studies, old age does not constitute a contraindication for elderly to undergo ambulatory surgery but this population may require more careful intraoperative cardiovascular management. Hospitalization of older patients is frequently associated with postoperative cognitive dysfunction (POCD). Management of postoperative pain in older patients may be complicated by a number of factors, including a higher risk of age- and disease-related changes in physiology and disease-drug and drug-drug interactions. Early studies evaluating approaches to facilitating the recovery process have demonstrated the benefits of multimodal analgesic techniques. A lot of studies show that even elderly patients can successfully undergo day surgery procedures by implementing evidence-based perioperative care programs, minimizing operative duration and tissue trauma and providing a comfortable setting.
Desebbe, Olivier; Lanz, Thomas; Kain, Zeev; Cannesson, Maxime
Contrary to the intraoperative period, the current perioperative environment is known to be fragmented and expensive. One of the potential solutions to this problem is the newly proposed perioperative surgical home (PSH) model of care. The PSH is a patient-centred micro healthcare system, which begins at the time the decision for surgery is made, is continuous through the perioperative period and concludes 30 days after discharge from the hospital. The model is based on multidisciplinary involvement: coordination of care, consistent application of best evidence/best practice protocols, full transparency with continuous monitoring and reporting of safety, quality, and cost data to optimize and decrease variation in care practices. To reduce said variation in care, the entire continuum of the perioperative process must evolve into a unique care environment handled by one perioperative team and coordinated by a leader. Anaesthesiologists are ideally positioned to lead this new model and thus significantly contribute to the highest standards in transitional medicine. The unique characteristics that place Anaesthesiologists in this framework include their systematic role in hospitals (as coordinators between patients/medical staff and institutions), the culture of safety and health care metrics innate to the specialty, and a significant role in the preoperative evaluation and counselling process, making them ideal leaders in perioperative medicine. Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
Sipples, Rebecca; Taylor, Richard; Kirk-Walker, Deborah; Bagcivan, Gulcan; Dionne-Odom, J Nicholas; Bakitas, Marie
To explore the opportunities to incorporate palliative care into perioperative oncology patient management and education strategies for surgical oncology nurses. Articles related to palliative care and surgical oncology to determine the degree of integration, gaps, and implications for practice. Although evidence supports positive patient outcomes when palliative care is integrated in the perioperative period, uptake of palliative care into surgical settings is slow. Palliative care concepts are not adequately integrated into surgical and nursing education. With appropriate palliative care education and training, surgical oncology nurses will be empowered to foster surgical-palliative care collaborations to improve patient outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.
White, Paul F; White, Lisa M; Monk, Terri; Jakobsson, Jan; Raeder, Johan; Mulroy, Michael F; Bertini, Laura; Torri, Giorgio; Solca, Maurizio; Pittoni, Giovanni; Bettelli, Gabriella
As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly will assume increased importance...
Balakas, Karen; Gallaher, Carol S; Tilley, Carra
Pediatric perioperative nurses care for a wide variety of children and adolescents, some of whom have special developmental or behavioral needs. Providing care for this vulnerable population can be challenging because they may not express their level of pain or anxiety through behaviors commonly observed in typically developing children. This quality improvement project was conducted to enhance perioperative care delivered to children with challenging behaviors and to their families. A screening tool to individualize the plan of care was developed to identify specific behaviors, triggers, and communication patterns of these children prior to hospitalization. Interventions were identified to address these behaviors that could be used by nurses, child life specialists, and occupational therapists. Partnering with parents and other members of the interprofessional healthcare team has resulted in best practice care planning for these children, ensuring a much more successful perioperative experience for patients and families. Findings from parent surveys demonstrate that by using the tool, nurses and other team members are able to minimize stressors and implement interventions specific to the child. As a result, the adaptive care planning tool has expanded beyond the perioperative area and is now being used by direct care nurses, support staff, nurse practitioners, and physicians across the organization.
Rekha Das; Upendra Hansda
Patients in the perioperative period and intensive care unit are commonly exposed to blood transfusion (BT). They are at increased risk of transfusion transmitted bacterial, viral and protozoal diseases. The risk of viral transmission has decreased steadily, but the risk of bacterial transmission remains same. Bacterial contamination is more in platelet concentrates than in red cells and least in plasma. The chances of sepsis, morbidity and mortality depend on the number of transfusions and u...
Gillies, Michael A; Sander, Michael; Shaw, Andrew; Wijeysundera, Duminda N; Myburgh, John; Aldecoa, Cesar; Jammer, Ib; Lobo, Suzana M; Pritchard, Naomi; Grocott, Michael P W; Schultz, Marcus J; Pearse, Rupert M
Surgical treatments are offered to more patients than ever before, and increasingly to older patients with chronic disease. High-risk patients frequently require critical care either in the immediate postoperative period or after developing complications. The purpose of this review was to identify and prioritise themes for future research in perioperative intensive care medicine. We undertook a priority setting process (PSP). A panel was convened, drawn from experts representing a wide geographical area, plus a patient representative. The panel was asked to suggest and prioritise key uncertainties and future research questions in the field of perioperative intensive care through a modified Delphi process. Clinical trial registries were searched for on-going research. A proposed "Population, Intervention, Comparator, Outcome" (PICO) structure for each question was provided. Ten key uncertainties and future areas of research were identified as priorities and ranked. Appropriate intravenous fluid and blood component therapy, use of critical care resources, prevention of delirium and respiratory management featured prominently. Admissions following surgery contribute a substantial proportion of critical care workload. Studies aimed at improving care in this group could have a large impact on patient-centred outcomes and optimum use of healthcare resources. In particular, the optimum use of critical care resources in this group is an area that requires urgent research.
Full Text Available Laryngotracheal reconstruction (LTR involves surgical correction of a stenotic airway with cartilage interpositional grafting, followed by either placement of a tracheostomy and an intraluminal stent (two-stage LTR or placement of an endotracheal tube with postoperative sedation and mechanical ventilation for an extended period of time (single-stage LTR. With single-stage repair, there may be several perioperative challenges including the provision of adequate sedation, avoidance of the development of tolerance to sedative and analgesia agents, the need to use neuromuscular blocking agents, the maintenance of adequate pulmonary toilet to avoid perioperative nosocomial infections, and optimization of postoperative respiratory function to facilitate successful tracheal extubation. We review the perioperative management of these patients, discuss the challenges during the postoperative period, and propose recommendations for the prevention of reversible causes of extubation failure in this article. Optimization to ensure a timely tracheal extubation and successful weaning of mechanical ventilator, remains the primary key to success in these surgeries as extubation failure or the need for prolonged postoperative mechanical ventilation can lead to failure of the graft site, the need for prolonged Pediatric Intensive Care Unit care, and in some cases, the need for a tracheostomy to maintain an adequate airway.
The complexity of the perioperative care process has resulted in a suboptimal use of resources, quality problems and a relatively high incidence of errors. In an attempt to optimize resources, patient safety, and quality, multimodal, multidisciplinary standardization of the care process has become an increasingly recognized goal. The anaesthesiologist as perioperative clinician plays a pivotal role in the development and implementation of standardized perioperative care. Historically, however, a significant portion of perioperative care has relied upon anecdotal information that represents an amalgam of any individual anaesthesiologist's collective influences and experiences. Current status of standardized perioperative care and different factors that influence successful implementation of guidelines, fast track surgery programs and clinical pathways are described. Although recent literature indicates that standardization of perioperative care improves efficiency, quality, and patient satisfaction, implementation of standardized care is difficult since resistance is still enormous.
Rygård, Sofie Louise; Holst, Lars Broksø; Perner, Anders
The critical care and perioperative settings are high consumers of blood products, with multiple units and different products often given to an individual patient. The recommendation of this review is always to consider the risks and benefits for a specific blood product for a specific patient in a specific clinical setting. Optimize patient status by treating anemia and preventing the need for red blood cell transfusion. Consider other options for correction of anemia and coagulation disorders and use an imperative non-overtransfusion policy for all blood products. Copyright © 2017 Elsevier Inc. All rights reserved.
Schoormans, D.; Smets, E.M.A.; Zwart, R.; Sprangers, M.A.G.; Veelenturg, T.H.; de Mol, B.A.; Hazekamp, M.G.; Koolbergen, D.R.; Sojak, V.; Bouma, B.J.; Groenink, M.; Boekholdt, M.S.; Backx, A.P.; Mulder, B.J.
Patient satisfaction with care has received little attention within the field of congenital heart disease. Our objective was to examine patient satisfaction with the care received when undergoing open-heart surgery in order to identify the best and worst aspects of peri-operative care. Moreover, we
Winters, H.; Tielemans, H.J.P.; Sprangers, P.N.; Ulrich, D.J.O.
BACKGROUND: Lymphaticovenular anastomosis (LVA) is a supermicrosurgical procedure that involves the anastomosis of a functional lymphatic channel to a venule. Although peri-operative care might be an important contributor to the success of this technique, evidence about optimal peri-operative care
Full Text Available Patients in the perioperative period and intensive care unit are commonly exposed to blood transfusion (BT. They are at increased risk of transfusion transmitted bacterial, viral and protozoal diseases. The risk of viral transmission has decreased steadily, but the risk of bacterial transmission remains same. Bacterial contamination is more in platelet concentrates than in red cells and least in plasma. The chances of sepsis, morbidity and mortality depend on the number of transfusions and underlying condition of the patient. Challenges to safe BT continue due to new emerging pathogens and various management problems. Strategies to restrict BT, optimal surgical and anaesthetic techniques to reduce blood loss and efforts to develop transfusion alternatives should be made. Literature search was performed using search words/phrases blood transfusion, transfusion, transfusion transmitted diseases, transfusion transmitted bacterial diseases, transfusion transmitted viral diseases, transfusion transmitted protozoal diseases or combinations, on PubMed and Google Scholar from 1990 to 2014.
Das, Rekha; Hansda, Upendra
Patients in the perioperative period and intensive care unit are commonly exposed to blood transfusion (BT). They are at increased risk of transfusion transmitted bacterial, viral and protozoal diseases. The risk of viral transmission has decreased steadily, but the risk of bacterial transmission remains same. Bacterial contamination is more in platelet concentrates than in red cells and least in plasma. The chances of sepsis, morbidity and mortality depend on the number of transfusions and underlying condition of the patient. Challenges to safe BT continue due to new emerging pathogens and various management problems. Strategies to restrict BT, optimal surgical and anaesthetic techniques to reduce blood loss and efforts to develop transfusion alternatives should be made. Literature search was performed using search words/phrases blood transfusion, transfusion, transfusion transmitted diseases, transfusion transmitted bacterial diseases, transfusion transmitted viral diseases, transfusion transmitted protozoal diseases or combinations, on PubMed and Google Scholar from 1990 to 2014.
Myers, Rachel E
Nursing has long been regarded as a stress-filled profession; the perioperative environment in particular is considered especially challenging. Chronic stress and burnout may have detrimental effects not only on perioperative nurses but also on their coworkers, employers, and patients. Nurses often sacrifice their own needs to care for others. Nurses must first take care of themselves, however, to sustain their optimal ability to provide care for patients. The cultivation of mindfulness is one way that perioperative nurses may promote self-care and well-being. This article discusses mindfulness and its history, the potential benefits and applications to perioperative nursing, and suggestions for cultivating mindfulness. Mindfulness research, practice, and education and the implications of mindfulness meditation in the perioperative environment are also discussed. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Blomberg, Ann-Catrin; Bisholt, Birgitta; Nilsson, Jan; Lindwall, Lillemor
The aim of this study was to describe operating theatre nurses' (OTNs') perceptions of caring in perioperative practice. A qualitative descriptive design was performed. Data were collected with interviews were carried out with fifteen strategically selected operating theatre nurses from different operating theatres in the middle of Sweden. A phenomenographic analysis was used to analyse the interviews. The findings show that operating theatre nurses' perceptions of caring in perioperative practice can be summarised in one main category: To follow the patient all the way. Two descriptive categories emerged: To ensure continuity of patient care and keeping a watchful eye. The operating theatre nurses got to know the patient and as a result became responsible for the patient. They protected the patient's body and preserved patient dignity in perioperative practice. The findings show different aspects of caring in perioperative practice. OTNs wanted to be more involved in patient care and follow the patient throughout the perioperative nursing process. Although OTNs have the ambition to make the care in perioperative practice visible, there is today a medical technical approach which promotes OTNs continuing to offer care in secret. © 2014 Nordic College of Caring Science.
Sjöberg, Carina; Amhliden, Helene; Nygren, Jens M; Arvidsson, Susann; Svedberg, Petra
To describe the experiences of participation in perioperative care of 8- to 11-year-old children. All children have the right to participate in decisions that affect them and have the right to express their views in all matters that concern them. Allowing children to be involved in their perioperative care can make a major difference in terms of their well-being by decreasing fear and anxiety and having more positive experiences. Taking the views of children into account and facilitating their participation could thus increase the quality of care. Descriptive qualitative design. The study was conducted in 2013 and data were collected by narrative interviews with 10 children with experience from perioperative care in Sweden. Qualitative content analysis was chosen to describe the variations, differences and similarities in children's experiences of participation in perioperative care. The result showed that receiving preparatory information, lack of information regarding postoperative care and wanting to have detailed information are important factors for influencing children's participation. Interaction with healthcare professionals, in terms of being listened to, being a part of the decision-making and feeling trust, is important for children's participation in the decision-making process. Poor adaptation of the care environment to the children's needs, feeling uncomfortable while waiting and needs for distraction are examples of how the environment and the care in the operating theatre influence the children's experiences of participation. Efforts should be made to improve children's opportunities for participation in the context of perioperative care and further research is needed to establish international standards for information strategies and care environment that promotes children's participation in perioperative care. Nurse anaesthetists need to acquire knowledge and develop strategies for providing preparatory visits and information to children prior to
Mahajan, Aman; Islam, Salim D; Schwartz, Michael J; Cannesson, Maxime
Many methods used to improve hospital and perioperative services productivity and quality of care have assumed that the hospital is essentially a factory, and therefore, that industrial engineering...
Yaung, Jill; Arabia, Francisco A; Nurok, Michael
Advanced heart failure continues to be a leading cause of morbidity and mortality despite improvements in pharmacologic therapy. High demand for cardiac transplantation and shortage of donor organs have led to an increase in the utilization of mechanical circulatory support devices. The total artificial heart is an effective biventricular assist device that may be used as a bridge to transplant and that is being studied for destination therapy. This review discusses the history, indications, and perioperative management of the total artificial heart with emphasis on the postoperative concerns.
Strychowsky, Julie E; Albert, David; Chan, Kenny; Cheng, Alan; Daniel, Sam J; De Alarcon, Alessandro; Garabedian, Noel; Hart, Catherine; Hartnick, Christopher; Inglis, Andy; Jacobs, Ian; Kleinman, Monica E; Mehta, Nilesh M; Nicollas, Richard; Nuss, Roger; Pransky, Seth; Russell, John; Rutter, Mike; Schilder, Anne; Thompson, Dana; Triglia, Jean-Michel; Volk, Mark; Ward, Bob; Watters, Karen; Wyatt, Michelle; Zalzal, George; Zur, Karen; Rahbar, Reza
OBJECTIVES: To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients. METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the
Strychowsky, Julie E; Albert, David; Chan, Kenny; Cheng, Alan; Daniel, Sam J; De Alarcon, Alessandro; Garabedian, Noel; Hart, Catherine; Hartnick, Christopher; Inglis, Andy; Jacobs, Ian; Kleinman, Monica E; Mehta, Nilesh M; Nicollas, Richard; Nuss, Roger; Pransky, Seth; Russell, John; Rutter, Mike; Schilder, Anne; Thompson, Dana; Triglia, Jean-Michel; Volk, Mark; Ward, Bob; Watters, Karen; Wyatt, Michelle; Zalzal, George; Zur, Karen; Rahbar, Reza
To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients. Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group. Consensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals. Pediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Saito, Hajime; Minamiya, Yoshihiro
Due to the recent advances in radiological diagnostic technology, the role of video-assisted thoracoscopic surgery in thoracic disease has expanded, surgical indication extended to the elderly patients. Cancer patients receiving surgery, radiation therapy and/or chemotherapy may encounter complications in conjunction with the oral cavity such as aspiration pneumonia, surgical site infection and various type of infection. Recently, it is recognized that oral health care management is effective to prevent the postoperative infectious complications, especially pneumonia. Therefore, oral management should be scheduled before start of therapy to prevent these complications as supportive therapy of the cancer treatment. In this background, perioperative oral function management is highlighted in the remuneration for dental treatment revision of 2012,and the importance of oral care has been recognized in generally. In this manuscript, we introduce the several opinions and evidence based on the recent previous reports about the perioperative oral health care and management on thoracic surgery.
Bougeard, A-M; Brent, A; Swart, M; Snowden, C
The majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115). They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%). Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%, 95%CI 55.8-75.4%) had clinics for high-risk surgical patients. However, 80 (93%, 70.2-87.2%) expressed a desire for support and training in shared decision-making. We asked about management of pre-operative anaemia, and identified that 69 (80%, 71.5-88.1%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively. A need for peri-operative support in managing frailty and cognitive impairment was identified, as few (24%, 6.5-34.5%) respondents indicated that they had access to specific interventions. Respondents were asked to rank their 'top five' priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction; and primary care collaboration. We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice. © 2017 The Association of Anaesthetists of Great Britain and Ireland.
Griffiths, R; Beech, F; Brown, A; Dhesi, J; Foo, I; Goodall, J; Harrop-Griffiths, W; Jameson, J; Love, N; Pappenheim, K; White, S
Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons. The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of their community care when in hospital. Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation. Multimodal intervention strategies are recommended for preventing postoperative delirium. Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published guidance on the management of pain in older people. Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good communication is essential to this process. If they clearly lack that capacity, proxy information should be sought to determine what treatment, if any, is in the patient's best interests. Anaesthetists must not ration surgical or critical care
Lambden, Simon; Martin, Bruce
Simulation in perioperative anesthesia training is a field of considerable interest, with an urgent need for tools that reliably train and facilitate objective assessment of performance. This article reviews the available simulation technologies, their evolution, and the current evidence base for their use. The future directions for research in the field and potential applications of simulation technology in anesthesia, critical care, and pain medicine are discussed. Copyright © 2011 Elsevier Inc. All rights reserved.
Aug 31, 2011 ... 2 mmol/l). Maintenance anaesthesia consisted of sevoflurane (exhaled concentration 1-2%) and fentanyl. (1.5 µg/kg). On completion of the surgical procedure, which lasted 100 minutes, the infant's trachea was extubated, and he was transported to the post-anaesthesia care unit. He resumed his usual diet ...
Tetanus is caused by tetanospasmin, a toxin that is produced by the anaerobic bacterium, Clostridium tetani. Despite widespread vaccination, which limits its incidence in many parts of the world, tetanus may still occur owing to lack of immunisation related to religious tenets, cultural beliefs or inaccessibility to medical care.
Nishino, Takeshi; Takizawa, Hiromitsu; Yoshida, Takahiro; Inui, Tomohiro; Takasugi, Haruka; Matsumoto, Daisuke; Kawakita, Naoya; Inoue, Seiya; Sakiyama, Shoji; Tangoku, Akira; Azuma, Masayuki; Yamamura, Yoshiko
The effectiveness of perioperative oral health care management to decrease the risk of postoperative pneumonia have been reported lately. Since 2014, we introduced perioperative oral health care management for lung cancer and esophageal cancer patients. We report current status and effectiveness of perioperative oral health care management for lung cancer and esophageal cancer patients. Every 100 cases of lung cancer and esophageal cancer patients treated by surgery were classified 2 group with or without perioperative oral health care management and compared about postoperative complications retrospectively. In the lung cancer patients, the group with oral health care management could prevent postoperative pneumonia significantly and had shorter length of hospital stay than the group without oral health care management. In the esophageal cancer patients, there was little occurrence of postoperative pneumonia without significant difference between both group with or without oral health care management. A large number of esophageal cancer patients received neo-adjuvant chemotherapy and some patients developed oral mucositis and received oral care treatment before surgery. Treatment for oral mucositis probably improved oral environment and affected prevention of postoperative pneumonia. Perioperative oral health care management can prevent postoperative pneumonia of lung cancer and esophageal cancer patients by improvement of oral hygiene.
Lassen, C L; Abel, R; Eichler, L; Zausig, Y A; Graf, B M; Wiese, C H R
Anesthetists will encounter palliative patients in the daily routine as palliative patients undergo operations and interventions as well, depending on the state of the disease. The first challenge for anesthetists will be to recognize the patient as being palliative. In the course of further treatment it will be necessary to address the specific problems of this patient group. Medical problems are optimized symptom control and the patient's pre-existing medication. In the psychosocial domain, good communication skills are expected of anesthetists, especially during the preoperative interview. Ethical conflicts exist with the decision-making process for surgery and the handling of perioperative do-not-resuscitate orders. This article addresses these areas of conflict and the aim is to enable anesthetists to provide the best possible perioperative care to this vulnerable patient group with the goal to maintain quality of life and keep postoperative recovery as short as possible.
Kowalczyk, Michał; Nestorowicz, Andrzej; Stachurska, Katarzyna; Fijałkowska, Anna; Stążka, Janusz
Nowadays, even hazardous cardiac surgery can be performed on patients with autoimmune diseases like myasthenia gravis. It requires a sensitive perioperative anesthetic approach especially in relation to nondepolarizing muscle relaxant administration. Myasthenic patients produce antibodies against the end-plate acetylcholine receptors causing muscle weakness and sensitivity to nondepolarizing muscle relaxants that could lead to respiratory failure. Perioperative nurse care is critical for uncomplicated course of treatment; therefore, apprehension of surgical procedure should be helpful on an everyday basis. We describe successful management without any pulmonary complications of two patients with myasthenia gravis undergoing coronary artery bypass grafting. In addition, antiacetylcholine receptor antibodies concentrations were evaluated during treatment time. In conclusion, we have found that reduced titrated doses of cisatracurium may be safely used in patients with myasthenia gravis undergoing cardiac surgery without anesthesia and respiratory-related complications.
Tetteh, Hassan A
Kaizen is a proven management technique that has a practical application for health care in the context of health care reform and the 2010 Institute of Medicine landmark report on the future of nursing. Compounded productivity is the unique benefit of kaizen, and its principles are change, efficiency, performance of key essential steps, and the elimination of waste through small and continuous process improvements. The kaizen model offers specific instruction for perioperative nurses to achieve process improvement in a five-step framework that includes teamwork, personal discipline, improved morale, quality circles, and suggestions for improvement. Published by Elsevier Inc.
Bittner, Edward A.; Shank, Erik; Woodson, Lee; Martyn, J.A. Jeevendra
Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury are characterized by a reduction in cardiac output, increased systemic and pulmonary vascular resistance. Approximately 2–5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic end points. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia and altered pharmacology. PMID:25485468
Auckley, Dennis; Cox, Robynn; Bolden, Norman; Thornton, J Daryl
Obstructive sleep apnea (OSA) is a risk factor for significant perioperative complications. This national survey study sought to determine the attitudes of physicians involved in the perioperative care of OSA patients. We modified the perioperative survey used by Turner et al. among Canadian anesthesiologists. We mailed the survey to 3,000 US physicians practicing in the following specialties (750 of each specialty): anesthesiology (A), primary care (family practice or internal medicine) (PC), sleep (SM), and general surgery (S). The survey asked questions about attitudes and practice patterns regarding OSA in the perioperative setting. Of 2,730 eligible subjects, 783 questionnaires (28.7 %) were returned. Overall, 94 % felt OSA was a risk factor for perioperative complications (no difference by specialty) and 90 % felt it was a moderate to major risk factor (A = 91 %, PC = 81 %, SM = 94 %, S = 72 %; p OSA in the perioperative setting. Despite this, only 71 % reported regularly screening for OSA preoperatively, mostly by history and physical examination (A = 89 %, PC = 52 %, SM = 88 %, S = 49 %; p OSA, 32 % would delay surgery pending a sleep study (A = 4 %, PC = 41 %, SM = 54 %, S = 27 %; p OSA patients. The majority of physicians in this survey felt OSA was a significant risk factor for perioperative complications and most reported experience with OSA patients having an adverse outcome. Perioperative management guidelines for OSA are not available at most institutions. Further work is needed to help physicians identify and intervene on patients with OSA in the perioperative setting before adverse events develop.
Muhammad Faisal Khan
Conclusion: The use of hypotonic fluid in perioperative care in pediatric population is still being practiced despite the current guidelines. These results point to a considerable gap between the available evidence and practice.
Nimeri, Abdelrahman; Al Hadad, Mohammed; Khoursheed, Mousa; Maasher, Ahmed; Al Qahtani, Aayed; Al Shaban, Talat; Fawal, Hayssam; Safadi, Bassem; Alderazi, Amer; Abdalla, Emad; Bashir, Ahmad
Bariatric surgery is common in the Middle East region. However, regional accreditation bodies and guidelines are lacking. We present the current peri-operative practice of bariatric surgery in the Middle East region. Public and private practice in the Middle East region. A questionnaire was designed to study trends of peri-operative care in bariatric surgery. It was sent to members of the Pan Arab Society for Metabolic and Bariatric Surgery (PASMBS). Ninety-three surgeons (88.6%) responded, 63.4% were in private practice, 68.5% have been in practice for more than 5 years, and 61.1% performed more than 125 cases per year. Laparoscopic sleeve gastrectomy (LSG) was the commonest procedure performed, then laparoscopic Roux-en-Y gastric bypass (LRYGB), one anastomosis gastric bypass/mini gastric bypass (OAGB/MGB), and laparoscopic adjustable gastric banding (LAGB). Pre-operatively as a routine, 65% referred patients for dietitian and (78.3%) for smoking cessation. In contrast as a routine, 22.6% referred patients to a psychologist, 30% screened for obstructive sleep apnea (OSA), and when they did, they did not use a questionnaire. For patients 50 years of age, 22% performed a screening colonoscopy and 33.7% referred patients to a cardiologist. Intra-operatively as a routine, 25.3% placed a drain and 42.2% placed urinary catheters. In contrast, 77.1% performed a leak test (82.7% as a methylene blue leak test). Post-operatively, 79.5% used chemoprophylaxis for venous thromboembolism and 89% required patients to take vitamins. In contrast, 25% prescribed ursodeoxycholic acid. The wide variation in the peri-operative care of bariatric surgery in the Middle East region highlights the need for regional guidelines based on international guidelines.
Ukawa, Naoto; Tanaka, Masayuki; Morishima, Toshitaka; Imanaka, Yuichi
The objective of this work was to elucidate aspects of organizational culture associated with hospital performance in perioperative antibiotic prophylaxis using quantitative data in a multicenter and multidimensional study. Cross-sectional retrospective study using a survey data and administrative data. Eighty-three acute hospitals in Japan. A total of 4856 respondents in the organizational culture study, and 23 172 patients for the quality indicator analysis. Multilevel models of various cultural dimensions were used to analyze the association between hospital organizational culture and guideline adherence. The dependent variable was adherence or non-adherence to Japanese and CDC guidelines at the patient level and main independent variable was hospital groups categorized according to organizational culture score. Other control variables included hospital characteristics such as ownership, bed capacity, region and urbanization level of location. The multilevel analysis showed that hospitals with a high score in organizational culture were more likely to adhere to the Japanese and CDC guidelines when compared with lower scoring hospitals. In particular, the hospital group with high scores in the 'collaboration' and 'professional growth' dimensions had three times the odds for Japanese guideline adherence in comparison with low-scoring hospitals. Our study revealed that various aspects of organizational culture were associated with adherence to guidelines for perioperative antibiotic use. Hospital managers aiming to improve quality of care may benefit from improving hospital organizational culture. © The Author 2014. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.
Arakelian, Erebouni; Swenne, Christine Leo; Lindberg, Susan; Rudolfsson, Gudrun; von Vogelsang, Ann-Christin
To determine the meaning of person-centred care from the patient's perspective and in the context of perioperative nursing. Person-centred care is used, but not defined in the perioperative context. The concept indicates an interest in the patient's own experience of health, illness, needs and preferences. As with many terms that are frequently used, there is a tendency for person-centred care to mean different things to different people in different contexts. Integrative Review. A two-part search strategy was employed: first, a computerised database search of PubMed and CINAHL, using Medical Subject Headings and free terms to search articles dating from 2004-2014, was performed, and second, a hand-search of those articles' reference lists was performed. Twenty-three articles were selected, and an integrative review was conducted. Four themes were discovered: 'being recognised as a unique entity and being allowed to be the person you are', 'being considered important by having one's personal wishes taken into account', 'the presence of a perioperative nurse is calming, prevents feelings of loneliness and promotes well-being, which may speed up recovery' and 'being close to and being touched by the perioperative nurse during surgery'. Person-centred care means respecting the patient as a unique individual, considering the patient's particularities and wishes and involving the patient in their own care. Person-centred care also implies having access to one's own nurse who is present both physically and emotionally through the entire perioperative process and who guides the patient and follows up postoperatively, guaranteeing that the patient is not alone. By having a common understanding of the concept of person-centred care, the nurse anaesthetists' and theatre nurses' caring actions or concerns will be directed towards the patient, resulting in personalisation of care rather than simply defining the concept. © 2016 John Wiley & Sons Ltd.
Mahajan, Aman; Islam, Salim D; Schwartz, Michael J; Cannesson, Maxime
Many methods used to improve hospital and perioperative services productivity and quality of care have assumed that the hospital is essentially a factory, and therefore, that industrial engineering and manufacturing-derived redesign approaches such as Six Sigma and Lean can be applied to hospitals and perioperative services just as they have been applied in factories. However, a hospital is not merely a factory but also a complex adaptive system (CAS). The hospital CAS has many subsystems, with perioperative care being an important one for which concepts of factory redesign are frequently advocated. In this article, we argue that applying only factory approaches such as lean methodologies or process standardization to complex systems such as perioperative care could account for difficulties and/or failures in improving performance in care delivery. Within perioperative services, only noncomplex/low-variance surgical episodes are amenable to manufacturing-based redesign. On the other hand, complex surgery/high-variance cases and preoperative segmentation (the process of distinguishing between normal and complex cases) can be viewed as CAS-like. These systems tend to self-organize, often resist or react unpredictably to attempts at control, and therefore require application of CAS principles to modify system behavior. We describe 2 examples of perioperative redesign to illustrate the concepts outlined above. These examples present complementary and contrasting cases from 2 leading delivery systems. The Mayo Clinic example illustrates the application of manufacturing-based redesign principles to a factory-like (high-volume, low-risk, and mature practice) clinical program, while the Kaiser Permanente example illustrates the application of both manufacturing-based and self-organization-based approaches to programs and processes that are not factory-like but CAS-like. In this article, we describe how factory-like processes and CAS can coexist within a hospital and how
Annual Meeting, at CERN, 29-31 October 2007 The CARE project started on 1st January 2004 and will end on 31st December 2008. At the end of each year, the progress and status of its activities are reported in a general meeting. This year, the meeting is taking place at CERN. The CARE objective is to generate structured and integrated European cooperation in the field of accelerator research and related R&D. The programme includes the most advanced scientific and technological developments, relevant to accelerator research for particle physics. It is articulated around three Networking Activities and four Joint Activities. The Networking Activities ELAN, BENE and HHH aim to better coordinate R&D efforts at the European level and to strengthen Europe’s ability to produce intense and high-energy particle beams (electrons and positrons, muons and neutrinos, protons and ions, respectively). The Joint Activities, SRF, PHIN, HIPPI and NED, aim at technical developments ...
Annual Meeting, at CERN, 29-31 October 2007 The CARE project started on 1st January 2004 and will end on 31st December 2008. At the end of each year, the progress and status of its activities are reported in a general meeting. This year, the meeting takes place at CERN. The CARE objective is to generate structured and integrated European cooperation in the field of accelerator research and related R&D. The programme includes the most advanced scientific and technological developments, relevant to accelerator research for particle physics. It is articulated around three Networking Activities and four Joint Activities. The Networking Activities ELAN, BENE and HHH aim to better coordinate R&D efforts at the European level and to strengthen Europe’s ability to produce intense and high-energy particle beams (electrons and positrons, muons and neutrinos, protons and ions, respectively). The Joint Activities, SRF, PHIN, HIPPI and NED, aim at technical developments on s...
Gregoretti, C; Moglia, B; Pelosi, P; Navalesi, P
Clonidine is classified as an imidazoline and it is the prototypical alpha-2 receptor agonists. It has been used for several years to treat hypertension. It has also been used, "off label", for a variety of purposes, including opioid and anesthetic sparing effects, anxiolysis and sedation, drug withdrawal as well as stabilizing blood pressure and reducing stress response to surgery. Particularly in the case of patients with overt or underlying cardiac disease and in those at risk of perioperative ischemia the action of clonidine can be expected to reduce the risk of procedure-related cardiac events. In addition, clonidine used as a premedication drug before surgery or surgical procedure, has been shown to substantially reduce anaesthetic, benzodiazepine and opioids requirements. However, its "off label" use, the absence of an intravenous form of in the United States, possible inadvertent hypotension, bradycardia or post-operative sedation, and the variability of the haemodynamic response to different doses or rates of administration, have limited its use in clinical practice. This review discusses the potential role of clonidine and the supporting evidence for the use of this drug beyond its anti-hypertensive use in perioperative medicine and critical care in adults patients.
Iorio, Matthew L; Verma, Kapil; Ashktorab, Samaneh; Davison, Steven P
The goal of this review was to identify the safety and medical care issues that surround the management of patients who had previously undergone medical care through tourism medicine. Medical tourism in plastic surgery occurs via three main referral patterns: macrotourism, in which a patient receives treatments abroad; microtourism, in which a patient undergoes a procedure by a distant plastic surgeon but requires postoperative and/or long-term management by a local plastic surgeon; and specialty tourism, in which a patient receives plastic surgery from a non-plastic surgeon. The ethical practice guidelines of the American Medical Association, International Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and American Board of Plastic Surgeons were reviewed with respect to patient care and the practice of medical tourism. Safe and responsible care should start prior to surgery, with communication and postoperative planning between the treating physician and the accepting physician. Complications can arise at any time; however, it is the duty and ethical responsibility of plastic surgeons to prevent unnecessary complications following tourism medicine by adequately counseling patients, defining perioperative treatment protocols, and reporting complications to regional and specialty-specific governing bodies. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Annual Meeting at CERN, 23-25 November 2005 CARE started on 1st January 2004 and will last for five years. At the end of each year it holds a general meeting to report on the progress and status of its activities. This year, the CARE annual meeting is taking place at CERN The objective of the CARE project is to generate structured and integrated European cooperation in the field of accelerator research and related R&D. The program includes the most advanced scientific and technological developments, relevant to accelerator research for Particle Physics. It is articulated around three Networking Activities and four Joint Activities. The Networking Activities ELAN, BENE and HHH aim to better coordinate R&D efforts at the European level and to strengthen Europe's ability to evaluate and develop methods of producing intense and high energy beams of electrons, protons, muons and neutrinos. These activities are embedded in world-wide efforts towards future e+e- linear colliders, superior neutrino beam fa...
Doi, Seiko; Iwai, Akiko; Mito, Saori; Utsumi, Tsukasa; Shinoki, Keiji; Nakashita, Chisako; Hata, Akiko; Ibata, Takeshi; Komuro, Ryutaro; Iijima, Andshohei
Dysphagia is usually a major problem for the elderly to go home after a surgical treatment for the bone fracture of the thigh bone cervix or trochanter part in the leg. We analyzed each clinical course with regard to a change of the oral intake and the nutritional status, the activity of daily living(ADL)and a nutritional management and the place after the patient was discharged. According to our results, about 20% of the patients among those surgical cases were pointed with dysphagia, and there were many cases that ADL was ultimately gotten worse. We took care of disphagia by doing a best practice of changing in feedings and deglutition function. However, some of the patients with the problem finally moved to another elderly health care institute against their primary wishes to go home. Furthermore, 55% of the disphagia patients became dementia. It seems that dementia might be a high risk factor of disphagia. We should do more better job for managing disphargia during a peri-operative period just after admission.
Smith, A; Boult, M; Woods, I; Johnson, S
Investigation of patient safety incidents has focused on retrospective analyses once incidents have occurred. Prospective risk analysis techniques complement this but have not been widely used in healthcare. Prospective risk identification of non-operative risks associated with adult elective surgery under general anaesthesia using a customised structured "what if" checklist and development of risk matrix. Prioritisation of recommendations arising by cost, ease and likely speed of implementation. Groups totalling 20 clinical and administrative healthcare staff involved in peri-operative care and risk experts convened by the UK National Patient Safety Agency. 102 risks were identified and 95 recommendations made. The top 20 recommendations together were judged to encompass about 75% of the total estimated risk attributable to the processes considered. Staffing and organisational issues (21% of total estimated risk) included recommendations for removing distractions from the operating theatre, ensuring the availability of senior anaesthetists and promoting standards and flexible working among theatre staff. Devices and equipment (19% of total estimated risk) could be improved by training and standardisation; airway control and temperature monitoring were identified as two specific areas. Pre-assessment of patients before admission to hospital (12% of estimated risk) could be improved by defining a data set for adequate pre-assessment and making this available throughout the NHS. This technique can be successfully applied by healthcare staff but expert facilitation of groups is advisable. Such wider-ranging processes can potentially lead to more comprehensive risk reduction than "single-issue" risk alerts.
Tamaki, Kentaro; Fukuyama, Akiko Komatsu; Terukina, Shigeharu; Kamada, Yoshihiko; Uehara, Kano; Arakaki, Miwa; Yamashiro, Kazuko; Miyashita, Minoru; Ishida, Takanori; McNamara, Keely May; Ohuchi, Noriaki; Tamaki, Nobumitsu; Sasano, Hironobu
Several studies focused on the effect of aromatherapy on mood, quality of life (QOL), and physical symptoms in patients with cancer. We compared the effects on QOL, vital signs, and sleep quality between aromatherapy and conventional therapy during perioperative periods of the breast cancer patients in this study. Patients were randomly assigned in a 2:1 ratio to receive aromatherapy or usual care. The primary endpoint was QOL, which was assessed using the quality of life questionnaire QLQ-C30, Version 3.0 of the European Organization for Research and Treatment of Cancer (EORTC) Study Group on quality of life. Secondary endpoints included the necessity of hypnotics, vital signs including blood pressure and heart rate and adverse events. In addition, we also summarized the patients' perception of the experience from a free description-type questionnaire. A total of 249 patients had breast cancer surgery and 162 patients gave physician consent and were recruited; 110 were randomly assigned to aromatherapy group (eight patients showed incomplete EORTC QLQ-C30) and 52 to control group (one patient showed incomplete EORTC QLQ-C30). There were no statistically significant differences between the aromatherapy group and control group in the EORTC QLQ-C30 at the surgery day. As for the results of the post-operation day 1, trends for differentiations of physical functioning and role functioning were detected between aromatherapy group and control group, but the differences did not reach statistical significance (p = 0.08 and 0.09). There were no significant differences of systolic and diastolic blood pressures between aromatherapy group and control group (p = 0.82 and 0.68). There was no statistically significant difference in heart rates between aromatherapy group (70.6 ± 11.0 bpm) and control group (71.2 ± 9.8 bpm) (p = 0.73). Likewise, the rate of hypnotic use was not statistically significant (p = 0.10). No adverse events were reported after aromatherapy
Walczewski, Mayra da Rosa Martins; Justino, Ariane Zanetta; Walczewski, Eduardo André Bracci; Coan, Tatiane
To evaluate the results of the introduction of new measures to accelerate the postoperative recovery of patients undergoing elective abdominal surgery. We observed 162 patients and interviewed them on two distinct periods: the first between October to December 2009 (n = 81) comprised patients who underwent conventional perioperative monitoring (pre-intervention) and the second between March and May 2010 (n = 81), formed by a new group of patients, submitted to the new protocol of perioperative monitoring. Data collection in the two periods occurred without the knowledge of the professionals in the service. The variables were: indication for preoperative nutritional support, duration of fasting, post-operative volume of hydration, use of catheters and drains, length of stay and postoperative morbidity. when comparing the two periods we observed a decrease of 2.5 hours in the time of preoperative fasting (p = 0.0002) in the post-intervention group. As for the reintroduction of oral diet, there was no difference between the two periods (p = 0.0007). When considering the patients without postoperative complications, there was a significantly decreased length of stay (p = 0.001325). There was a reduction of approximately 50% in antibiotic use in the post-intervention group (p = 0.00001). The adoption of multidisciplinary perioperative measures is feasible within our reality, and although there was no statistically significant changes in the present study, it may improve morbidity and reduce length of stay in general surgery.
Solsky, Ian; Edelstein, Alex; Brodman, Michael; Kaleya, Ronald; Rosenblatt, Meg; Santana, Calie; Feldman, David L; Kischak, Patricia; Somerville, Donna; Mudiraj, Santosh; Leitman, I Michael; Shamamian, Peter
Morbid obesity can complicate perioperative management. Best practice guidelines have been published but are typically followed only in bariatric patients. Little is known regarding physician awareness of and compliance with these clinical recommendations for nonbariatric operations. Our study evaluated if an educational intervention could improve physician recognition of and compliance with established best practices for all morbidly obese operatively treated patients. A care map outlining best practices for morbidly obese patients was distributed to all surgeons and anesthesiologists at 4 teaching hospitals in 2013. Pre- and postintervention surveys were sent to participants in 2012 and in 2015 to evaluate changes in clinical practice. A chart audit performed postintervention determined physician compliance with distributed guidelines. In the study, 567 physicians completed the survey in 2012 and 375 physicians completed the survey in 2015. Postintervention, statistically significant improvements were seen in the percentage of surgeons and anesthesiologists combined who reported changing their management of morbidly obese, operatively treated patients to comply with best practices preoperatively (89% vs 59%), intraoperatively (71% vs 54%), postoperatively (80% vs 57%), and overall (88% vs 72%). Results were similar when surgeons and anesthesiologists were analyzed separately. A chart audit of 170 cases from the 4 hospitals found that 167 (98%) cases were compliant with best practices. After care map distribution, the percentage of physicians who reported changing their management to match best practices significantly improved. These findings highlight the beneficial impact this educational intervention can have on physician behavior. Continued investigation is needed to evaluate the influence of this intervention on clinical outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.
Gierek, Danuta; Cyzowski, Tomasz; Kaczmarska, Adrianna; Janowska-Rodak, Anna; Budziarz, Barbara; Koczur, Tomasz
The incidence of abdominal aortic aneurysm has been estimated at 20-40 cases per 100,000 per annum. The disease is often asymptomatic; in many cases, its first symptom is shock caused by a ruptured aneurysm. The aim of the present study was to assess retrospectively the selected perioperative factors in patients hospitalised in the intensive care unit (ICU) after repair of ruptured abdominal aortic aneurysm. Analysis involved medical records of patients after repair of ruptured abdominal aortic aneurysm treated in ICU in the years 2009-2010. Patients were divided into two groups: group I - survivors who were discharged from ICU and group II - non-survivors. Demographic factors, intraoperative data, vital parameters, laboratory results and severity of patient's state on admission to ICU were analysed. Analysis of laboratory results on admission to ICU showed lower values of pH and HCO(3)(-) concentrations as well as higher international normalised ratio (INR) and activated partial thromboplastin time (APTT) in group II. Mean intraoperative diuresis differed between the groups; in group I - 303 mL and in group II - 155 mL. Mean diuresis on ICU day 1 was higher in group I compared to group II, i.e. 20.87 and 11.27 mL kg b.w.-1, respectively. APACHE II, SAPS II, MODS and SOFA point values were higher in group I than in group II. Markers of impaired homeostasis, such as pH, HCO(3)(-) concentration, INR and APTT assessed on admission to ICU can be relevant prognostic factors in patients after repair of ruptured abdominal aortic aneurysm. Monitoring of diuresis during surgery and on day 1 of ICU treatment was a sensitive risk marker for acute kidney injury. Multiple organ failure scales such as APACHE II, MODS, SOFA and SAPS II were reliable prognostic tools to be used in the early period of ICU treatment.
Marta Inés Berrío Valencia
Full Text Available BACKGROUND AND OBJECTIVE: Anaphylaxis remains one of the potential causes of perioperative death, being generally unanticipated and quickly progress to a life threatening situation. A narrative review of perioperative anaphylaxis is performed.CONTENT: The diagnostic tests are primarily to avoid further major events. The mainstays of treatment are adrenaline and intravenous fluids.CONCLUSION: The anesthesiologist should be familiar with the proper diagnosis, management and monitoring of perioperative anaphylaxis.
Chand, Manish; De'Ath, Henry D; Rasheed, Shahnawaz; Mehta, Chaitanya; Bromilow, James; Qureshi, Tahseen
Laparoscopic surgery is well established in the modern management of colorectal disease. More recently, enhanced recovery after surgery (ERAS) protocols have been introduced to further promote accelerated discharge and faster recovery. However, not all patients are suitable for early discharge. The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge. Data were prospectively collected on consecutive patients undergoing laparoscopic colorectal surgery. All patients followed the institution's ERAS protocol and were discharged once specific criteria were fulfilled. Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery. Thereafter, the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model. Three hundred patients were included in the analysis. The most common operation was laparoscopic anterior resection (n = 123, 41%). Mean length of stay was 4.8 days (standard deviation 5.9), with 185 (62%) patients discharged within 72 h. Ten (3%) patients had a post-operative complication. Three independent predictors of delayed discharge were identified; BMI (OR 1.06, 95%CI 1.01-1.11), operation length (OR 0.99, 95%CI 0.98-0.99) and complications (OR 16.26, 95%CI 4.88-54.08). A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay. This enables more than 60% of patients to be discharged within 72 h. Increased BMI, duration of operation and complications post-operatively independently predict a longer length of stay. Copyright © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.
Full Text Available BACKGROUND Perioperative hypertension is a situation whose management is suggested by the clinical judgement much more than clinical evidences. JNC 7 guidelines give a classification of blood pressure (BP, without any mention specifically dedicated to patients undergoing surgery. The ACC/AHA guidelines recommend deferring surgery if diastolic BP is above 110 mmHg and systolic BP is above 180 mmHg. AIM OF THE STUDY In this review we considered pathogenetic, clinical and therapeutic factors related to perioperative management of hypertensive patients. DISCUSSION In actual trend of the preoperative evaluation, alone hypertension is considered as a minor risk factor. BP values ≤ 180/110 mmHg do not influence the outcomes in patients who underwent noncardiac surgery. Therefore, in these conditions it’s not necessary to delay surgery. Hypertensive picks are possible during the operation, mostly because of the intubation, but, much more dangerous, falls of pressure are possible. The intraoperative arterial pressure should be maintained within 20% of the best estimated preoperative arterial pressure, especially in patients with markedly elevated preoperative pressures. After surgery the arterial BP can increase for stress factors, pain, hypoxia and hypercapnia, hypothermia and infusional liquids overload. For all these reasons a careful monitoring is mandatory. Anti-hypertensive medication should be continued during the postoperative period in patients with known and treated hypertension, as unplanned withdrawal of treatment can result in rebounded hypertension. The decision to give anti-hypertensive drugs must be made for each patient, taking into account their normal BP and their postoperative BP. With regard to the optimal treatment of the patient with poorly or uncontrolled hypertension in the perioperative evaluation, recent guidelines suggest that the best treatment may consider cardioselective β-blockers therapy, but also clonidin by
Smith, Zaneta; Leslie, Gavin; Wynaden, Dianne
To discuss and explore the levels of support provided to perioperative nurses when participating in multi-organ procurement surgery and the impact to their overall well-being. Assisting within multi-organ procurement surgical procedures has been recognised to impact on the well-being of perioperative nurses leaving little opportunity for them to recover from their participation or to seek available support resources. To date, this area has remained largely unexplored with limited evidence of how nurses manage and cope with these procedures, in addition to the support received in the workplace. A qualitative grounded theory method. The study was informed by perioperative nurses (n = 35) who had previous participatory experience in these surgical procedures from two Australian states. Theoretical sampling directed the collection of data via semistructured in-depth interviews. Data were analysed using the constant comparative method. Three components of levels of support were identified from the data: lacking support within the operating room organisation; surgical team support and access to external professional support. These findings offer new insights into how nurses manage and cope with their participation in organ procurement surgical procedures and what types of support resources can be seen as barriers or enablers to their overall experiences. The need for timely and adequate support is vital to their overall well-being and future participation in organ procurement surgery. These findings have the potential to guide further research with implications for clinical initiatives and practices, looking at new ways of supporting perioperative nurses within the clinical environment both locally and internationally. Healthcare organisations need to acknowledge the emotional, psychosocial and psychological health and well-being of nurses impacted by these surgical procedures and provide appropriate and timely clinical support within the work environment. © 2016
Hui, Man Lin; Kumar, Arun; Adama, Gary G.
Abstract Perioperative hyperglycaemia is associated with poor outcomes in patients undergoing cardiac surgery. Frequent postoperative hyperglycaemia in cardiac surgery patients has led to the initiation of an insulin infusion sliding scale for quality improvement. A systematic review was conducted to determine whether a protocol-directed insulin infusion sliding scale is as safe and effective as a conventional practitioner-directed insulin infusion sliding scale, within target blood glucose r...
... Accelerated Development Learning Sessions; Center for Medicare and Medicaid Innovation, September 15th and... second Accelerated Development Learning Session (ADLS) hosted by CMS to help Accountable Care... while improving the quality of care for our beneficiaries. Through Accelerated Development Learning...
Manjeet Singh Dhallu
Full Text Available Perioperative care of the patients with neurological diseases can be challenging. Most important consideration is the management and understanding of pathophysiology of these disorders and evaluation of new neurological changes that occur perioperatively. Perioperative generally refers to 3 phases of surgery: preoperative, intraoperative, and postoperative. We have tried to address few commonly encountered neurological conditions in clinical practice, such as delirium, stroke, epilepsy, myasthenia gravis, and Parkinson disease. In this article, we emphasize on early diagnosis and management strategies of neurological disorders in the perioperative period to minimize morbidity and mortality of patients.
Bharadwaj, Shishira; Trivax, Brandon; Tandon, Parul; Alkam, Bilal; Hanouneh, Ibrahim; Steiger, Ezra
Postoperative infectious complications are independently associated with increased hospital length of stay (LOS) and cost and contribute to significant inpatient morbidity. Many strategies such as avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, metabolic control and early mobilization have been used to either prevent or reduce the incidence of postoperative infections. Despite these efforts, it remains a big challenge to our current healthcare system to mitigate the cost of postoperative morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Perioperative nutritional support using enteral and parenteral routes has been shown to decrease postoperative morbidity, especially in high-risk patients. Recently, the role of immunonutrition (IMN) in postoperative infectious complications has been studied extensively. These substrates have been found to positively modulate postsurgical immunosuppression and inflammatory responses. They have also been shown to be cost-effective by decreasing both tpostoperative infectious complications and hospital LOS. In this review, we discuss the postoperative positive outcomes associated with the use of perioperative IMN, their cost-effectiveness, current guidelines and future clinical implications. © The Author(s) 2016. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-Sen University.
Bharadwaj, Shishira; Trivax, Brandon; Tandon, Parul; Alkam, Bilal; Hanouneh, Ibrahim; Steiger, Ezra
Postoperative infectious complications are independently associated with increased hospital length of stay (LOS) and cost and contribute to significant inpatient morbidity. Many strategies such as avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, metabolic control and early mobilization have been used to either prevent or reduce the incidence of postoperative infections. Despite these efforts, it remains a big challenge to our current healthcare system to mitigate the cost of postoperative morbidity. Furthermore, preoperative nutritional status has also been implicated as an independent risk factor for postoperative morbidity. Perioperative nutritional support using enteral and parenteral routes has been shown to decrease postoperative morbidity, especially in high-risk patients. Recently, the role of immunonutrition (IMN) in postoperative infectious complications has been studied extensively. These substrates have been found to positively modulate postsurgical immunosuppression and inflammatory responses. They have also been shown to be cost-effective by decreasing both tpostoperative infectious complications and hospital LOS. In this review, we discuss the postoperative positive outcomes associated with the use of perioperative IMN, their cost-effectiveness, current guidelines and future clinical implications. PMID:27081153
Bouwsma, Esther V A; Huirne, Judith A F; van de Ven, Peter M; Vonk Noordegraaf, Antonie; Schaafsma, Frederieke G; Schraffordt Koops, Steven E; van Kesteren, Paul J M; Brölmann, Hans A M; Anema, Johannes R
To evaluate the implementation and effectiveness of an internet-based perioperative care programme for patients following gynaecological surgery for benign disease. Stepped-wedge cluster randomised controlled trial. Secondary care, nine hospitals in the Netherlands, 2011-2014. 433 employed women aged 18-65 years scheduled for hysterectomy and/or laparoscopic adnexal surgery. An internet-based care programme was sequentially rolled out using a multifaceted implementation strategy. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or the care programme (n=227). The care programme included an e-health intervention equipping patients with tailored personalised convalescence advice. The primary outcome was duration until full sustainable return to work (RTW). The degree of implementation of the care programme was evaluated at the level of the patient, healthcare provider and organisation by indicators measuring internet-based actions by patients and providers. Median time until RTW was 49 days (IQR 27-76) in the intervention group and 62 days (42-85) in the control group. A piecewise Cox model was fitted to take into account non-proportionality of hazards. In the first 85 days after surgery, patients receiving the intervention returned to work faster than patients in the control group (HR 2.66, 95% CI 1.88 to 3.77), but this effect was reversed in the small group of patients that did not reach RTW within this period (0.28, 0.17 to 0.46). Indicators showed that the implementation of the care programme was most successful at the level of the patient (82.8%) and professional (81.7%). Implementation of an internet-based care programme has a large potential to lead to accelerated recovery and improved RTW rates following different types of gynaecological surgeries. NTR2933; Results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use
Goldschneider, Kenneth; Lucky, Anne W; Mellerio, Jemima E; Palisson, Francis; del Carmen Viñuela Miranda, Maria; Azizkhan, Richard G
Epidermolysis bullosa (EB) has become recognized as a multisystem disorder that poses a number of pre-, intra-, and postoperative challenges. While anesthesiologists have long appreciated the potential difficult intubation in patients with EB, other systems can be affected by this disorder. Hematologic, cardiac, skeletal, gastrointestinal, nutritional, and metabolic deficiencies are foci of preoperative medical care, in addition to the airway concerns. Therefore, multidisciplinary planning for operative care is imperative. A multinational, interdisciplinary panel of experts assembled in Santiagio, Chile to review the best practices for perioperative care of patients with EB. This paper presents guidelines that represent a synthesis of evidence-based approaches and the expert consensus of this panel and are intended to aid physicians new to caring for patients with EB when operative management is indicated. With proper medical optimization and attention to detail in the operating room, patients with EB can have an uneventful perioperative course.
Napoly, O.; Aleksan, A.; Devred, A.; den Ouden, A.
CARE, an ambitious and coordinated programme of accelerator research and developments oriented towards high energy physics projects, has been launched in January 2004 by the main European laboratories and the European Commission. This project aims at improving existing infrastructures dedicated to
О. S. Lashkul
Full Text Available Aim – тo assess the impact of the early multimodal rehabilitation concept on postoperative period after laparoscopic operations on uterine appendages. Маterials and methods. The study involved 79 patients who were randomized by envelope method in two groups. In the main group (26 patients, a protocol of early multimodal rehabilitation (ERAS was used. In the control group (53 patients, the traditional perioperative regimen was used. In both groups, laparoscopic operations were performed under general anesthesia with mechanical ventilation (propofol + fentanyl. In perioperative anesthesia NSAIDs (dexketoprofen, ketorolac, paracetamol were included. Non-invasive monitoring was performed by the «Leon» monitor (StO2, blood pressure, heart rate, capnogram, hourly diuresis was taken into account, thermometry was performed. In the postoperative period analgesia with combination with systemic administration of dexketoprofen (100–150 mg/day + ketorolac (60 mg/day + paracetamol (3000 mg/day was used. Results. The groups were homogeneous according to anamnestic (the beginning of menstruation, the number of pregnancies, childbirth, abortions, miscarriages, anthropometric and demographic characteristics, the duration of operations, blood loss and baseline values of systolic, diastolic, mean arterial pressures and heart rate. In groups the volumes of diuresis did not differ significantly (p < 0.05. Positive intraoperative hemohydrate balance in the FTS group was almost half that in the control group. When assessing pain at rest by VAS, a statistically significant difference was found at the 6 and 24 hours study stages. Nevertheless, at the study stages the pain level in the control group did not exceed 30 mm, which indicates adequate analgesia at rest. The level of cough pain in the control group exceeded the level of pain in the main group, the statistical difference was determined after 6 hours and 24 hours, but was above 30 mm, which required
Westra, Bonnie L; Peterson, Jessica J
Big data are large volumes of digital data that can be collected from disparate sources and are challenging to analyze. These data are often described with the five "Vs": volume, velocity, variety, veracity, and value. Perioperative nurses contribute to big data through documentation in the electronic health record during routine surgical care, and these data have implications for clinical decision making, administrative decisions, quality improvement, and big data science. This article explores methods to improve the quality of perioperative nursing data and provides examples of how these data can be combined with broader nursing data for quality improvement. We also discuss a national action plan for nursing knowledge and big data science and how perioperative nurses can engage in collaborative actions to transform health care. Standardized perioperative nursing data has the potential to affect care far beyond the original patient. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Dort, Joseph C; Farwell, D Gregory; Findlay, Merran; Huber, Gerhard F; Kerr, Paul; Shea-Budgell, Melissa A; Simon, Christian; Uppington, Jeffrey; Zygun, David; Ljungqvist, Olle; Harris, Jeffrey
Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this patient population but evidence-based protocols on perioperative care for this population are lacking. To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction. Following endorsement by the Enhanced Recovery After Surgery (ERAS) Society to develop this protocol, a systematic review was conducted for each topic. The PubMed and Cochrane databases were initially searched to identify relevant publications on head and neck cancer surgery from 1965 through April 2015. Consistent key words for each topic included "head and neck surgery," "pharyngectomy," "laryngectomy," "laryngopharyngectomy," "neck dissection," "parotid lymphadenectomy," "thyroidectomy," "oral cavity resection," "glossectomy," and "head and neck." The final selection of literature included meta-analyses and systematic reviews as well as randomized controlled trials where available. In the absence of high-level data, case series and nonrandomized studies in head and neck cancer surgery patients or randomized controlled trials and systematic reviews in non-head and neck cancer surgery patients, were considered. An international panel of experts in major head and neck cancer surgery and enhanced recovery after surgery reviewed and assessed the literature for quality and developed recommendations for each topic based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations were graded following a consensus discussion among the expert panel. The literature search, including a hand search of reference lists, identified 215 relevant publications that were considered to be the best evidence for the topic areas. A total of 17 topic areas were identified for inclusion in the protocol for the perioperative
A one-day presentation of the project will take place on Monday February 10th in the CERN Council Chamber. The meeting will start a 9am and is expected to end at 4:30pm. The meeting, which is open to the whole community, will present an initiative on accelerator R&D in Europe, supported by ECFA, with the aim to bid for European Union support through the Framework 6 scheme. This initiative is coordinated by a steering group (ESGARD - European Steering Group on Accelerator Research and Development), which has been set up to coordinate European efforts on accelerator R&D and the submission of such bids. The initial bids have to be submitted by April 15th. All those interested in accelerator R&D are welcome to attend. Presentation of the CARE project (Coordinated Accelerator Research in Europe) to be submitted within FP6 February 10th, at CERN in the council room Agenda Chair : C. Wyss 9:00 General presentation of FP6 and introduction of IA proposal (R. Aleksan) 9:45 Networking activities on e ...
Nicholas B. Robertson
Full Text Available Accelerated rehabilitation following total joint replacement (TJR surgery has become more common in contemporary orthopaedic practice. Increased utilization demands improvements in resource allocation with continued improvement in patient outcomes. We describe an accelerated rehab protocol (AR instituted at a community based hospital. All patients undergoing total knee arthroplasty (TKA and total hip arthroplasty (THA were included. The AR consisted of preoperative patient education, standardization of perioperative pain management, therapy, and next day in-home services consultation following discharge. Outcomes of interest include average length of stay (ALOS, discharge disposition, 42-day return to Urgent Care (UC, Emergency Department (ED, or readmission. A total of 4 surgeons performed TJR procedures on 1,268 patients in the study period (696 TKA, 572 THA. ALOS was reduced from 3.5 days at the start of the observation period to 2.4 days at the end. Discharge to skilled nursing reduced from 25% to 14%. A multifaceted and evidence based approach to standardization of care delivery has resulted in improved patient outcomes and a reduction in resource utilization. Adoption of an accelerated rehab protocol has proven to be effective as well as safe without increased utilization of UC, ER, or readmissions.
Manash Ranjan Sahoo
Full Text Available Objective: To evaluate the safety and efficacy of early rehabilitation after surgery program (ERAS in patients undergoing laparoscopic assisted total gastrectomy. Materials And Methods: This is a study where 47 patients who are undergoing lap assisted total gastrectomy are selected. Twenty-two (n = 22 patients received enhanced recovery programme (ERAS management and rest twenty-five (n = 25 conventional management during the perioperative period. The length of postoperative hospital stay, time to passage of first flatus, intraoperative and postoperative complications, readmission rate and 30 day mortality is compared. Serum levels of C-reactive protein pre-operatively and also on post-op day 1 and 3 are compared. Results: Postoperative hospital stay is shorter in ERAS group (78 ± 26 h when compared to conventional group (140 ± 28 h. ERAS group passed flatus earlier than conventional group (37 ± 9 h vs. 74 ± 16 h. There is no significant difference in complications between the two groups. Serum levels of CRP are significantly low in ERAS group in comparison to conventional group. [d1 (52.40 ± 10.43 g/L vs. (73.07 ± 19.32 g/L, d3 (126.10 ± 18.62 g/L vs. (160.72 ± 26.18 g/L]. Conclusion: ERAS in lap-assisted total gastrectomy is safe, feasible and efficient and it can ameliorate post-operative stress and accelerate postoperative rehabilitation in patients with gastric cancer. Short term follow up results are encouraging but we need long term studies to know its long term benefits.
Nanavati, Aditya J; Prabhakar, S
A 'fast-track protocol' in surgery suggests the application of evidence-based practices to expedite patient recovery. It has shown to reduce hospital stay, hasten recovery as well as facilitate earlier return to work. It has a considerable impact in reducing healthcare costs. The basic tenet is to treat the patient's disease by minimal disturbance of their physiology. The protocol encompasses pre-operative, intra-operative and post-operative interventions which when carried out together would show maximal benefits. The surgeon is usually the leader of the team managing the patient, but it cannot be over-emphasised that this is a multi-disciplinary team approach. We conducted a prospective interventional study to investigate whether 'fast-track' surgery protocols improve patient outcome when compared to traditional peri-operative care followed at our institute. By doing so, we observed that the patients who underwent 'fast tracking' required lesser analgesia, had earlier ambulation, earlier return of intestinal motility, were free from tubes, catheters and drains earlier and lastly were discharged earlier. This was achieved without a rise in complications or re-admissions. The results have proved that implementing the fast-track protocol for gastrointestinal surgeries is not only safe and effective, but also improves patient outcome.
Feistritzer, N R; Keck, B R
Faced with declining revenues and increasing operating expenses, hospitals are evaluating numerous mechanisms designed to reduce costs while simultaneously maintaining quality care. Many facilities have targeted initial cost reduction efforts in the reduction of labor expenses. Once labor expenses have been "right sized," facilities have continued to focus on service delivery improvements by the optimization of the "supply chain" process. This report presents a case study of the efforts of Vanderbilt University Medical Center in the redesign of its supply chain management process in the department of Perioperative Services. Utilizing a multidisciplinary project management structure, 3 work teams were established to complete the redesign process. To date, the project has reduced costs by $2.3 million and enhanced quality patient care by enhancing the delivery of appropriate clinical supplies during the perioperative experience.
Bennett, Jennifer L; Ha, Christina Y; Efron, Jonathan E; Gearhart, Susan L; Lazarev, Mark G; Wick, Elizabeth C
To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating medical therapy after Crohn's disease (CD) surgery at a tertiary care referral center. CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery. Eighty-eight patients met study inclusion criteria with 92% (n=81) of patients returning for surgical follow-up compared to only 41% (n=36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P<0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery. Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.
Lonergan, Daniel F; Ehrenfeld, Jesse M
SUMMARY Information systems assist in documentation and clinical decision support in settings ranging from an outpatient clinical encounter to the monitoring in an operating room. Such information, if stored and categorized well in a centralized database, offers a treasure trove of information for translational researchers. At Vanderbilt University Medical Center (TN, USA), there is an ongoing effort to advance information systems in all areas and couple this data with a robust genetic repository. It is hoped that such an effort will achieve improvements in quality of care and decreases in costs, while simultaneously providing a fertile ground for translational research.
Boney, Oliver; Bell, Madeline; Bell, Natalie; Conquest, Ann; Cumbers, Marion; Drake, Sharon; Galsworthy, Mike; Gath, Jacqui; Grocott, Michael P W; Harris, Emma; Howell, Simon; Ingold, Anthony; Nathanson, Michael H; Pinkney, Thomas; Metcalf, Leanne
To identify research priorities for Anaesthesia and Perioperative Medicine. Prospective surveys and consensus meetings guided by an independent adviser. UK. 45 stakeholder organisations (25 professional, 20 patient/carer) affiliated as James Lind Alliance partners. First 'ideas-gathering' survey: Free text research ideas and suggestions. Second 'prioritisation' survey: Shortlist of 'summary' research questions (derived from the first survey) ranked by respondents in order of priority. Final 'top ten': Agreed by consensus at a final prioritisation workshop. First survey: 1420 suggestions received from 623 respondents (49% patients/public) were refined into a shortlist of 92 'summary' questions. Second survey: 1718 respondents each nominated up to 10 questions as research priorities. Top ten: The 25 highest-ranked questions advanced to the final workshop, where 23 stakeholders (13 professional, 10 patient/carer) agreed the 10 most important questions: ▸ What can we do to stop patients developing chronic pain after surgery? ▸ How can patient care around the time of emergency surgery be improved? ▸ What long-term harm may result from anaesthesia, particularly following repeated anaesthetics?▸ What outcomes should we use to measure the 'success' of anaesthesia and perioperative care? ▸ How can we improve recovery from surgery for elderly patients? ▸ For which patients does regional anaesthesia give better outcomes than general anaesthesia? ▸ What are the effects of anaesthesia on the developing brain? ▸ Do enhanced recovery programmes improve short and long-term outcomes? ▸ How can preoperative exercise or fitness training, including physiotherapy, improve outcomes after surgery? ▸ How can we improve communication between the teams looking after patients throughout their surgical journey? Almost 2000 stakeholders contributed their views regarding anaesthetic and perioperative research priorities. This is the largest example of patient and public
Marquardt, R; Christ, T; Bonfils, P
The effect of Vidisic (a new jelly artificial tear solution) and an ointment basing on Dexpanthenol on the tear production and the tear film stability was studied both on patients in the intensive care units (ICU) and during operations. In 10 relaxed and ventilated patients of the ICU there was no significant change in the tear production after application of either therapy. In 30 patients, undergoing surgery in endotracheal anaesthesia, the break-up-time and the test according to Schirmer were measured pre- and postoperatively. Like in the ICU-patients no difference in tear production could be found. Regarding the stability of the precorneal tear film however Vidisic was more effective than ointment basing on Dexpanthenol. Especially this clear jelly artificial tear solution allowed in contrast to the ointment a permanent and reliable judgement of the pupillary reaction. In addition the patients felt more comfortable with Vidisic.
Full Text Available Background and goals of study: Patient satisfaction in relation to perioperative anesthesia care represents essential aspect of quality health-care management. We analyzed the influence of multi-level anesthesia care exposure and patient profile on perioperative patient satisfaction in short-stay surgical inpatients. Methods : 120 short-stay surgical inpatients who underwent laparoscopic surgery have been included in this prospective study. Pertaining to demographic parameters (age, gender, education, profession, duration of stay (preoperative room, recovery room, various patient problems and patient satisfaction (various levels, overall were recorded by an independent observer and analyzed. Overall, adults, male and uneducated patients experienced more problems. Conversely, elderly, females and educated patients were more dissatisfied. Female patients suffered more during immediate postoperative recovery room stay and were more dissatisfied than their male counterparts (p< 0.05. However, patient′s professional status had no bearing on the problems encountered and dissatisfaction levels. Preoperative and early postoperative period accounted for majority of the problems encountered among the study population. There was a positive correlation between problems faced and dissatisfaction experienced at respective levels of anesthesia care (p< 0.05. Conclusion(s : Patient′s demographic profile and problems faced during respective level of anesthesia care has a correlation with dissatisfaction. Interestingly, none of the above stated factors had any effect on overall satisfaction level.
Soutome, Sakiko; Yanamoto, Souichi; Funahara, Madoka; Hasegawa, Takumi; Komori, Takahide; Yamada, Shin-Ichi; Kurita, Hiroshi; Yamauchi, Chika; Shibuya, Yasuyuki; Kojima, Yuka; Nakahara, Hirokazu; Oho, Takahiko; Umeda, Masahiro
The aim of this study was to investigate the effectiveness of oral care in prevention of postoperative pneumonia associated with esophageal cancer surgery.Postoperative pneumonia is a severe adverse event associated with esophageal cancer surgery. It is thought to be caused by aspiration of oropharyngeal fluid containing pathogens. However, the relationship between oral health status and postoperative pneumonia has not been well investigated.This study included 539 patients with esophageal cancer undergoing surgery at 1 of 7 university hospitals. While 306 patients received perioperative oral care, 233 did not. Various clinical factors as well as occurrence of postoperative pneumonia were retrospectively evaluated. Propensity-score matching was performed to minimize selection biases associated with comparison of retrospective data between the oral care and control groups. Factors related to postoperative pneumonia were analyzed by logistic regression analysis.Of the original 539 patients, 103 (19.1%) experienced postoperative pneumonia. The results of multivariate analysis of the 420 propensity score-matched patients revealed longer operation time, postoperative dysphagia, and lack of oral care intervention to be significantly correlated with postoperative pneumonia.The present findings demonstrate that perioperative oral care can reduce the risk of postoperative pneumonia in patients undergoing esophageal cancer surgery.
... Accelerated Development Learning Sessions; Center for Medicare and Medicaid Innovation November 17 and 18... third and final Accelerated Development Learning Session (ADLS) hosted by CMS to help Accountable Care... while improving the quality of care for beneficiaries. Through Accelerated Development Learning Sessions...
O. N. Boitsova
Full Text Available The number of perioperative monitoring methods is constantly increasing due to the achievements of modern science. However, an increasing number of indicators for monitoring and introduction of the newest monitoring systems was not enough to guarantee the exclusion of perioperative complications. Standard monitoring allows us to control the most common characteristics of homeostasis, the internal environment of the body, which are only a belated reflection of changes in energy-structural activity in the mass of cells in the patient's organism. Therefore, the life expectancy of operated patients does not reach the average life expectancy of the population. Aim. Improvement in treatment results of patients with acute abdominal surgical pathology, by energy-protective perioperative management, based on personified energy-structural monitoring. Materials and methods. The research was performed on the results of the study of energy-protective ability, anesthetic management and perioperative intensive care of 317 patients with acute abdominal surgical pathology. At all the stages of anesthesia management we analyzed the oxygen regime features, acid-base and water-electrolyte status, basal metabolic rate, indicators of oxygen transport, central hemodynamics and microcirculation, reliability of energy-structural activity (ESA, its properties, reserves and possibilities for autoregulation. Brain ischemia markers levels, neurospecific proteins S100 and NSE (neuron specific enolase were additionally determined in venous blood serum by enzyme immunoassay at the main stages of monitoring. Results. A close correlation has been established between early manifestations of neurons and glial cells damage and energy-structural changes in patient's organism. The strongest correlation is observed between energy-osmolar autoregulation and levels of cerebral ischemia markers (p<0,01. Inclusion of energy-structural activity, its properties, reserves, efficiency of
Philip J. Peyton
Full Text Available Minimally invasive measurement of cardiac output as a central component of advanced haemodynamic monitoring has been increasingly recognised as a potential means of improving perioperative outcomes in patients undergoing major surgery. Methods based upon pulmonary carbon dioxide elimination are among the oldest techniques in this field, with comparable accuracy and precision to other techniques. Modern adaptations of these techniques suitable for use in the perioperative and critical are environment are based on the differential Fick approach, and include the partial carbon dioxide rebreathing method. The accuracy and precision of this approach to cardiac output measurement has been shown to be similar to other minimally invasive techniques. This paper reviews the underlying principles and evolution of the method, and future directions including recent adaptations designed to deliver continuous breath-by-breath monitoring of cardiac output.
Pyati, Srinivas; Gan, Tong J
The under-treatment of postoperative pain has been recognised to delay patient recovery and discharge from hospital. Despite recognition of the importance of effective pain control, up to 70% of patients still complain of moderate to severe pain postoperatively. The mechanistic approach to pain management, based on current understanding of the peripheral and central mechanisms involved in nociceptive transmission, provides newer options for clinicians to manage pain effectively. In this article we review the rationale for a multimodal approach with combinations of analgesics from different classes and different sites of analgesic administration. The pharmacological options of commonly used analgesics, such as opioids, NSAIDs, paracetamol, tramadol and other non-opioid analgesics, and their combinations is discussed. These analgesics have been shown to provide effective pain relief and their combinations demonstrate a reduction in opioid consumption. The basis for using non-opioid analgesic adjuvants is to reduce opioid consumption and consequently alleviate opioid-related adverse effects. We review the evidence on the opioid-sparing effect of ketamine, clonidine, gabapentin and other novel analgesics in perioperative pain management. Most available data support the addition of these adjuvants to routine analgesic techniques to reduce the need for opioids and improve quality of analgesia by their synergistic effect. Local anaesthetic infiltration, epidural and other regional techniques are also used successfully to enhance perioperative analgesia after a variety of surgical procedures. The use of continuous perineural techniques that offer prolonged analgesia with local anaesthetic infusion has been extended to the care of patients beyond hospital discharge. The use of nonpharmacological options such as acupuncture, relaxation, music therapy, hypnosis and transcutaneous nerve stimulation as adjuvants to conventional analgesia should be considered and incorporated to
Seim, Lynsey A; Irizarry-Alvarado, Joan M
No clear guideline exists for the management of female hormone therapy in the perioperative period. Besides oral contraceptives (OCPs), hormone medications have been prescribed to treat cancer, osteoporosis, and menopausal symptoms. Since the introduction of OCPs in the 1960s, the thromboembolic risk associated with these medications has been studied and alterations have been made in the hormone content. The continuation of hormone therapy in the perioperative period and its possible interactions with commonly used anesthetic agents are important information for all perioperative health care providers. A review was done on the current guideline and available literature for the mechanisms of action and perioperative management of OCPs, hormone replacement therapy (HRT), and antineoplastic hormonal modulators. Available guidelines and literature were reviewed and summarized. Based on the available literature, no definite guidelines have been established for perioperative management of OCPs and HRT. However, manufacturers have recommended that these medications should be held perioperatively. Other antineoplastic hormonal modulators have increased the risk of venous thromboembolism and have perioperative implications that should be discussed with the prescribing physicians and addressed with the patient. Until additional studies are performed, the risks and benefits must be weighed on an individual basis with consideration of prophylaxis when a decision is made to continue these medications in the perioperative period. Part of this decision making includes the risk of fetal harm in an unwanted pregnancy in preparation for nonobstetric surgery versus an increased risk of venous thromboembolism. Copyright© Bentham Science Publishers; For any queries, please email at email@example.com.
Francisco, Saionara Cristina; Batista, Sandra Teixeira; Pena, Geórgia das Graças
Prolonged preoperative fasting may impair nutritional status of the patient and their recovery. In contrast, some studies show that fasting abbreviation can improve the response to trauma and decrease the length of hospital stay. Investigate whether the prescribed perioperative fasting time and practiced by patients is in compliance with current multimodal protocols and identify the main factors associated. Cross-sectional study with 65 patients undergoing elective surgery of the digestive tract or abdominal wall. We investigated the fasting time in the perioperative period, hunger and thirst reports, physical status, diabetes diagnosis, type of surgery and anesthesia. The patients were between 19 and 87 years, mostly female (73.8%). The most performed procedure was cholecystectomy (47.69%) and general anesthesia the most used (89.23%). The most common approach was to start fasting from midnight for liquids and solids, and most of the patients received grade II (64.6%) to the physical state. The real fasting average time was 16 h (9.5-41.58) was higher than prescribed (11 h, 6.58 -26.75). The patients submitted to surgery in the afternoon were in more fasting time than those who did in the morning (pfasting period (p=0.010 and 0.027). The average period of postoperative fasting was 18.25 h (3.33-91.83) and only 23.07% restarted feeding on the same day. Patients were fasted for prolonged time, higher even than the prescribed time and intensity of the signs of discomfort such as hunger and thirst increased over time. To better recovery and the patient's well-being, it is necessary to establish a preoperative fasting abbreviation protocol.
The main objective of the CARE project was to generate a structured and integrated European area in the field of accelerator research and related R&D. A set of integrating activities involving the largest European infrastructure laboratories and their user communities “active in accelerator R&D”, including industrial partners was established with the following general objectives: 1) To optimise the use of existing infrastructures for improving the European knowledge on accelerator physics By promoting a coherent and coordinated utilization and development of infrastructures and to facilitate the access to accelerators and test facilities for carrying accelerator studies By understanding accelerator operation and reliability issues 2) To tackle new or state-of-the-art technologies in a more co-ordinated and collaborative approach By developing a coherent and coordinated accelerator R&D program in Europe and carrying out joint R&D projects allowing one to enhance the existing (or...
Chadha, Ryan M; Aniskevich, Stephen; Egan, Brian J
Pain continues to be the most common medical concern, and perioperative health care providers are encountering increasing numbers of patients with chronic pain conditions. It is important to have a clear understanding of how long-term use of pain medications impacts anesthesia during the intraoperative and postoperative periods. To review common medications used to treat chronic pain and summarize current recommendations regarding perioperative care. We reviewed the literature by searching PubMed and Google Scholar for articles from 2000-2016. The search strategy included searching for the various classes of pain medications and including the terms perioperative, anesthesiology, and recommendations. We also reviewed the reference lists of each article to identify other relevant sources regarding the perioperative management of pain medications. After the literature review, we were able to establish the pharmacology, anesthetic interactions, and recommendations for management of each of the common classes of pain medication. Management of postoperative pain is an important concern for all perioperative health care providers. Although most pain medications should be continued in the perioperative period, it is important to preoperatively discontinue those that antagonize pain receptors to avoid significant postoperative morbidities associated with poorly managed pain. Copyright© Bentham Science Publishers; For any queries, please email at firstname.lastname@example.org.
Ward, Paul R
Many countries of the world have outlined clearly defined and distinct roles, for the perioperative environment, that are played by various individuals from a range of professions. Each of these professions tends to educate its practitioners in an environment that is almost completely isolated from the other perioperative professions and from its peers in other countries. One can only, currently, imagine the potential benefits to be gained from the sharing of educational and clinical experience between countries and between nursing and non-nursing perioperative team members, for both patient and the entire perioperative team. If such a level of sharing existed then the entire global perioperative community would benefit. The transfer of education and clinical practice, however, between countries needs careful thought. Many educational and professional disciplines have conducted research into ways of transferring/borrowing good practice between established systems and those just commencing similar practices. Perioperative practice needs a similar research base that has explored the dilemmas of transfer and borrowing between countries. It is important to determine what information should be shared, in the best interest of the patients, what sharing is affordable, and what method of sharing will fit in to an overall, global, strategy for perioperative practice. This paper seeks to use a recent example of multi-professional perioperative learning undertaken by Advanced Scrub Practitioners to provide a possible first glance in to the "crystal ball" of future practice. The aim of the discussion is to stimulate further discussion and effective research that, if carried out correctly, will seek to encourage interprofessional and international co-operation between perioperative professionals worldwide.
Drew, Barbara L; Motter, Tracey; Ross, Ratchneewan; Goliat, Laura M; Sharpnack, Patricia A; Govoni, Amy L; Bozeman, Michelle C; Rababah, Jehad
Stress affects the well-being of both nursing students and the individuals with whom they work. With the theory of cognitive appraisal as a framework for this study, it is proposed that mind-body self-care strategies promote stress management by stabilization of emotions. Outcomes will be a perception of less stress and more mindful engagement with the environment. Objective of the study was to describe an evaluation of student perceived stress and mindfulness to 1-hour per week of class time dedicated to mind-body self-care (yoga, mindful breathing, Reiki, and essential oil therapy). It was a quasi-experimental study; data collection took place at 4 time points. Participants were entry-level accelerated nursing students from 3 US universities: 50 in the treatment group, 64 in the comparison group. Data included health-promoting practices using Health-Promoting Promotion Lifestyle Profile II as a control variable, stress and mindfulness (Perceived Stress Scale [PSS] and Mindful Attention Awareness Scale [MAAS]), and demographic information; analysis using mixed-design repeated-measures analysis of variances. There was a statistically significant interaction between intervention and time on PSS scores, F(3, 264) = 3.95, P = .009, partial η(2) = 0.043, with PSS scores of the intervention group decreasing from baseline to T3 when intervention ended whereas PSS scores of the comparison group increased from baseline. The average scores on the MAAS did not differ significantly. Evaluation of an embedded mind-body self-care module in the first nursing course demonstrated promising improvements in stress management. The findings support the appropriateness of integrating mind-body self-care content into nursing curricula to enhance students' ability to regulate stress.
Levey, Janet A; Chappy, Sharon L
Service dogs are critical for the independence of individuals with disabilities because they assist with daily living activities and help these individuals navigate society. Perioperative nurses need a working knowledge of disability laws pertaining to service dogs to provide patient-centered care for individuals using service dogs. This article provides information on the Americans With Disabilities Act regulations regarding service dogs, makes recommendations for the care of patients with service dogs across the perioperative continuum, and offers policy directives to ensure that safe, high-quality care is delivered to patients using service dogs. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Pedersen, Tom; Nicholson, Amanda; Hovhannisyan, Karen
of hypoxaemia reduce morbidity and mortality in the perioperative period.3. Use of pulse oximetry per se reduces morbidity and mortality in the perioperative period.4. Use of pulse oximetry reduces unplanned respiratory admissions to the intensive care unit (ICU), decreases the length of ICU readmission or both....... SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 5), MEDLINE (1966 to June 2013), EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), ISI Web of Science (1956 to June 2013), LILACS (1982 to June 2013) and databases of ongoing trials; we also....... Results indicated that hypoxaemia was reduced in the pulse oximetry group, both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5 to three times less. Postoperative cognitive function was independent...
Kozek-Langenecker, Sibylle A; Ahmed, Aamer B; Afshari, Arash
healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All......: The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia...... articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline...
Many states are having success turning to telepsychiatry-based solutions to connect mental health patients with needed care while also decompressing crowded EDs. Just one year into a statewide telepsychiatry initiative in North Carolina (NC-STeP), administrators say the approach has saved as much as $7 million, and hospital demand for the service is higher than anticipated. In Texas, mental health emergency centers (MHEC) that use telepsychiatry to connect patients in rural areas with needed psychiatric care are freeing up EDs to focus on medical care. In just 11 months, 91 North Carolina hospitals have at least started the process to engage in NC-STeP. Much of the savings from NC-STeP come from involuntary commitment orders being overturned as a result of the telepsychiatry consults, reducing the need for expensive inpatient care. Implementing NC-STeP has involved multiple hurdles including credentialing difficulties and technical/firewall challenges. The Texas model provides 24/7 availability of psychiatrists via telemedicine through a network of MHECs. In-person staff at the MHECs perform basic screening tests and blood draws so that medical clearance can be achieved without the need for an ED visit in most cases. Funding for the MHECs comes from the state, hospitals in the region, and local governmental authorities that reap savings or benefits from the initiative.
Basse, Linda; Thorbøl, Jens Erik; Løssl, Kristine
BACKGROUND: For patients undergoing colonic surgery, the postoperative hospital stay is usually 6 to 10 days, and the morbidity rate is 15 to 20 percent. Fast-track rehabilitation programs have reduced the hospital stay to 2 to 3 days. The aim of this study was to evaluate the postoperative outcome...... after colonic resection with conventional care compared with fast-track multimodal rehabilitation. METHODS: One hundred thirty consecutive patients receiving conventional care (group 1) in one hospital were compared with 130 consecutive patients receiving multimodal, fast-track rehabilitation (group 2......) in another hospital. Outcomes were time to first defecation after surgery, postoperative hospital stay, and morbidity during the first postoperative month. RESULTS: Median age was 74 years (group 1) and 72 years (group 2). American Society of Anesthesiologists (ASA) score was significantly higher in group 2...
Bundgaard-Nielsen, M; Secher, N H; Kehlet, H
clinical trials and cited studies, comparing two different fixed fluid volumes on post-operative clinical outcome in major surgery. Studies were assessed for the type of surgery, primary and secondary outcome endpoints, the type and volume of administered fluid and the definition of the perioperative...... found differences in the selected outcome parameters. CONCLUSION: Liberal vs. restrictive fixed-volume regimens are not well defined in the literature regarding the definition, methodology and results, and lack the use of or information on evidence-based standardized perioperative care-principles (fast...... for fluid therapy and outcome endpoints were inconsistently defined and only two studies reported perioperative care principles and discharge criteria. Three studies found an improved outcome (morbidity/hospital stay) with a restrictive fluid regimen whereas two studies found no difference and two studies...
Cima, Robert R; Dhanorker, Sarah R; Ostendorf, Christopher L; Ntekpe, Mfonabasi; Mudundi, Raghu V; Habermann, Elizabeth B; Deschamps, Claude
The metric "Unplanned returns to operating room (ROR)" is being tracked in surgical quality dashboards; 70% of unplanned RORs may be related to surgical complications. With increasing regionalization of trauma and complex surgical care at tertiary care academic centers, it is unclear if a simple ROR metric is a valid assessment of surgical quality at such centers. A real-time electronic tool was used to identify all RORs-planned and unplanned-in a high-volume, high-complexity academic surgical practice at Mayo Clinic-Rochester within 45 days of the index operation. Analysis by ROR type and indication was performed. During the analysis period (June 2014-February 2015) 44,031 operations were performed, with 5,552 subsequent RORs (13%). Of all RORs, 51% (n = 2,818) were planned staged returns, 29% (n = 1,589) were unrelated, 15% (n = 830) were unplanned and 6% (n = 315) were planned because of previous complications. Overall, unplanned reoperations were uncommon (n = 830, 2% of all operations). The most common indications for unplanned RORs included "other" (32%, n = 266), bleeding related (24%, n = 198) and wound complications (20%, n = 166). In a high-volume, high-complexity academic surgical practice, RORs occurred after 13% of cases. Unplanned returns were infrequent and usually were associated with complications; most RORs were planned staged or unrelated returns. A simple ROR metric that does not consider planned/unrelated returns is likely not a valid surgical quality measure. Electronic tools designed specifically to identify in real-time RORs, associated indication, and clinical validation should provide more reliable data for public reporting and quality improvement efforts. Copyright © 2016 The Joint Commission. Published by Elsevier Inc. All rights reserved.
Bignami, Elena; Belletti, Alessandro; Moliterni, Paola; Frati, Elena; Guarnieri, Marcello; Tritapepe, Luigi
This study was to investigate and define what is considered as a current clinical practice in hemodynamic monitoring and vasoactive medication use after cardiac surgery in Italy. A 33-item questionnaire was sent to all intensive care units (ICUs) admitting patients after cardiac surgery. 71 out of 92 identified centers (77.2 %) returned a completed questionnaire. Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature and blood gas analysis were identified as routinely used hemodynamic monitoring, whereas advanced monitoring was performed with pulmonary artery catheter or echocardiography. Crystalloids were the fluids of choice for volume replacement (86.8 % of Centers). To guide volume management, central venous pressure (26.7 %) and invasive blood pressure (19.7 %) were the most frequently used parameters. Dobutamine was the first choice for treatment of left heart dysfunction (40 %) and epinephrine was the first choice for right heart dysfunction (26.8 %). Half of the Centers had an internal protocol for vasoactive drugs administration. Intra-aortic balloon pump and extra-corporeal membrane oxygenation were widely available among Cardiothoracic ICUs. Angiotensin-converting enzyme inhibitors were suspended in 28 % of the Centers. The survey shows what is considered as standard monitoring in Italian Cardiac ICUs. Standard, routinely used monitoring consists of ECG, SpO2, etCO2, invasive BP, CVP, diuresis, body temperature, and BGA. It also shows that there is large variability among the various Centers regarding hemodynamic monitoring of fluid therapy and inotropes administration. Further research is required to better standardize and define the indicators to improve the standards of intensive care after cardiac surgery among Italian cardiac ICUs.
Willis, Simon; Bordelon, Gregory J; Rana, Maunak V
Obesity has increased in incidence worldwide. Along with the increased number of obese patients, comorbid conditions are also more prevalent in this population. Obesity leads to changes in the physiology of patients along with an altered response to pharmacologic therapy. Vigilant perioperative physicians must be aware of the unique characteristics of administered agents in order to appropriately provide anesthetic care for obese patients. Because of the variability in tissue content in obese patients and changes in pharmacokinetic modeling, a one-size-fits-all approach is not justified and a more sophisticated and prudent approach is indicated. Copyright © 2017 Elsevier Inc. All rights reserved.
Perioperative care of infants with diaphragmatic hernias can be a challenge because of pulmonary hypertension and systemic hypotension. The objective of this study was to report the usefulness of vasopressin infusion in improving pulmonary and systemic haemodynamics in an infant with congenital diaphragmatic hernia.
de Haan, L.S.; Calsbeek, H; Wolff, André
Importance: There is a growing interest in enabling ways for patients to participate in their own care to improve perioperative safety, but little is known about the effectiveness of interventions enhancing an active patient role. Objective: To evaluate the effect of patient participation on
Kubicek, Bettina; Korunka, Christian; Ulferts, Heike
This paper introduces the concept of acceleration-related demands in the care of older adults. It examines these new demands and their relation to cognitive, emotional, and physical job demands and to employee well-being. Various changes in the healthcare systems of Western societies pose new demands for healthcare professionals' careers and jobs. In particular today's societal changes give rise to acceleration-related demands, which manifest themselves in work intensification and in increasing requirements to handle new technical equipment and to update one's job-related knowledge. It is, therefore, of interest to investigate the effects of these new demands on the well-being of employees. Survey. Between March-June 2010 the survey was conducted among healthcare professionals involved in care of older adults in Austria. A total of 1498 employees provided data on cognitive, emotional, and physical job demands and on acceleration-related demands. The outcome variables were the core dimensions of burnout (emotional exhaustion and depersonalization) and engagement (vigour and dedication). Hierarchical regression analyses show that acceleration-related demands explain additional variance for exhaustion, depersonalization, vigour, and dedication when controlling for cognitive, emotional, and physical demands. Furthermore, acceleration-related demands associated with increasing requirements to update one's knowledge are related to positive outcomes (vigour and dedication). Acceleration-related demands associated with an increasing work pace are related to negative outcomes such as emotional exhaustion. Results illustrate that new demands resulting from social acceleration generate potential challenges for on-the-job learning and potential risks to employees' health and well-being. © 2012 Blackwell Publishing Ltd.
Full Text Available Government-funded systems of health and social care are facing enormous fiscal and human-resource challenges. The space for innovation in care is wide open and new disruptive patterns are emerging. These include self-management and personal budgets, participatory and integrated care, supported decision making and a renewed focus on prevention. Taking these disruptive patterns to scale can be accelerated by a technologically enabled shift to a network model of care to co-create the best outcomes for individuals, family caregivers, and health and social care organizations. The connections, relationships, and activities within an individual’s personal network lay the foundation for care that health and social care systems/policy must simultaneously support and draw on for positive outcomes. Practical tools, adequate information, and tangible resources are required to coordinate and sustain care. Tyze Personal Networks is a social venture that uses technology to engage and inform the individual, their personal networks, and their care providers to co-create the best outcomes. In this article, we demonstrate how Tyze contributes to a shift to a network model of care by strengthening our networks and enhancing partnerships between care providers, individuals, and family and friends.
Gliedt, Jordan A; Daniels, Clinton J; Wuollet, Adam
Acupuncture is one of the oldest forms of the natural healing arts. The exact mechanisms of action are unknown at this time; however, current theories to explain the benefits experienced after acupuncture include Traditional Chinese Medicine and Western medicine concepts. Acupuncture may improve the quality of perioperative care and reduce associated complications. Perioperative acupuncture is apparently effective in reducing preoperative anxiety, postoperative nausea and vomiting, and postoperative pain. The Pericardium-6 (P-6; Nei Guan), Yintang (Extra 1), and Shenmen acupuncture points are the most studied and effective acupuncture points in reducing preoperative anxiety, postoperative nausea and vomiting, and postoperative pain experiences. Intraoperatively administered acupuncture may reduce immunosuppression in patients and lessen intraoperative anesthetic requirements, although the clinical usefulness of acupuncture in the intraoperative period remains inconclusive. Perioperative acupuncture is a promising intervention, but additional studies are needed to further understand and define acupuncture's role throughout the perioperative period and determine its clinical usefulness. The purpose of this article is to provide a brief clinical review concerning acupuncture and its application for common issues that occur in the perioperative period. Copyright © 2015. Published by Elsevier B.V.
This article describes post-graduate perioperative education in Australia at the Australian Catholic University and St. Vincent's Public Hospital: The Graduate Certificate in Perioperative Practice. The Australian Catholic University operates from eight campuses along the east coast of Australia. There are approximately 9000 students along with 1000 staff. The University consists of major faculties that all have clear relevance to the workplace-namely Arts and Sciences, Education and Health Sciences. Qualifications are offered at Certificate of Doctoral level studies in the areas of business, education, ethics, human movement, management, information systems, music, nursing, religion, social work and theology.
Full Text Available The geriatric population is growing in number and complexity in modern surgical practice. This challenging group presents differences in physiology and outcomes that make a more comprehensive and multidisciplinary approach necessary. This review emphasizes the meticulous assessment and preparation in all facets before surgery, including a thorough examination, nutrition evaluation and intervention, and preoperative optimization of pulmonary function and cardiovascular hemodynamics. This article highlights the importance of age-related pharmacokinetic and pharmacodynamic considerations, effective pain control, as well as prevention and treat-ment of hypothermia, fluid and electrolyte imbalance, and postoperative delirium. The vulnerable elderly patient with multiple medical problems and functional impairment is best served by a surgeon with a particular interest and working knowledge of the changes associated with aging and the physiology of surgery and anesthesia.
Ko, Hanjo; Kaye, Alan David; Urman, Richard D
There is emerging evidence related to the effects of nitrous oxide on important perioperative patient outcomes. Proposed mechanisms include metabolic effects linked to elevated homocysteine levels and endothelial dysfunction, inhibition of deoxyribonucleic acid and protein formation, and depression of chemotactic migration by monocytes. Newer large studies point to possible risks associated with the use of nitrous oxide, although data are often equivocal and inconclusive. Cardiovascular outcomes such as stroke or myocardial infarction were shown to be unchanged in previous studies, but the more recent Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia I trial shows possible associations between nitrous oxide and increased cardiovascular and pulmonary complications. There are also possible effects on postoperative wound infections and neuropsychological function, although the multifactorial nature of these complications should be considered. Teratogenicity linked to nitrous oxide use has not been firmly established. The use of nitrous oxide for routine anesthetic care may be associated with significant costs if complications such as nausea, vomiting, and wound infections are taken into consideration. Overall, definitive data regarding the effect of nitrous oxide on major perioperative outcomes are lacking. There are ongoing prospective studies that may further elucidate its role. The use of nitrous oxide in daily practice should be individualized to each patient's medical conditions and risk factors.
Humphreys, Kathryn L; Esteves, Kyle; Zeanah, Charles H; Fox, Nathan A; Nelson, Charles A; Drury, Stacy S
Studies examining the association between early adversity and longitudinal changes in telomere length within the same individual are rare, yet are likely to provide novel insight into the subsequent lasting effects of negative early experiences. We sought to examine the association between institutional care history and telomere shortening longitudinally across middle childhood and into adolescence. Buccal DNA was collected 2-4 times, between the ages of 6 and 15 years, in 79 children enrolled in the Bucharest Early Intervention Project (BEIP), a longitudinal study exploring the impact of early institutional rearing on child health and development. Children with a history of early institutional care (n=50) demonstrated significantly greater telomere shortening across middle childhood and adolescence compared to never institutionalized children (n=29). Among children with a history of institutional care, randomization to high quality foster care was not associated with differential telomere attrition across development. Cross-sectional analysis of children randomized to the care as usual group indicated shorter telomere length was associated with greater percent of the child's life spent in institutional care up to age 8. These results suggest that early adverse care from severe psychosocial deprivation may be embedded at the molecular genetic level through accelerated telomere shortening. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.
Lombardi, Marilyn M; Spratling, Regena G; Pan, Wei; Shapiro, Susan E
In an era of rising clinical costs and shrinking federal research dollars, the survival of the academic health center may depend on its capacity to cultivate high-impact innovations in care delivery on an accelerated basis. Yet, the health sciences literature offers little guidance regarding the key organizational determinants most likely to facilitate such innovation. We report on the conceptualization, development, and preliminary testing of a new 21-item Accelerated Healthcare Innovation Capacity scale for addressing that knowledge gap. Instrument development followed a standardized process, including expert panel testing of the new scale's content relevance validity. A sample (N = 53) of academic health center administrators, clinicians, and faculty affiliated with a single organization volunteered to complete the Accelerated Healthcare Innovation Capacity scale in survey form. Data were analyzed to evaluate scale reliability, internal consistency, and construct validity. High-expert agreement (overall S-CVI of 0.91) was obtained on content relevance validity. Cronbach α for the scale was 0.941. Exploratory factor analysis confirmed the theoretical soundness of the scale's conceptual framework, which showed high-impact health care innovation support to be a complex, multidimensional concept involving key facilitating factors across 3 major constructs-that is, Culture, Structure, and Policy-with implications for future research and managerial practice, particularly for staff development educators engaged in evaluating quality management and organizational change strategies.
Sakamoto, Yasuo; Hayashi, Hiromitsu; Baba, Hideo
The role of perioperative chemotherapy in the management of initially resectable colorectal liver metastases (CRLM) is still unclear. The EPOC trial [the European Organization for Research and Treatment of Cancer (EORTC) 40983] is an important study that declares perioperative chemotherapy as the standard of care for patients with resectable CRLM, and the strategy is widely accepted in western countries. Compared with surgery alone, perioperative FOLFOX therapy significantly increased progression-free survival (PFS) in eligible patients or those with resected CRLM. Overall survival (OS) data from the EPOC trial were recently published in The Lancet Oncology, 2013. Here, we discussed the findings and recommendations from the EORTC 40983 trial. PMID:25713806
Morrison, J D
Perioperative nursing roles continue to rapidly change as we enter the twenty-first century. The need for strong leadership skills, expert clinical skills, creative management, ongoing continuing education, and research continues to grow in every department of surgical services. The clinical nurse specialist plays an important role in addressing each of these needs. Great opportunities exist within the field of nursing for perioperative nurses to expand their practice using their creativity, ideas, and skills. Using the clinical nurse specialist in the perioperative setting can foster creativity, stimulate development of new methods based on research, and maximize the delivery of high quality care by the entire OR staff.
Møller, Ann; Tønnesen, Hanne
of postoperative intensive care admission. Even passive smoking is associated with increased risk at operation. Preoperative smoking intervention 6-8 weeks before surgery can reduce the complications risk significantly. Four weeks of abstinence from smoking seems to improve wound healing. An intensive, individual......Smoking is a well-known risk factor for perioperative complications. Smokers experience an increased incidence of respiratory complications during anaesthesia and an increased risk of postoperative cardiopulmonary complications, infections and impaired wound healing. Smokers have a greater risk...... approach to smoking intervention results in a significantly better postoperative outcome. Future research should focus upon the effect of a shorter period of preoperative smoking cessation. All smokers admitted for surgery should be informed of the increased risk, recommended preoperative smoking cessation...
Møller, Ann; Tønnesen, Hanne
Smoking is a well-known risk factor for perioperative complications. Smokers experience an increased incidence of respiratory complications during anaesthesia and an increased risk of postoperative cardiopulmonary complications, infections and impaired wound healing. Smokers have a greater risk...... of postoperative intensive care admission. Even passive smoking is associated with increased risk at operation. Preoperative smoking intervention 6-8 weeks before surgery can reduce the complications risk significantly. Four weeks of abstinence from smoking seems to improve wound healing. An intensive, individual...... approach to smoking intervention results in a significantly better postoperative outcome. Future research should focus upon the effect of a shorter period of preoperative smoking cessation. All smokers admitted for surgery should be informed of the increased risk, recommended preoperative smoking cessation...
... following: Incorrectly referenced the learning sessions as accelerated development sessions (ADSs) instead of accelerated development learning sessions (ADLSs). Made inadvertent errors in our description of... ``Accelerated Development Sessions'' is corrected to read ``Accelerated Development Learning Sessions''. (2) In...
Lai, Fuji; Spitz, Gabriel; Brzezinski, Philip
The perioperative environment is a complex, high risk environment that requires real-time coordination by all perioperative team members and accurate, up-to-date information for situation assessment and decision-making. There is the need for a "Gestalt" holistic awareness of the perioperative environment to enable synthesis and contextualization of the salient information such as: patient information, case and procedure information, staff information, operative site view, physiological data, resource availability. One potential approach is to augment the medical toolkit with a large screen wall display that integrates and makes accessible information that currently resides in different data systems and care providers. The objectives are to promote safe workflows, team coordination and communication, and to enable diagnosis, anticipation of events, and information flow from upstream to downstream care providers. We used the human factors engineering design process to design and develop a display that provides a common operational picture for shared virtual perioperative team situation awareness to enhance patient safety.
Full Text Available Abstract Acute kidney injury (AKI is a serious complication in the perioperative period, and is consistently associated with increased rates of mortality and morbidity. Two major consensus definitions have been developed in the last decade that allow for easier comparison of trial evidence. Risk factors have been identified in both cardiac and general surgery and there is an evolving role for novel biomarkers. Despite this, there has been no real change in outcomes and the mainstay of treatment remains preventive with no clear evidence supporting any therapeutic intervention as yet. This review focuses on definition, risk factors, the emerging role of biomarkers and subsequent management of AKI in the perioperative period, taking into account new and emerging strategies.
Morán López, Jesús Manuel; Piedra León, María; García Unzueta, María Teresa; Ortiz Espejo, María; Hernández González, Miriam; Morán López, Ruth; Amado Señaris, José Antonio
The relationship between preoperative malnutrition and morbi-mortality has been documented for years. Despite the existence of tools that allow its detection, and therefore treat this entity, their introduction into clinical practice is not wide-spread. Both perioperative insulin resistance and hyperglycemia are associated with increased perioperative morbidity and length of hospital stay. The intake of carbohydrate-rich drinks 2-4h prior to surgery reduces insulin resistance. In the immediate postoperative period, the enteral route is safe and well tolerated and its early use reduces hospital stay and postoperative complications compared with parenteral nutritional support. Inmunonutrition has been proven effective to decrease postoperative complications and hospital stay. In view of these data we opted for the adoption of these measures replacing bowel rest and the indiscriminate use of postoperative parenteral nutrition. Copyright © 2013 AEC. Published by Elsevier Espana. All rights reserved.
Silva, Marcelina Jasmine; Rubinstein, Andrea
Buprenorphine, a semisynthetic thebaine derivative, is a unique opioid, as it has activity at multiple receptors, including mu (partial agonist), kappa (antagonist), OLR-1 (agonist), and delta (antagonist). Because buprenorphine's pharmacology is relatively complex, misconceptions about its actions are common. Most other opioids act solely or predominately as full mu receptor agonists. Common practice at many institutions calls for the cessation of regular buprenorphine use 48-72 hours prior to surgery. This practice is based on three foundational theories that have come from scant data about the properties of buprenorphine: (1) that buprenorphine is only a partial mu agonist and therefore is not a potent analgesic; (2) because buprenorphine has a ceiling effect on respiratory depression, it also has a ceiling effect on analgesia; and (3) that buprenorphine acts as a "blockade" to the analgesic effects of other opiates when coadministered due to its strong binding affinity. However, several recent studies have called this practice into question. At our institution, we continue buprenorphine perioperatively, whenever possible, in order to provide superior pain control, discourage potentially problematic use and the more dangerous side effects of full mu agonist opiates, and avoid putting recovery at risk for those with opiate dependency issues. We present a unique case comparing two different outcomes for the same surgical course performed at two different times on the same chronic pain patient. These differences may be attributable to the variable of buprenorphine being present for one perioperative course and not the other. Pain control was easier to achieve, and functional recovery was greater when buprenorphine was maintained throughout the perioperative period when compared with using a full mu agonist opioid for chronic pain preoperatively. This is an outcome that much of the literature heretofore suggests would be unlikely. We review some aspects of
Maynard, Andrew A; Burger, Christina F; Schlesinger, Joseph J
To describe the perioperative management of a patient with acquired angioedema (AAE). A 66-year-old Caucasian male presented from an outside hospital with a history of acquired angioedema and gastrointestinal stromal tumor-related intractable urticaria and mastocytosis. He was admitted for urgent laparoscopic partial gastrectomy, secondary to gastric outlet obstruction symptomatology. Previous combined attacks were characterized by a widespread rash, abdominal pain and respiratory distress resulting in hospitalization. Following preoperative consultation with the patient's allergist and a hospital pharmacist, he was treated preoperatively with fresh frozen plasma and his home prednisone dose. C1-inhibitor (Berinert®) was on standby along with epinephrine, given that the underlying etiology (C1- inhibitor deficiency vs histaminergic) was not known. There were no intraoperative complications, and the patient was discharged home 3 days after the procedure. Optimization of perioperative outcomes in patients, especially during urgent or emergent surgery, with a history of angioedema requires the development of a patient-specific perioperative plan, including prophylaxis, rescue therapies and opioid-sparing strategies.
Eeles, Alex; Baikady, Ravishankar Rao
Anaemia and allogeneic blood transfusions in surgical patients are associated with poor outcomes. Patient blood management (PBM) has been developed as an evidence-based clinical tool, by which clinicians can optimise anaemia, manage peri-operative bleeding, avoid unnecessary blood transfusion and improve patient outcome. This article aims to highlight the recent updates regarding evidence-based PBM in the perioperative period, following a thorough literature review involving original research articles, published guidelines and consensus documents discovered through an extensive PubMed and Medline search. PBM addresses three main pillars of the patient's journey through the pre-operative, intra-operative and post-operative periods. PBM encourages a restrictive approach to transfusion of blood products and promotes alternatives to blood transfusion to maximise clinical efficacy while minimising risks. Anaemia has been identified as an independent risk factor for poor outcomes. PBM highlights the importance of treating anaemia in the pre-operative period. Major elective surgery may be postponed until anaemia is corrected preoperatively. The intra-operative approach to PBM is a collaborative effort between the anaesthesia, surgery and transfusion laboratory teams. Use of tranexamic acid, meticulous haemostasis and cell salvage techniques play an important role during the intra-operative management of surgical and traumatic haemorrhage. Point-of-care coagulation tests with visco-elastographic methods and haemoglobin measurement ensure that the transfusion prescription is tailored to a patient. In the post-operative period, PBM highlights the need for patients to be optimised before discharge from the hospital. Implementation of the PBM has been shown to have individual health as well as economic benefits.
O'Brien, Brid; Andrews, Tom; Savage, Eileen
To explore and explain how nurses minimise risk in the perioperative setting. Perioperative nurses care for patients who are having surgery or other invasive explorative procedures. Perioperative care is increasingly focused on how to improve patient safety. Safety and risk management is a global priority for health services in reducing risk. Many studies have explored safety within the healthcare settings. However, little is known about how nurses minimise risk in the perioperative setting. Classic grounded theory. Ethical approval was granted for all aspects of the study. Thirty-seven nurses working in 11 different perioperative settings in Ireland were interviewed and 33 hr of nonparticipant observation was undertaken. Concurrent data collection and analysis was undertaken using theoretical sampling. Constant comparative method, coding and memoing and were used to analyse the data. Participants' main concern was how to minimise risk. Participants resolved this through engaging in anticipatory vigilance (core category). This strategy consisted of orchestrating, routinising and momentary adapting. Understanding the strategies of anticipatory vigilance extends and provides an in-depth explanation of how nurses' behaviour ensures that risk is minimised in a complex high-risk perioperative setting. This is the first theory situated in the perioperative area for nurses. This theory provides a guide and understanding for nurses working in the perioperative setting on how to minimise risk. It makes perioperative nursing visible enabling positive patient outcomes. This research suggests the need for training and education in maintaining safety and minimising risk in the perioperative setting. © 2017 John Wiley & Sons Ltd.
Md Nazmul Kayes
Full Text Available Diabetes increases the requirements of surgery as well as perioperative morbidity and mortality. Careful preoperative evaluation and treatment of cardiac and renal diseases, intensive intraoperative and postoperative management are essential to optimize the best outcome. Stress hyperglycemia in response to surgery, osmotic diuresis and hypoinsulinemia can lead to life threatening complications like ketoacidosis or hyperglycemic hyperosmolar syndrome. Wound healing is impaired by hyperglycemia and chance of postoperative wound infection is more in diabetics. Therefore aseptic precautions must be taken. Adequate insulin, glucose, fluid and electrolytes should be provided for good metabolic control. Though some current study reveals that oral hypoglycemic agents can be used for the effective management of perioperative diabetes; the adverse effects of newly introduced agents need more clinical observations. Subcutaneous administration of insulin as in Sliding Scale may be a less preferable method, because of unreliable absorption and unpredictable blood glucose. Intravenous administration of rapid onset soluble (short acting insulin as in Alberti (GIK regimen, is safe and effective method controlling perioperative hyperglycemia. Patient with type 1 diabetes needs frequent monitoring of glucose, electrolytes and acid-base balance as chance of high hyperglycemia and ketoacidosis is more. In case of emergency surgery assessment for diabetic ketoacidosis (DKA and meticulous management is essential. Postoperative pain and hyperglycemia should be treated carefully to avoid complications.
Full Text Available Hyperglycemia has long been recognized to have detrimental effects on postoperative outcomes in patients undergoing surgery. The manifestations of uncontrolled diabetes are manifold and can include risk of hyperglycemic crises, postoperative infection, poor wound healing, and increased mortality. There is substantial literature supporting the role of diligent glucose control in the prevention of adverse surgical outcomes, but considerable debate remains as to the optimal glucose targets. Hence, most organizations advocate the avoidance of hypoglycemia while striving for adequate glucose control in the perioperative period. These objectives can be accomplished with careful preoperative evaluation, clear patient instructions the day of surgery, frequent blood glucose monitoring during the perioperative period, and use of effective strategies for insulin initiation and titration. This article highlights the major issues concerning patients with diabetes undergoing surgery and reviews the management recommendations put forth by general consensus guidelines and expert opinion.
Heckmann, Maura; Beauchesne, Michelle A
Identifying existing practices is a first step in the creation of developmentally and culturally effective teaching materials for children and families. This national survey queried two groups to explore current pediatric perioperative education practices: 81 nurses from a perioperative pediatric specialty association and 30 administrators representing leading children's hospitals within the United States. The aim was to improve perioperative care through the design of educational materials from the child's perspective.
Bräuer, Anselm; Perl, Thorsten; English, Michael J M; Quintel, Michael
Perioperative hypothermia remains a common problem during anesthesia and surgery. Unfortunately, the implementation of new minimally invasive surgical procedures has not lead to a reduction of this problem. Heat losses from the skin can be reduced by thermal insulation to avoid perioperative hypothermia. However, only a small amount of information is available regarding the physical properties of insulating materials used in the Operating Room (OR). Therefore, several materials using validated manikins were tested. Heat loss from the surface of the manikin can be described as:"Q = h . DeltaT . A" where Q = heat flux, h = heat exchange coefficient, DeltaT = temperature gradient between the environment and surface, and A = covered area. Heat flux per unit area and surface temperature were measured with calibrated heat flux transducers. Environmental temperature was measured using a thermoanemometer. The temperature gradient between the surface and environment (DeltaT) was varied and "h" was determined by linear regression analysis as the slope of "DeltaT" versus heat flux per unit area. The reciprocal of the heat exchange coefficient defines the insulation. The insulation values of the materials varied between 0.01 Clo (plastic bag) to 2.79 Clo (2 layers of a hospital duvet). Given the range of insulating materials available for outdoor activities, significant improvement in insulation of patients in the OR is both possible and desirable.
Lawn, Joy E; Kinney, Mary V; Belizan, José M; Mason, Elizabeth Mary; McDougall, Lori; Larson, Jim; Lackritz, Eve; Friberg, Ingrid K; Howson, Christopher P
Preterm birth complication is the leading cause of neonatal death resulting in over one million deaths each year of the 15 million babies born preterm. To accelerate change, we provide an overview of the comprehensive strategy required, the tools available for context-specifi c health system implementation now, and the priorities for research and innovation. There is an urgent need for action on a dual track: (1) through strategic research to advance the prevention of preterm birth and (2) improved implementation and innovation for care of the premature neonate. We highlight evidence-based interventions along the continuum of care, noting gaps in coverage, quality, equity and implications for integration and scale up. Improved metrics are critical for both burden and tracking programmatic change. Linked to the United Nation’s Every Women Every Child strategy, a target was set for 50% reduction in preterm deaths by 2025. Three analyses informed this target: historical change in high income countries, recent progress in best performing countries, and modelling of mortality reduction with high coverage of existing interventions. If universal coverage of selected interventions were to be achieved, then 84% or more than 921,000 preterm neonatal deaths could be prevented annually, with antenatal corticosteroids and Kangaroo Mother Care having the highest impact. Everyone has a role to play in reaching this target including government leaders, professionals, private sector, and of course families who are aff ected the most and whose voices have been critical for change in many of the countries with the most progress.
Abrahams, Edward; Foti, Margaret; Kean, Marcia A
Significant progress has been made in the past 50 years across the field of oncology, and, as a result, the number of cancer survivors in the United States is more than 14.5 million. In fact, the number of cancer survivors continues to grow on an annual basis, which is due in part to improved treatments that help people with cancer live longer, and improvements in early detection that allow doctors to find cancer earlier when the disease is easier to treat. However, in spite of this progress, innovation in cancer research and care is at risk as the rise in health care spending is leading to significant pressure to contain costs. As the oncology community seeks to ensure that innovation in cancer research and care continues, it is imperative that stakeholders focus their attention on the value that the research and care continuum provides. Over the past several years, the Turning the Tide Against Cancer initiative has worked with the cancer community to accelerate the delivery of patient-centered, high-quality cancer research and care, while addressing value and cost. This article highlights policy recommendations that resulted from the convening of an expert working group comprising leaders from across the oncology field. Of the recommendations, the co-conveners have identified several issue areas that merit particular focus in 2015: Support FDA's efforts to modernize its framework for bringing new medicines to patients, through facilitating and implementing innovative approaches to drug development and regulatory review. Ensure that cancer clinical pathways or similar decision-support tools are transparent; developed through a physician-driven process that includes patient input; and meet minimum standards for clinical appropriateness, timeliness, and patient centeredness. Support oncology decision-support tools that are timely, clinically appropriate, and patient centered. Build on existing efforts to convene a multistakeholder committee and develop a report on
Jordan, Aubrey L; Rojnica, Marko; Siegler, Mark; Angelos, Peter; Langerman, Alexander
Family members are important in the perioperative care of surgical patients. During the perioperative period, communication about the patient occurs between surgeons and family members. To date, however, surgeon-family perioperative communication remains unexplored in the literature. Surgeons were recruited from the surgical faculty of an academic hospital to participate in an interview regarding their approach to speaking with family members during and immediately after an operative procedure. An iterative process of transcription and theme development among 3 researchers was used to compile a well-defined set of qualitative themes. Thirteen surgeons were interviewed and described what informs their communication, how they practice surgeon-family perioperative communication, and how the skills integral to perioperative communication are taught. Surgeons saw perioperative communication with family members as having a special role of providing support and anxiety alleviation that is distinct from the role of communication during clinic or postoperative visits. Wide variability exists in how interviewed surgeons practice perioperative communication, including who communicates with the family, and the frequency and content of the communication. Surgeons universally reported that residents' instruction in perioperative communication with families was lacking. Surgeons recognize perioperative communication with family members to be a part of their role and responsibility to the patient. However, during the perioperative period, they also acknowledge an independent responsibility to alleviate family members' anxieties. This independent responsibility supports the existence of a distinct "surgeon-family relationship." Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Page, E; Akiboye, F; Jackson, S; Kerry, C; Round, R; Rayman, G
To determine whether a handheld 'perioperative passport' could improve the experience of perioperative care for people with diabetes and overcome some of the communication issues commonly identified in inpatient extracts. Individuals with diabetes undergoing elective surgery requiring at least an overnight stay were identified via a customized information technology system. Those allocated to the passport group were given the perioperative passport before their hospital admission. A 26-item questionnaire was completed after surgery by 50 participants in the passport group (mean age 69 years) and by 35 participants with diabetes who followed the usual surgical pathway (mean age 70 years). In addition, the former group had a structured interview about their experience of the passport. The prevalence of those who reported having received prior information about their expected diabetes care was 35% in the control group vs 92% in the passport group (Phospital (Pdischarge (P≤0.001). The mean length of hospital stay was shorter in the passport group, although the difference did not reach significance (4.4 vs 6.5 days; P<0.058). Content analysis indicated that the passport was well liked and innovative. Our data indicate that the perioperative passport is effective in both informing and involving people in their diabetes care throughout the perioperative period. © 2017 Diabetes UK.
Hofer, SOP; Dhar, BK; Robinson, PH; Goorhuis-Brouwer, SM; Nicolai, JPA
A 10-year retrospective study was undertaken to investigate perioperative complications in pharyngeal flap surgery in one institution using inferiorly and superiorly based flaps. In this fashion the current practice of surgical technique based on local findings and perioperative care, through
Full Text Available Melatonin, a new addition to the armamentarium of anesthesiologist, has some unique properties that are highly desirable in routine peri-operative care. Available clinical data show that preoperative melatonin is as effective as benzodiazepines in reducing preoperative anxiety with minimal action on psychomotor performance and sleep wake cycle. It may be considered as a safe and effective alternative of benzodiazepines as preoperative anxiolytic. It may have opioid sparing effect, may reduce intraocular pressure, and have role in prevention of postoperative delirium. The short-term administration of melatonin is free from significant adverse effects also.
Maitra, Souvik; Baidya, Dalim Kumar; Khanna, Puneet
Melatonin, a new addition to the armamentarium of anesthesiologist, has some unique properties that are highly desirable in routine peri-operative care. Available clinical data show that preoperative melatonin is as effective as benzodiazepines in reducing preoperative anxiety with minimal action on psychomotor performance and sleep wake cycle. It may be considered as a safe and effective alternative of benzodiazepines as preoperative anxiolytic. It may have opioid sparing effect, may reduce intraocular pressure, and have role in prevention of postoperative delirium. The short-term administration of melatonin is free from significant adverse effects also.
PURPOSE OF REVIEW: Recent biochemical evidence increasingly implicates inflammatory mechanisms as precipitants of acute renal failure. In this review, we detail some of these pathways together with potential new therapeutic targets. RECENT FINDINGS: Neutrophil gelatinase-associated lipocalin appears to be a sensitive, specific and reliable biomarker of renal injury, which may be predictive of renal outcome in the perioperative setting. For estimation of glomerular filtration rate, cystatin C is superior to creatinine. No drug is definitively effective at preventing postoperative renal failure. Clinical trials of fenoldopam and atrial natriuretic peptide are, at best, equivocal. As with pharmacological preconditioning of the heart, volatile anaesthetic agents appear to offer a protective effect to the subsequently ischaemic kidney. SUMMARY: Although a greatly improved understanding of the pathophysiology of acute renal failure has offered even more therapeutic targets, the maintenance of intravascular euvolaemia and perfusion pressure is most effective at preventing new postoperative acute renal failure. In the future, strategies targeting renal regeneration after injury will use bone marrow-derived stem cells and growth factors such as insulin-like growth factor-1.
Irizarry-Alvarado, Joan M; Seim, Lynsey A
The prevalence of anticoagulant use has increased in the United States. Medical providers have the responsibility to explain to patients the management of anticoagulant regimens before an invasive procedure. The pharmacologic characteristics of these medications-specifically, their half-lives-are important in timing an interruption of anticoagulant therapy. The authors review the current guidelines and recommendations for therapeutic interruption of anticoagulants and the involved pharmacologic factors. Guidelines and other literature are summarized with discussion of the pharmacology of each medication. Recommendations on how and when to provide bridging for anticoagulants are discussed. Newer oral anticoagulants also are discussed, as well as interruption recommendations. Literature reveals a conservative approach at using bridging when anticoagulation is interrupted because of higher risks of bleeding. Caution is advised when resuming anticoagulant therapy when neuraxial anesthesia is used. Perioperative healthcare providers need to balance risks and benefits of anticoagulant therapy with its interruption preoperatively. Copyright© Bentham Science Publishers; For any queries, please email at email@example.com.
These children may have craniofacial abnormalities and reactive airway disease that may complicate perioperative care. Controversy surrounds the use of sedative premedication as it can affect the evaluation of neurological status, and anaesthetic drug metabolism can be substantially altered by anticonvulsant therapy.2–4.
Introduction: Globally, increasing consideration has been given to the assessment of patient satisfaction as a method of monitor of the quality of health care provision in the health institutions. Perioperative patient satisfaction has been contemplated to be related with the level of postoperative pain intensity, patients' ...
Full Text Available Background: Impaired wound healing is a common complication of diabetes. It has complex pathophysiologic mechanisms and often necessitates amputation. Our study aimed to evaluate the effectiveness of combined laser-puncture and conventional wound care in the treatment of diabetic foot ulcers.Methods: This was a double-blind controlled randomized clinical trial on 36 patients, conducted at the Metabolic Endocrine Outpatient Clinic, Cipto Mangunkusumo Hospital, Jakarta, between May and August 2015. Stimulation by laser-puncture (the treatment group or sham stimulation (the control group were performed on top of the standard wound care. Laser-puncture or sham were done on several acupuncture points i.e. LI4 Hegu, ST36 Zusanli, SP6 Sanyinjiao and KI3 Taixi bilaterally, combined with irradiation on the ulcers itself twice a week for four weeks. The mean reduction in ulcer sizes (week 2–1, week 3–1, week 4–1 were measured every week and compared between the two groups and analyzed by Mann-Whitney test.Results: The initial median ulcer size were 4.75 (0.10–9.94 cm2 and 2.33 (0.90–9.88 cm2 in laser-puncture and sham groups, respectively (p=0.027. The median reduction of ulcer size at week 2–1 was -1.079 (-3.25 to -0.09 vs -0.36 (-0.81 to -1.47 cm2, (p=0.000; at week 3–1 was -1.70 (-3.15 to -0.01 vs -0.36 (-0.80 to -0.28 cm2, (p=0.000; and at week 4–1 was -1.22 (-2.72 to 0.00 vs -0.38 (-0.74 to -0.57 cm2, (p=0.012.Conclusion: Combined laser-puncture and conventional wound care treatment are effective in accelerating the healing of diabetic foot ulcer.
Wahba, R W
The literature dealing with the magnitude, mechanism and effects of reduced FRC in the perioperative period is reviewed. During general anaesthesia FRC is reduced by approximately 20%. The reduction is greater in the obese and in patients with COPD. The most likely mechanism is the loss of inspiratory muscle tone of the muscles acting on the rib cage. Gas trapping is an additional mechanism. Lung compliance decreases and airways resistance increases, in large part, due to decreased FRC. The larynx is displaced anteriorly and elongated, making laryngoscopy and intubation more difficult. The change in FRC creates or increases intrapulmonary shunt and areas of low ventilation to perfusion. This is due to the occurrence of compression atelectasis, and to regional changes in mechanics and airway closure which tend to reduce ventilation to dependent lung zones which are still well perfused. Abdominal and thoracic operations tend to increase shunting further. Large tidal volume but not PEEP will improve oxygenation, although both increase FRC. Both FRC and vital capacity are reduced following abdominal and thoracic surgery in a predictable pattern. The mechanism is the combined effect of incisional pain and reflex dysfunction of the diaphragm. Additional effects of thoracic surgery include pleural effusion, cooling of the phrenic nerve and mediastinal widening. Postoperative hypoxaemia is a function of reduced FRC and airway closure. There is no real difference among the various methods of active lung expansion in terms of the speed of restoration of lung function, or in preventing postoperative atelectasis/pneumonia. Epidural analgesia does not influence the rate of recovery of lung function, nor does it prevent atelectasis/pneumonia.
Full Text Available Cold urticaria consists of an allergic immune response to cold temperatures with symptoms ranging from pruritic wheals to life-threatening angioedema, bronchospasm, or anaphylactic shock. Adequate planning to maintain normothermia perioperatively is vital due to impaired hypothalamic thermoregulation and overall depression of sympathetic outflow during deep sedation and general anesthesia. This case report describes the successful perioperative management of a 45-year-old female with a history of cold urticaria undergoing a laparoscopic Nissen fundoplication for refractory gastroesophageal reflux disease and discusses how to appropriately optimize the care of these patients.
Johnson, Fay; Logsdon, Patty; Fournier, Kim; Fisher, Sandra
Communication breakdown is the leading cause of reported sentinel events in the perioperative setting. Barriers to optimal communication include noise, stress, multitasking, and rapid turnover between procedures. AORN has identified communication during personnel changes (ie, hand offs) as a point of vulnerability for the surgical patient. A standardized hand-off method provides an opportunity for personnel to ask and answer questions and should be available in the perioperative setting. At one facility, the standardization of hand-off reporting resulted in the development of new hand-off tools specific to the perioperative environment. A standardized reporting method enabled health care providers to address communication barriers and to maintain their focus on the patient during critical moments (eg, shift changes), thereby improving patient safety. Copyright © 2013 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Jollis, James G.; Al-Khalidi, Hussein R.; Roettig, Mayme L.; Berger, Peter B.; Corbett, Claire C.; Dauerman, Harold L.; Fordyce, Christopher B.; Fox, Kathleen; Garvey, J. Lee; Gregory, Tammy; Henry, Timothy D.; Rokos, Ivan C.; Sherwood, Matthew W.; Suter, Robert E.; Wilson, B. Hadley; Granger, Christopher B.
Background Up to 50% of patients fail to meet ST-segment elevation myocardial infarction (STEMI) guideline goals recommending a first-medical-contact (FMC)-to-device time of leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical service (EMS) agencies in 16 regions across the United States. Results Between July 2012 and December 2013, 23,809 patients presented with acute STEMI (direct to PCI hospital: 11,765 EMS-transported and 6502 self-transported; transferred: 5542). EMS-transported patients differed from self-transported patients in symptom onset to FMC time (median: 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%) (p<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of FMC-to-device time, including those directly presenting via EMS (50% to 55%; p<0.001) and transferred patients (44% to 48%; p=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most-improved regions, increasing from 45% to 57% (direct EMS; p<0.001), and 38% to 50% (transfers; p<0.001). Conclusions This Mission: Lifeline™ STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on FMC-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to significantly increase the proportion of patients treated within guideline goals. PMID:27482000
Jollis, James G; Al-Khalidi, Hussein R; Roettig, Mayme L; Berger, Peter B; Corbett, Claire C; Dauerman, Harold L; Fordyce, Christopher B; Fox, Kathleen; Garvey, J Lee; Gregory, Tammy; Henry, Timothy D; Rokos, Ivan C; Sherwood, Matthew W; Suter, Robert E; Wilson, B Hadley; Granger, Christopher B
Up to 50% of patients fail to meet ST-segment-elevation myocardial infarction (STEMI) guideline goals recommending a first medical contact-to-device time of leadership teams, coordinated protocols, and provided regular feedback for 484 hospitals and 1253 emergency medical services (EMS) agencies in 16 regions across the United States. Between July 2012 and December 2013, 23 809 patients presented with acute STEMI (direct to percutaneous coronary intervention hospital: 11 765 EMS transported and 6502 self-transported; 5542 transferred). EMS-transported patients differed from self-transported patients in symptom onset to first medical contact time (median, 47 versus 114 minutes), incidence of cardiac arrest (10% versus 3%), shock on admission (11% versus 3%), and in-hospital mortality (8% versus 3%; P<0.001 for all comparisons). There was a significant increase in the proportion of patients meeting guideline goals of first medical contact-to-device time, including those directly presenting via EMS (50% to 55%; P<0.001) and transferred patients (44%-48%; P=0.002). Despite regional variability, the greatest gains occurred among patients in the 5 most improved regions, increasing from 45% to 57% (direct EMS; P<0.001) and 38% to 50% (transfers; P<0.001). This Mission: Lifeline STEMI Systems Accelerator demonstration project represents the largest national effort to organize regional STEMI care. By focusing on first medical contact-to-device time, coordinated treatment protocols, and regional data collection and reporting, we were able to increase significantly the proportion of patients treated within guideline goals. © 2016 American Heart Association, Inc.
Fu, Huiqun; Fan, Long; Wang, Tianlong
The extrinsic risk factors for postoperative cognitive disturbance have been a source of concern during the perioperative period, and these risk factors remain the subject of controversy. This review of recent studies focuses on the effect of these factors on postoperative cognitive disturbance during the perioperative period. Impairment of cerebral autoregulation may predispose patients to intraoperative cerebral malperfusion, which may subsequently induce postoperative cognitive disturbance. The neurotoxicity of several volatile anesthetics may contribute to cognitive functional decline, and the impact of intravenous anesthesia on cognitive function requires further exploration. Multimodal analgesia may not outperform traditional postoperative analgesia in preventing postoperative delirium. Furthermore, acute pain and chronic pain may exacerbate the cognitive functional decline of patients with preexisting cognitive impairment. The nuclear factor-kappa beta pathway is an important node in the neuroinflammatory network. Several intraoperative factors are associated with postoperative cognitive disturbance. However, if these factors are optimized in perioperative management, postoperative cognitive disturbance will improve.
Kozek-Langenecker, Sibylle A; Afshari, Arash; Albaladejo, Pierre
and stabilisation of the macro- and microcirculations in order to optimise the patient's tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject......The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia...
Mariscal, A; Medrano, I Hernández; Cánovas, A Alonso; Lobo, E; Loinaz, C; Vela, L; Espiga, P García-Ruiz; Castrillo, J C Martínez
One of the particular characteristics of Parkinson's disease (PD) is the wide clinical variation as regards the treatment that can be found in the same patient. This occurs with specific treatment for PD, as well as with other drug groups that can make motor function worse. For this reason, the perioperative management of PD requires experience and above all appropriate planning. In this article, the peculiarities of PD and its treatment are reviewed, and a strategy is set out for the perioperative management of these patients. Copyright Â© 2010 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved.
Møller, M H; Adamsen, S; Thomsen, R W
Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU.......Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU....
Sørensen, Erik Elgaard; Olsen, Ida Østrup; Tewes, Marianne
of the longstanding relationship between nursing and technology, it is interesting that few studies with this focus have been performed. Therefore, our research question was: What is the content of perioperative nursing and how do nurses facilitate the interaction between nursing care and technology in highly...... specialized operating rooms in public university hospitals? METHODS: An ethnography involving participant observations and interviews was conducted during a 9-month study period. The participants comprised 24 nurses from 9 different operating wards at 2 university hospitals in different regions of Denmark...... the patients were viewed contributed to the development of three levels of interaction between technology and nursing care: the interaction, declining interaction, and failing interaction levels. CONCLUSION: Nursing practice at the interaction level is characterized by flexibility and excellence, while...
Lynn, Andrew; Brownie, Sonya
The aim of this study was to obtain Perioperative Nurse Surgeon's Assistants' views about their emerging new role in contemporary nursing practice in Australia. Internationally advanced practice nursing has led to a range of specialist roles aimed at delivering higher quality, efficient nursing care. In 2005 an Australian university developed the Perioperative Nurse Surgeon's Assistant graduate education and training program to provide nurses with an opportunity to gain advanced practice knowledge and extended skills specifically in the perioperative setting. This study was a qualitative research design that used online surveys and in-depth interviews to explore the issues and challenges associated with the introduction of the (currently non-accredited) Perioperative Nurse Surgeon's Assistant role in Australia. Experienced Australia perioperative nurses who had undertaken graduate education and training in this field were recruited for this study. Data were collected between August and October 2011. An inductive thematic analysis was used to interpret the findings. Eighteen nurses completed the online survey and six were interviewed (n = 24). Nurses cited their commitment to professional development and the delivery of high quality patient care, along with surgeons' encouragement for them to complete specialist clinical training, as key reasons for undertaking Perioperative Nurse Surgeon's Assistant education and training. The Perioperative Nurse Surgeon's Assistant role led to greater job satisfaction and autonomy, and assisted nurses to better meet the needs of patients, surgeons and clinical perioperative teams. Without formal recognition of the Perioperative Nurse Surgeon's Assistant role its future in the Australian health care system is under threat.
Beydler, Kathy Williams
Many responsibilities of perioperative professionals involve concrete tasks that require high technical competence. Emotional intelligence, referred to as EQ, which involves the ability to relate to and influence others, may also be important for perioperative professionals. High EQ has been linked to higher performance in the workplace, higher job satisfaction, lower turnover intentions, and less burnout. Perioperative professionals who demonstrate a combination of technical skills and EQ could be more attuned to the humanity of health care (ie, providing more holistic care for the patient). Perioperative nurses who value providing holistic care for their patients may possess many of the elements of EQ. Leaders who recognize the importance of their own EQ and actively assist staff members to enhance and develop their EQ competency may help to create a competitive advantage by establishing a workforce of nurses who possess strong technical skills and high EQ. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Stelma Regina Sodré Pontes
Full Text Available OBJETIVO: Avaliar as condições pré-operatórias e o procedimento cirúrgico relacionando-os à morbidade e mortalidade de pacientes cirúrgicos em uma unidade de terapia intensiva geral de um hospital universitário. MÉTODOS: Foram estudados os prontuários de pacientes submetidos a procedimentos cirúrgicos de médio e grande porte, admitidos na unidade de terapia intensiva geral. Foram analisados: dados demográficos, quadro clínico, registros de antecedentes pessoais e exames laboratoriais pré-operatórios e de admissão na unidade de terapia intensiva, exames de imagem, relato operatório, boletim anestésico e antibioticoprofilaxia. Após a admissão, as variáveis estudadas foram: tempo de internação, tipo de suporte nutricional, utilização de tromboprofilaxia, necessidade de ventilação mecânica, descrição de complicações e mortalidade. RESULTADOS: Foram analisados 130 prontuários. A mortalidade foi 23,8% (31 pacientes; Apache II maior do que 40 foi observado em 57 pacientes submetidos à operação de grande porte (64%; a classificação ASA e" II foi observada em 16 pacientes que morreram (51,6%; o tempo de permanência na unidade de terapia intensiva variou de um a nove dias e foi observado em 70 pacientes submetidos à cirurgia de grande porte (78,5%; a utilização da ventilação mecânica por até cinco dias foi observada em 36 pacientes (27,7%; hipertensão arterial sistêmica foi observada em 47 pacientes (47,4%; a complicação mais frequente foi a sepse. CONCLUSÃO: a correta estratificação do paciente cirúrgico determina sua alta precoce e menor exposição a riscos aleatóriosOBJECTIVE: To evaluate the preoperative condition and the surgical procedure of surgical patients in a general intensive care unit of a university hospital, relating them to morbidity and mortality. METHODS: We studied the medical records of patients undergoing medium and large surgical procedures, admitted to the general intensive
The relevant literature since the 1940s has been collected from the Medline database, using the keywords: child, operation, anxiety, distress, postoperative complications, preparation, premedication, parental presence, prevention. Preoperative anxiety, emergence delirium, and postoperative behavior changes are all manifestations of psychological distress in children undergoing surgery. Preoperative anxiety is most prominent during anaesthesia induction. Emergence delirium is frequent and somewhat independent of pain levels. Postoperative behavior changes most often include separation anxiety, tantrums, fear of strangers, eating problems, nightmares, night terrors and bedwetting. These difficulties tend to resolve themselves with time but can last up to one year in some children. The major risk factors for postoperative behavior problems are young age, prior negative experience with hospitals or medical care, certain kinds of hospitalization, postoperative pain, parental anxiety, and certain personality traits of the child. Currently, tools exist for quantifying anxiety (m-YPAS) and postoperative behavior (PHBQ). It is possible to identify those children who are at risk for postoperative complications during the preanaesthesia consultation by paying close attention to children under six years with higher levels of emotionality and impulsivity and poorer socialization skills with anxious parents. Suggested strategies for reducing child distress include preoperative preparation, premedication, parental presence during anaesthesia induction, and interventions affecting the child's environment, such as hypnosis. There are numerous ways to provide preoperative preparation (information, modeling, role playing, encouraging effective coping) and their effectiveness is proven in the preoperative setting but not during anaesthesia induction or in the operating room. Midazolam has been shown to be an effective preoperative sedative for reducing anxiety. Parental presence
Pettigrew, Melinda M; Forman, Howard P; Pistell, Anne F; Nembhard, Ingrid M
Increasingly, there is recognition of the need for individuals with expertise in both management and public health to help health care organizations deliver high-quality and cost-effective care. The Yale School of Public Health and Yale School of Management began offering an accelerated Master of Business Administration (MBA) and Master of Public Health (MPH) joint degree program in the summer of 2014. This new program enables students to earn MBA and MPH degrees simultaneously from 2 fully accredited schools in 22 months. Students will graduate with the knowledge and skills needed to become innovative leaders of health care organizations. We discuss the rationale for the program, the developmental process, the curriculum, benefits of the program, and potential challenges.
Conclusion: Recipients who did or did not develop ALI after liver transplantation had a longer mechanical ventilation duration and showed different patterns of perioperative thoracic fluid indices, especially in the pretransplant status of PVPI level. Knowledge of these perioperative changes may provide clinicians with helpful information to make postoperative care choices.
Subramani, Yamini; Wong, Jean; Nagappa, Mahesh; Chung, Frances
Obstructive sleep apnea (OSA) is a chronic disease affecting millions of people worldwide. Untreated OSA can lead to about a 2-fold increase in medical expenses, mainly because of cardiovascular morbidity. OSA is highly prevalent in the surgical population, with an increased risk of perioperative complications. This article describes the perioperative and long-term social and economic benefits of preoperative screening for OSA. Screening patients to identify high-risk OSA is important to decrease the adverse outcomes and associated health care costs in the perioperative period. Screening for OSA is particularly relevant because most patients are undiagnosed at the time of surgery. Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available Hypertrophic cardiomyopathy with or without left ventricular outflow tract obstruction is characterized by asymmetric hypertrophy of the interventricular septum causing intermittent obstruction of the left ventricular outflow tract. Because Hypertrophic cardiomyopathy is the most common genetic cardiovascular disease, it may present to the anesthesiologist more often than anticipated, sometimes in undiagnosed form during routine preoperative visit. Surgery and anesthesia often complicate the perioperative outcome if adequate monitoring and proper care are not taken. Therefore, a complete understanding of the pathophysiology, hemodynamic changes and anesthetic implications is needed for successful perioperative outcome. We hereby describe the perioperative management of three patients with Hypertrophic cardiomyopathy for different surgical procedures.
Stevens, Wendy S; Gous, Natasha M; MacLeod, William B; Long, Lawrence C; Variava, Ebrahim; Martinson, Neil A; Sanne, Ian; Osih, Regina; Scott, Lesley E
Lack of accessible laboratory infrastructure limits HIV antiretroviral therapy (ART) initiation, monitoring, and retention in many resource-limited settings. Point-of-care testing (POCT) is advocated as a mechanism to overcome these limitations. We executed a pragmatic, prospective, randomized, controlled trial comparing the impact of POCT vs. standard of care (SOC) on treatment initiation and retention in care. Selected POC technologies were embedded at 3 primary health clinics in South Africa. Confirmed HIV-positive participants were randomized to either SOC or POC: SOC participants were venesected and specimens referred to the laboratory with patient follow-up as per algorithm (∼3 visits); POC participants had phlebotomy and POCT immediately on-site using Pima CD4 to assess ART eligibility followed by hematology, chemistry, and tuberculosis screening with the goal of receiving same-day adherence counseling and treatment initiation. Participant outcomes measured at recruitment 6 and 12 months after initiation. Four hundred thirty-two of 717 treatment eligible participants enrolled between May 2012 and September 2013: 198 (56.7%) SOC; 234 (63.6%) POC. Mean age was 37.4 years; 60.5% were female. Significantly more participants were initiated using POC [adjusted prevalence ratio (aPR) 0.83; 95% confidence interval (CI): 0.74 to 0.93; P ART was similar for both arms at 6 months (47 vs. 50%) (aPR 0.96; 95% CI: 0.79 to 1.16) and 12 months (32 vs. 32%) (aPR 1.05; 95% CI: 0.80 to 1.38), with similar mortality rates. Loss to follow-up at 12 months was higher for POC (36% vs. 51%) (aPR 0.82; 95% CI: 0.65 to 1.04). Adoption of POCT accelerated ART initiation but once on treatment, there was unexpectedly higher loss to follow-up on POC and no improvement in outcomes at 12 months over SOC.
Davis, Janice L; Doyle, Robert
Economic challenges compel pediatric perioperative departments to reduce nonlabor supply costs while maintaining the quality of patient care. Optimization of the supply chain introduces a framework for decision making that drives fiscally responsible decisions. The cost-effective supply chain is driven by implementing a value analysis process for product selection, being mindful of product sourcing decisions to reduce supply expense, creating logistical efficiency that will eliminate redundant processes, and managing inventory to ensure product availability. The value analysis approach is an analytical methodology for product selection that involves product evaluation and recommendation based on consideration of clinical benefit, overall financial impact, and revenue implications. Copyright © 2011 AORN, Inc. Published by Elsevier Inc. All rights reserved.
... across the HIV care continuum. (a) Membership. The Working Group shall be co- chaired by the Director of... increased coordination, collaboration, and accountability across executive departments and agencies... and move closer to an AIDS-free generation. Sec. 2. Establishment of the HIV Care Continuum Initiative...
Dean, Sohni V; Lassi, Zohra S; Imam, Ayesha M; Bhutta, Zulfiqar A
Preconception care includes any intervention to optimize a woman's health before pregnancy with the aim to improve maternal, newborn and child health (MNCH) outcomes. Preconception care bridges the gap in the continuum of care, and addresses pre-pregnancy health risks and health problems that could have negative maternal and fetal consequences. It therefore has potential to further reduce global maternal and child mortality and morbidity, especially in low-income countries where the highest burden of pregnancy-related deaths and disability occurs. A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on MNCH outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture. Women who received preconception care in either a healthcare center or the community showed improved outcomes, such as smoking cessation; increased use of folic acid; breastfeeding; greater odds of obtaining antenatal care; and lower rates of neonatal mortality. Preconception care is effective in improving pregnancy outcomes. Further studies are needed to evaluate consistency and magnitude of effect in different contexts; develop and assess new preconception interventions; and to establish guidelines for the provision of preconception care.
Full Text Available Jorinde AW Polderman, Robert van Wilpe, Jan H Eshuis, Benedikt Preckel, Jeroen Hermanides Department of Anaesthesiology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands Abstract: Given the growing number of patients with diabetes mellitus (DM and the growing number of surgical procedures performed in an ambulatory setting, DM is one of the most encountered comorbidities in patients undergoing ambulatory surgery. Perioperative management of ambulatory patients with DM requires a different approach than patients undergoing major surgery, as procedures are shorter and the stress response caused by surgery is minimal. However, DM is a risk factor for postoperative complications in ambulatory surgery, so should be managed carefully. Given the limited time ambulatory patients spend in the hospital, improvement in management has to be gained from the preanesthetic assessment. The purpose of this review is to summarize current literature regarding the anesthesiologic management of patients with DM in the ambulatory setting. We will discuss the risks of perioperative hyperglycemia together with the pre-, intra-, and postoperative considerations for these patients when encountered in an ambulatory setting. Furthermore, we provide recommendations for the optimal perioperative management of the diabetic patient undergoing ambulatory surgery. Keywords: diabetes mellitus, perioperative period, ambulatory surgery, insulin, complications, GLP-1 agonist, DPP-4 inhibitor
Kotler, Howard S
To construct a reliable, accurate, and easy-to-use handheld computer database that facilitates the point-of-care acquisition of perioperative text and image data specific to rhinoplasty. A user-modified database (Pendragon Forms [v.3.2]; Pendragon Software Corporation, Libertyville, Ill) and graphic image program (Tealpaint [v.4.87]; Tealpaint Software, San Rafael, Calif) were used to capture text and image data, respectively, on a Palm OS (v.4.11) handheld operating with 8 megabytes of memory. The handheld and desktop databases were maintained secure using PDASecure (v.2.0) and GoldSecure (v.3.0) (Trust Digital LLC, Fairfax, Va). The handheld data were then uploaded to a desktop database of either FileMaker Pro 5.0 (v.1) (FileMaker Inc, Santa Clara, Calif) or Microsoft Access 2000 (Microsoft Corp, Redmond, Wash). Patient data were collected from 15 patients undergoing rhinoplasty in a private practice outpatient ambulatory setting. Data integrity was assessed after 6 months' disk and hard drive storage. The handheld database was able to facilitate data collection and accurately record, transfer, and reliably maintain perioperative rhinoplasty data. Query capability allowed rapid search using a multitude of keyword search terms specific to the operative maneuvers performed in rhinoplasty. Handheld computer technology provides a method of reliably recording and storing perioperative rhinoplasty information. The handheld computer facilitates the reliable and accurate storage and query of perioperative data, assisting the retrospective review of one's own results and enhancement of surgical skills.
Ahuja, Kartikya; Charap, Mitchell H
Hypertension is the major risk factor for cardiovascular (CV) disease such as myocardial infarction (MI) and stroke. This risk is well known to extend into the perioperative period. Although most perioperative hypertension can be managed with the patient's outpatient regimen, there are situations in which oral medications cannot be administered and parenteral medications become necessary. They include postoperative nil per os status, severe pancreatitis, and mechanical ventilation. This article reviews the management of perioperative hypertensive urgency with parenteral medications. A PubMed search was conducted by cross-referencing the terms "perioperative hypertension," "hypertensive urgency," "hypertensive emergency," "parenteral anti-hypertensive," and "medication." The search was limited to English-language articles published between 1970 and 2008. Subsequent PubMed searches were performed to clarify data from the initial search. As patients with hypertensive urgency are not at great risk for target-organ damage (TOD), continuous infusions that require intensive care unit (ICU) monitoring and intraarterial catheters seem to be unnecessary and a possible misuse of resources. When oral therapy cannot be administered, patients with hypertensive urgency can have their blood pressure (BP) reduced with hydralazine, enalaprilat, metoprolol, or labetalol. Due to the scarcity of comparative trials looking at clinically significant outcomes, the medication should be chosen based on comorbidity, efficacy, toxicity, and cost.
Renew, J Ross
Coronary artery disease is a common comorbidity encountered during the perioperative period. Whether patients are scheduled for cardiac or noncardiac surgery, this cardiovascular disease must be addressed in the preoperative period to decrease the accompanying risks and potential postoperative problems. Lipid-lowering medications are often used to treat hyperlipidemia, a risk factor for the development of atherosclerosis and coronary artery disease. To discuss the medications most commonly used to treat hyperlipidemia and to describe strategies for handling these treatment regimens in the perioperative period. I conducted an online search of studies and review articles through PubMed and Medline that addressed pharmacology and perioperative management of hyperlipidemia medications. Statins are the most commonly prescribed lipid-lowering agents, with benefits that extend beyond correcting lipid levels. However, statins can have clinically significant adverse effects that may necessitate the use of other lipid-lowering medications with different mechanisms of action. Alternative medications such as nicotinic acid and omega-3 fatty acids should be withheld in the preoperative period because these agents have been associated with hypotension and increased bleeding. Clinicians must be familiar with the various lipid-lowering agents because it is very likely they will encounter such medications during preoperative visits. Copyright© Bentham Science Publishers; For any queries, please email at firstname.lastname@example.org.
Burger, Leona; Fitzpatrick, Jane
All patients undergoing surgery are at risk of developing hypothermia; up to 70% develop hypothermia perioperatively. Inadvertent hypothermia is associated with complications such as impaired wound healing, increased blood loss, cardiac arrest and increased risk of wound infection. Anaesthesia increases the risk as the normal protective shivering reflex is absent. Ambient temperature also has a major effect on the patient's body temperature. Prevention of hypothermia not only reduces the incidence of complications, but patients also experience a greater level of comfort, and avoid postoperative shivering and the unpleasant sensation of feeling cold. Nurses should be aware of the risks of hypothermia so that preventative interventions can be employed to minimize the risk of hypothermia. Preoperative assessment is essential to enable identification of at-risk patients. Simple precautionary measures initiated by nurses can considerably reduce the amount of heat lost, minimize the risk of associated complications and ultimately improve patients' short- and long-term recovery. Minimizing skin exposure, providing adequate bed linen for the transfer to theatre and educating patients about the importance of keeping warm perioperatively are all extremely important. It is also worth considering using forced-air warmers preoperatively as research suggests that initiating active warming preoperatively may be successful in preventing hypothermia during the perioperative period.
Lillemor Lindwall; Iréne von Post
Aim: The aim of the study was to describe how the basic concepts, human being, health, suffering, caring and culture appear in perioperative practice in order to obtain an understanding of the concepts in practice.Methods: A hermeneutic text interpretation of results from ten previous studies and reports from perioperative research meetings with co-researchers was conducted in order to gain an understanding ofthe concepts in practice.Results: The basic concepts were understood as; The human b...
The development of accelerator technology in Poland is strictly combined with the cooperation with specialist accelerator centers of global character, where the relevant knowledge is generated, allowing to build big and modern machines. These are relatively costly undertakings of interdisciplinary character. Most of them are financed from the local resources. Only the biggest machines are financed commonly by many nations like: LHC in CERN, ILC in Fermi Lab, E-XFEL in DESY. A similar financing solution has to be implemented in Poland, where a scientific and political campaign is underway on behalf of building two big machines, a Polish Synchrotron in Kraków and a Polish FEL in Świerk. Around these two projects, there are realized a dozen or so smaller ones.
The development of accelerator technology in Poland is strictly combined with the cooperation with specialist accelerator centers of global character, where the relevant knowledge is generated, allowing to build big and modern machines. These are relatively costly undertakings of interdisciplinary character. Most of them are financed from the local resources. Only the biggest machines are financed commonly by many nations like: LHC in CERN, ILC in Fermi Lab, E-XFEL in DESY. A similar financing solution has to be implemented in Poland, where a scientific and political campaign is underway on behalf of building two big machines, a Polish Synchrotron in Kraków and a Polish FEL in Świerk. Around these two projects, there are realized a dozen or so smaller ones.
Keegan, Mark T.; Goldberg, Michael E.; Torjman, Marc C.; Coursin, Douglas B
Patients with dysglycemia related to known or unrecognized diabetes, stress hyperglycemia, or hypoglycemia in the presence or absence of exogenous insulin routinely require care during the perioperative period or critical illness. Recent single and multicenter studies, a large multinational study, and three meta-analyses evaluated the safety of routine tight glycemic control (80–110 mg/dl) in critically ill adults. Results led to a call for more modest treatment goals (initiation of insulin a...
Martin, Karen K
The staffing challenges faced by perioperative nurse managers today are not easily met by waiting for experienced perioperative nurses to apply for positions. As Baby Boomer nurses retire, managers must consider hiring and orienting new graduates and nurses experienced in other subspecialties who are interested in working in the OR. An effective didactic and clinical education program can produce nurses with a basic perioperative knowledge from which they can build a solid clinical practice. Using Periop 101: A Core Curriculum™, the director of perioperative services at a level II trauma center implemented a successful program to solve a staffing need and help students gain the knowledge and skills necessary to become effective perioperative nurses. Strong interest from capable applicants, a dedicated educator, and financial resources and support from hospital administrators helped make this program a viable way to staff the OR. Copyright © 2011 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Rosenstein, Alan H; O'Daniel, Michelle
There is a growing concern about the role of human factor issues and their effect on patient safety and clinical outcomes of care. Problems with disruptive behaviors negatively affect communication flow and team dynamics, which can lead to adverse events and poor quality outcomes. A 25-question survey tool was used to assess the status and significance of disruptive behaviors around perioperative services in a large metropolitan academic medical center. Results were analyzed and compared with those from a national databank to identify areas of concern and opportunities for improvement. Disruptive behaviors were a common occurrence in the perioperative setting. These types of behaviors were most prevalent in attending surgeons. Disruptive behaviors increased levels of stress and frustration, which impaired concentration, impeded communication flow, and adversely affected staff relationships and team collaboration. These events were perceived to increase the likelihood of medical errors and adverse events and to compromise patient safety and quality of care. Disruptive behaviors in the perioperative arena have a significant impact on team dynamics and communication flow, which can have a negative impact on patient care. Organizations need to recognize the prevalence and significance of disruptive behaviors and develop policies and processes to address the issue. Key areas of focus include recognition and awareness, organizational and cultural commitment, implementation of appropriate codes of behavior policies and procedures, and provision of education and training programs to discuss contributing factors and tools to build effective communication and team collaboration skills.
Arnold, Brook; Elliott, Anila; Laohamroonvorapongse, Dean; Hanna, John; Norvell, Daniel; Koh, Jeffrey
Children with autism spectrum disorders (ASD) are an increasingly common patient population in the perioperative setting. Children with ASD present with abnormal development in social interaction, communication, and stereotyped patterns of behavior and may be more prone to elevated perioperative anxiety. The perioperative experience for these patients is complex and presents a unique challenge for clinicians. The aim of the current study was to provide a further understanding of the premedication patterns and perioperative experiences of children with ASD in comparison to children without ASD. Using a retrospective cohort study design, medical records were evaluated for patients with and without ASD undergoing general anesthesia for dental rehabilitation from 2006-2011. The following objectives were measured and compared: (i) premedication patterns and (ii) complications, pain, anesthetic type, PACU time, and time to discharge. To compare categorical variables, the chi-square test was used. Bivariate and multivariable analyses were performed to control for potential confounding as a result of baseline differences between the two groups. A total of 121 ASD patients and 881 non-ASD patients were identified. When controlling for age, weight, and gender, children in the ASD group were more likely to have nonstandard premedication types (P < 0.0001), while children without ASD were more likely to have standard premedication types (P < 0.0001). No significant group differences were identified in regards to the other outcome measures. Other than a significant difference in the premedication type and route, we found that children with ASD seemed to have similar perioperative experiences as non-ASD subjects. It was especially interesting to find that their postoperative period did not pose any special challenges. There is much to be learned about this unique patient population, and a more in-depth prospective evaluation is warranted to help better delineate the best
Miller, Timothy E.; Shaw, Andrew D.; Mythen, Michael G; Gan, Tong J
The 1st POQI Consensus Conference occurred in Durham, NC, on March 4?5, 2016, and was supported by the American Society of Enhanced Recovery (ASER) and Evidence-Based Perioperative Medicine (EBPOM). The conference focused on enhanced recovery for colorectal surgery and discussed four topics?perioperative analgesia, perioperative fluid management, preventing nosocomial infection, and measurement and quality in enhanced recovery pathways.
... Location: The first ADS will be held at the Doubletree by Hilton, Minneapolis-Park Place, 1500 Park Place...; the clinical and operating challenge of transforming care delivery, including use of health IT; the...
Alderson, Phil; Campbell, Gillian; Smith, Andrew F; Warttig, Sheryl; Nicholson, Amanda; Lewis, Sharon R
Inadvertent perioperative hypothermia occurs because of interference with normal temperature regulation by anaesthetic drugs and exposure of skin for prolonged periods. A number of different interventions have been proposed to maintain body temperature by reducing heat loss. Thermal insulation, such as extra layers of insulating material or reflective blankets, should reduce heat loss through convection and radiation and potentially help avoid hypothermia. To assess the effects of pre- or intraoperative thermal insulation, or both, in preventing perioperative hypothermia and its complications during surgery in adults. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 2), MEDLINE, OvidSP (1956 to 4 February 2014), EMBASE, OvidSP (1982 to 4 February 2014), ISI Web of Science (1950 to 4 February 2014), and CINAHL, EBSCOhost (1980 to 4 February 2014), and reference lists of articles. We also searched Current Controlled Trials and ClinicalTrials.gov. Randomized controlled trials of thermal insulation compared to standard care or other interventions aiming to maintain normothermia. Two authors extracted data and assessed risk of bias for each included study, with a third author checking details. We contacted some authors to ask for additional details. We only collected adverse events if reported in the trials. We included 22 trials, with 16 trials providing data for some analyses. The trials varied widely in the type of patients and operations, the timing and measurement of temperature, and particularly in the types of co-interventions used. The risk of bias was largely unclear, but with a high risk of performance bias in most studies and a low risk of attrition bias. The largest comparison of extra insulation versus standard care had five trials with 353 patients at the end of surgery and showed a weighted mean difference (WMD) of 0.12 ºC (95% CI -0.07 to 0.31; low quality evidence). Comparing extra insulation
A special-investigations unit is helping the Ontario Health Insurance Plan (OHIP) curb the fraud and abuse that has been draining millions of health care dollars from the province. The government is taking a tougher line on foreigners who use friends' or relatives' OHIP cards, people who use misplaced, stolen or counterfeit cards, and on snowbirds who deliberately bend residency requirements as they try to hang on to medicare benefits. In 1994-95, Ontario spent $74 million on health care for ...
Leong, Katharina Brigitte Margarethe Siew Lan; Hanskamp-Sebregts, Mirelle; van der Wal, Raymond A; Wolff, Andre P
This study was carried out to improve patient safety in the operating theatre by the introduction of perioperative briefing and debriefing, which focused on an optimal collaboration between surgical team members. A prospective intervention study with one pretest and two post-test measurements: 1 month before and 4 months and 2.5 years after the implementation of perioperative briefing and debriefing, respectively. Operating theatres of a tertiary care hospital with 875 beds in the Netherlands. All members of five surgical teams participated in the perioperative briefing and debriefing. The implementation of perioperative briefing and debriefing from July 2012 to January 2014. The primary outcome was changes in the team climate, measured by the Team Climate Inventory. Secondary outcomes were the experiences of surgical teams with perioperative briefing and debriefing, measured with a structured questionnaire, and the duration of the briefings, measured by an independent observer. Two and a half years after the introduction of perioperative briefing and debriefing, the team climate increased statistically significant (p≤0.05). Members of the five surgical teams strongly agreed with the positive influence of perioperative briefing and debriefing on clear agreements and reminding one another of the agreements of the day. They perceived a higher efficiency of the surgical programme with more operations starting on time and less unexpectedly long operation time. The perioperative briefing took less than 4 min to conduct. Perioperative briefing and debriefing improved the team climate of surgical teams and the efficiency of their work within the operating theatre with acceptable duration per briefing. Surgical teams with alternating team compositions have the most benefit of briefing and debriefing. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise
Dyke, Cornelius; Aronson, Solomon; Dietrich, Wulf; Hofmann, Axel; Karkouti, Keyvan; Levi, Marcel; Murphy, Gavin J.; Sellke, Frank W.; Shore-Lesserson, Linda; von Heymann, Christian; Ranucci, Marco
Perioperative bleeding is common among patients undergoing cardiac surgery; however, the definition of perioperative bleeding is variable and lacks standardization. We propose a universal definition for perioperative bleeding (UDPB) in adult cardiac surgery in an attempt to precisely describe and
Boivin, Ariane; Antonelli, Richard; Sethna, Navil F
In past decades, Duchenne muscular dystrophy patients have been living longer and as the disease advances, patients experience multisystemic deterioration. Older patients often require gastrostomy tube placement for nutritional support. For optimizing the perioperative care, a practice of multidisciplinary team can better anticipate, prevent, and manage possible complications and reduce the overall perioperative morbidity and mortality. The aim of this study was to review our experience with perioperative care of adolescent and young adults with Duchenne muscular dystrophy undergoing gastrostomy by various surgical approaches in order to identify challenges and improve future perioperative care coordination to reduce morbidity. We retrospectively examined cases of gastrostomy tube placement in patients of ages 15 years and older between 2005 and 2016. We reviewed preoperative evaluation, anesthetic and surgical management, and postoperative complications. Twelve patients were identified; 1 had open gastrostomy, 3 laparoscopic gastrostomies, 5 percutaneous endoscopic guided, and 3 radiologically inserted gastrostomy tubes. All patients had preoperative cardiac evaluation with 6 patients demonstrating cardiomyopathy. Nine patients had preoperative pulmonary consultations and the pulmonary function tests reported forced vital capacity of ≤36% of predicted. Eight patients were noninvasive positive pressure ventilation dependent. General anesthesia with tracheal intubation was administered in 8 patients, and intravenous sedation in 4 patients; 1 received sedation supplemented with regional anesthesia and 3 received deep sedation. One patient had a difficult intubation that resulted in trauma and prolonged tracheal intubation. Three patients developed postoperative respiratory complications. Two patients' procedures were postponed due to inadequate preoperative evaluation and 1 because of disagreement between anesthesia and procedural services as to the optimal
Poor communication in the perioperative setting contributes to an unsafe OR culture and affects patient safety and employee engagement, decision making, productivity, morale, and retention. Communication breakdowns can lead to surgical delays, patient inconvenience, and serious errors. Simplification and standardization of communication processes and the use of effective communication skills (eg, clear verbal communication, awareness of the effects of nonverbal communication, use of listening and conflict management skills) are ways to improve OR interactions and minimize or prevent errors. Copyright © 2011 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Fesler-Birch, Diane M
The purpose of this quantitative descriptive correlational study was to assess for presence and degree of critical thinking skills among perioperative (OR) nurses. Critical thinking has become a multidisciplinary "buzz phrase"; however, critical thinking, reflective thinking, or mental discipline was discussed among educators, as early as 1912. As nurses' roles change in response to the dynamics of managed care and an increase in use of biotechnology in health care, more is expected of nurses in terms of both psychomotor and cognitive skills. Thus, critical thinking may be central to nurses' ability to meet the care expectations of patients and the skill expectations of managers, peers, and themselves. Data collected from 1 university-affiliated medical center, 1 non-university-affiliated medical center, and 3 ambulatory surgicenters. Data were collected over a 12-month period from 2008 to 2009. Convenience sample of 92 OR nurses. The sample comprised nurses with various educational levels for entry into practice: diploma, associate, and bachelor of science in nursing degrees. Subjects' clinical experience ranged from 1 month to 40 years. Administered California Critical Thinking Disposition Inventory; Assessment of Critical Thinking Skills of Perioperative Nurses, an investigator-developed tool; and a demographic survey. Descriptive statistics, multiple regression, and step-wise regression were performed; power of 80% with a medium effect size was calculated. Aggregate (N = 92) for the dependent variable (level of critical thinking)and predictor variables (dispositions) were not significant. The group (medical center 1) indicated that as the level of critical thinking increased, the level of truth increased. Also, as the level of critical thinking increased, the level of open-mindedness decreased. In groups 2, 4, and 5 (surgicenters) coefficient indicated that none of the predictors were significant. A stepwise regression was calculated for group 3 (medical center
Garg, Amit X; Kurz, Andrea; Sessler, Daniel I
IMPORTANCE: Acute kidney injury, a common complication of surgery, is associated with poor outcomes and high health care costs. Some studies suggest aspirin or clonidine administered during the perioperative period reduces the risk of acute kidney injury; however, these effects are uncertain...... and each intervention has the potential for harm. OBJECTIVE: To determine whether aspirin compared with placebo, and clonidine compared with placebo, alters the risk of perioperative acute kidney injury. DESIGN, SETTING, AND PARTICIPANTS: A 2 × 2 factorial randomized, blinded, clinical trial of 6905...... patients undergoing noncardiac surgery from 88 centers in 22 countries with consecutive patients enrolled between January 2011 and December 2013. INTERVENTIONS: Patients were assigned to take aspirin (200 mg) or placebo 2 to 4 hours before surgery and then aspirin (100 mg) or placebo daily up to 30 days...
Full Text Available Modern surgery is faced with the emergence of newer “risk factors” and the challenges associated with identifying and managing these risks in the perioperative period. Obstructive sleep apnea and obesity hypoventilation syndrome pose unique challenges in the perioperative setting. Recent studies have identified some of the specific risks arising from caring for such patients in the surgical setting. While all possible postoperative complications are not yet fully established or understood, the prevention and management of these complications pose even greater challenges. Pulmonary hypertension with its changing epidemiology and novel management strategies is another new disease for the surgeon and the anesthesiologist in the noncardiac surgical setting. Traditionally most such patients were not considered surgical candidates for any required elective surgery. Our review discusses these disease entities which are often undiagnosed before elective noncardiac surgery.
The growing prevalence of atherosclerosis means that perioperative myocardial infarction (PMI) is of significant concern to anesthesiologists. Perioperative revascularization (if indicated medically), beta blockade (in high risk patients) and statin therapy are therapeutic modalities that are currently employed to reduce PMI.
Duncan, Andra E.
Hyperglycemia is associated with increased mortality and morbidity in critically ill patients. Surgical patients commonly develop hyperglycemia related to the hypermetabolic stress response, which increases glucose production and causes insulin resistance. Although hyperglycemia is associated with worse outcomes, the treatment of hyperglycemia with insulin infusions has not provided consistent benefits. Despite early results, which suggested decreased mortality and other advantages of “tight” glucose control, later investigations found no benefit or increased mortality when hyperglycemia was aggressively treated with insulin. Because of these conflicting data, the optimal glucose concentration to improve outcomes in critically ill patients is unknown. There is agreement, however, that hypoglycemia is an undesirable complication of intensive insulin therapy and should be avoided. In addition, the risk of increased glucose variability should be recognized, because of the associated increased risk for worse outcomes. Patients with diabetes mellitus experience chronic hyperglycemia and often require more intensive perioperative glucose management. When diabetic patients are evaluated before surgery, appropriate management of oral hypoglycemic agents is necessary as several of these agents warrant special consideration. Current recommendations for perioperative glucose management from national societies are varied, but, most suggest that tight glucose control may not be beneficial, while mild hyperglycemia appears to be well-tolerated. PMID:22762467
Devred, Arnaud; Baynham, D Elwyn; Boutboul, T; Canfer, S; Chorowski, M; den Ouden, A; Fabbricatore, P; Farinon, S; Fessia, P; Fydrych, J; Félice, H; Greco, Michela; Greenhalgh, J; Leroy, D; Loveridge, P W; Michel, F; Oberli, L R; Pedrini, D; Polinski, J; Previtali, V; Quettier, L; Rifflet, J M; Rochford, J; Rondeaux, F; Sanz, S; Sgobba, Stefano; Sorbi, M; Toral-Fernandez, F; Van Weelderen, R; Vincent-Viry, O; Volpini, G; Védrine, P
Plans for LHC upgrade and for the final focalization of linear colliders call for large aperture and/or high-performance dipole and quadrupole magnets that may be beyond the reach of conventional NbTi magnet technology. The Next European Dipole (NED) activity was launched on January 1st, 2004 to promote the development of high-performance, Nb3Sn wires in collaboration with European industry (aiming at a non-copper critical current density of 1500Â A/mm2 at 4.2 K and 15 T) and to assess the suitability of Nb3Sn technology to the next generation of accelerator magnets (aiming at an aperture of 88 mm and a conductor peak field of 15 T). It is integrated within the Collaborated Accelerator Research in Europe (CARE) project, involves seven collaborators, and is partly funded by the European Union. We present here an overview of the NED activity and we report on the status of the various work packages it encompasses.
Wennström, Berith; Hallberg, Lillemor R-M; Bergh, Ingrid
This paper is a report of a study to explore what it means for children to attend hospital for day surgery. Hospitalization is a major stressor for children. Fear of separation, unfamiliar routines, anaesthetic/operation expectations/experiences and pain and needles are sources of children's negative reactions. A grounded theory study was carried out during 2005-2006 with 15 boys and five girls (aged 6-9 years) scheduled for elective day surgery. Data were collected using tape-recorded interviews that included a perioperative dialogue, participant observations and pre- and postoperative drawings. A conceptual model was generated on the basis of the core category 'enduring inflicted hospital distress', showing that the main problem for children having day surgery is that they are forced into an unpredictable and distressful situation. Pre-operatively, the children do not know what to expect, as described in the category 'facing an unknown reality'. Additional categories show that they perceive a 'breaking away from daily routines' and that they are 'trying to gain control' over the situation. During the perioperative period, the categories 'losing control' and 'co-operating despite fear and pain' are present and intertwined. Post-operatively, the categories 'breathing a sigh of relief' and 'regaining normality in life' emerged. The perioperative dialogue used in our study, if translated into clinical practice, might therefore minimize distress and prepare children for the 'unknown' stressor that hospital care often presents. Further research is needed to compare anxiety and stress levels in children undergoing day surgery involving the perioperative dialogue and those having 'traditional' anaesthetic care.
Parston, Greg; McQueen, Julie; Patel, Hannah; Keown, Oliver P; Fontana, Gianluca; Al Kuwari, Hanan; Al Kuwari, Hannan; Darzi, Ara
There is a widely acknowledged time lag in health care between an invention or innovation and its widespread use across a health system. Much is known about the factors that can aid the uptake of innovations within discrete organizations. Less is known about what needs to be done to enable innovations to transform large systems of health care. This article describes the results of in-depth case studies aimed at assessing the role of key agents and agencies that facilitate the rapid adoption of innovations. The case studies-from Argentina, England, Nepal, Singapore, Sweden, the United States, and Zambia-represent widely varying health systems and economies. The implications of the findings for policy makers are discussed in terms of key factors within a phased approach for creating a climate for change, engaging and enabling the whole organization, and implementing and sustaining change. Purposeful and directed change management is needed to drive system transformation. Project HOPE—The People-to-People Health Foundation, Inc.
DePasse, Jacqueline W; Carroll, Ryan; Ippolito, Andrea; Yost, Allison; Santorino, Data; Chu, Zen; Olson, Kristian R
Medical technology offers enormous potential for scalable medicine--to improve the quality and access in health care while simultaneously reducing cost. However, current medical device innovation within companies often only offers incremental advances on existing products, or originates from engineers with limited knowledge of the clinical complexities. We describe how the Hacking Medicine Initiative, based at Massachusetts Institute of Technology has developed an innovative "healthcare hackathon" approach, bringing diverse teams together to rapidly validate clinical needs and develop solutions. Hackathons are based on three core principles; emphasis on a problem-based approach, cross-pollination of disciplines, and "pivoting" on or rapidly iterating on ideas. Hackathons also offer enormous potential for innovation in global health by focusing on local needs and resources as well as addressing feasibility and cultural contextualization. Although relatively new, the success of this approach is clear, as evidenced by the development of successful startup companies, pioneering product design, and the incorporation of creative people from outside traditional life science backgrounds who are working with clinicians and other scientists to create transformative innovation in health care.
Both patients and caregivers but also treating physicians are concerned about complications along with surgical interventions. A major problem is abrupt cessation of anti-Parkinson medication, which leads to manifold disturbances, sometimes even to an akinetic crisis. There are several means to guarantee continuous dopaminergic stimulation even in patients that are not allowed to take medication orally before they undergo surgery. Amongst others rectally applied levodopa, amantadine infusions, and especially the use of a rotigotine patch are good means to overcome oral intake. Perioperative management is important due to the fact that in Germany alone each year more than 10 000 PD patients undergo surgery. Main reasons for this are fractures, but also elective interventions. Further emergency situations that cause treatment as an inpatient are psychosis, motoric disability, but also pneumonia and cardiovascular disturbances. In contrast PD patients suffer less often from cancer. © Georg Thieme Verlag KG Stuttgart · New York.
Husain, Zain A; Mahmood, Usama; Hanlon, Alexandra; Neuner, Geoffrey; Buras, Robert; Tkaczuk, Katherine; Feigenberg, Steven J
The 2002 Food and Drug Administration approval of the MammoSite catheter (Hologic, Inc., Beford, MA) led to a surge of interest in accelerated partial breast irradiation (APBI). Until recently, guidelines as to the optimal candidates for this treatment were unavailable. We performed a patterns-of-care analysis for patients undergoing breast brachytherapy and compared these results with the American Society for Radiation Oncology (ASTRO) consensus statement. The Surveillance, Epidemiology, and End Results database was used to examine female breast cancer patients treated with brachytherapy between 2002 and 2007. The patients were then categorized into suitable, cautionary, and unsuitable groups based on the ASTRO guidelines. We identified 4172 female breast cancer patients treated within the stated years. The number of brachytherapy cases increased nearly 10-fold over the time period studied from 163 in 2002 to 1427 in 2007 (pASTRO cautionary or unsuitable groupings. This is the largest patterns-of-care analysis for APBI patients and serves as a baseline for future comparison. Copyright Â© 2011 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.
Mıngır, Tarkan; Ervatan, Zekeriya; Turgut, Namigar
Objective Anxiety is a pathological condition with a feeling of fear accompanied by somatic symptoms due to hyperactivity of the autonomic nervous system. In this study, we aimed to compare perioperative anxiety status and the effects of age, gender, educational status, and The American Society of Anesthesiologists physical status classification (ASA) score on perioperative anxiety in patients undergoing elective surgery under spinal anaesthesia. Methods After IRB approval and signed informed consent, 100 healthy patients undergoing elective surgery under spinal anaesthesia were enrolled. The demographic data of patients and ASA scores were recorded. After spinal anaesthesia, State Trait Anxiety Inventory (STAI) and anxiety levels were measured. Results The mean anxiety score in patients undergoing surgery under spinal anaesthesia indicate the presence of an intermediate level of anxiety (44.58±19.06). A statistically significant positive correlation was found between anxiety scores and age of patients with increased age (p<0.01). Statistically significant differences were found between anxiety scores of patients according to gender, and women’s anxiety scores were found to be significantly higher than in men (p<0.05). Anxiety scores did not differ significantly between education levels. A statistically significant difference was found between anxiety scores regarding ASA scores (p<0.05). Evaluation of patients revealed that the anxiety score of patients with ASA score 1 was significantly higher than the anxiety score of patients with ASA score 2. There was no significant difference between anxiety score of patients with ASA scores 2 and 3. Conclusion There is a mid-level anxiety, associated more with advanced age, female gender, and low ASA score, in patients undergoing elective surgery under spinal anaesthesia. PMID:27366419
D. B. Borisov
Full Text Available Objective: to evaluate the efficiency and safety of various perioperative analgesia modes during total hip joint replacement (THR. Subjects and methods. A randomized controlled trial enrolled 90 patients who were divided into 3 groups according to the choice of a perioperative analgesia mode on day 1: general sevofluorane anesthesia, by switching to intravenous patient-controlled analgesia with fentanyl (PCA, GA group, a combination of general and spinal bupiva-caine anesthesia, by switching to PCA with fentanyl (SA group, a combination of general and epidural ropivacaine anesthesia with continuous postoperative epidural ropivacaine infusion (EA group. All the patients received non-opi-oid analgesics after surgery. Results. Prolonged epidural block ensures better postoperative analgesia at rest and during mobilization and a less need for opioids than other analgesia modes (p<0.05. With neuroaxial block, the preoperative need for sympatomimetics is much higher than that in the GA group (p<0.05. There is also a trend toward a higher incidence of cardiac arrhythmias and postoperative nausea and vomiting in the SA and EA groups. There are no differences in the frequency of hemotransfusion and postoperative complications and the length of hospital stay. Conclusion. Prolonged epidural block provides excellent perioperative analgesia during THR, but the risk-benefit ratio needs to be carefully assessed when an analgesia mode is chosen.
Kurup, Viji; Hersey, Denise
There has been an explosion of medical information in the past decade. Current clinical practice demands that anesthesiologists be aware of current treatments and procedures, along with the latest practice standards and guidelines. The need to be able to rapidly retrieve relevant, accurate clinical information at the point of care is now felt more than ever. This review explores the impact of clinical medical librarians, with particular emphasis on their application in the perioperative setting. An increasing number of hospitals are turning to medical librarians to help clinicians improve their information-seeking skills. As a result, the role of medical librarians has expanded dramatically. Most studies evaluating the effectiveness of clinical medical librarian programs support their value in clinical teams, yet the studies rely primarily on descriptive surveys and qualitative data. Anesthesiologists have particular information needs for which the physical library is no longer sufficient. New outcome measures to define the 'success' of clinical medical librarian programs need to be formulated, and economic considerations need to be factored into these programs.
Garson, Leslie; Schwarzkopf, Ran; Vakharia, Shermeen; Alexander, Brenton; Stead, Stan; Cannesson, Maxime; Kain, Zeev
The perioperative setting in the United States is noted for variable and fragmented care that increases the chance for errors and adverse outcomes as well as the overall cost of perioperative care. Recently, the American Society of Anesthesiologists put forward the Perioperative Surgical Home (PSH) concept as a potential solution to this problem. Although the PSH concept has been described previously, "real-life" implementation of this new model has not been reported. Members of the Departments of Anesthesiology and Perioperative Care and Orthopedic Surgery, in addition to perioperative hospital services, developed and implemented a series of clinical care pathways defining and standardizing preoperative, intraoperative, postoperative, and postdischarge management for patients undergoing elective primary hip (n = 51) and knee (n = 95) arthroplasty. We report on the impact of the Total Joint Replacement PSH on length of hospital stay (LOS), incidence of perioperative blood transfusions, postoperative complications, 30-day readmission rates, emergency department visits, mortality, and patient satisfaction. The incidence of major complication was 0.0 (0.0-7.0)% and of perioperative blood transfusion was 6.2 (2.9-11.4)%. In-hospital mortality was 0.0 (0.0-7.0)% and 30-day readmission was 0.7 (0.0-3.8)%. All Surgical Care Improvements Project measures were at 100.0 (93.0-100.0)%. The median LOS for total knee arthroplasty and total hip arthroplasty, respectively, was (median (95% confidence interval [interquartile range]) 3 (2-3) [2-3] and 3 (2-3) [2-3] days. Approximately half of the patients were discharged to a location other than their customary residence (70 to skilled nursing facility, 1 to rehabilitation, 39 to home with organization health services, and 36 to home). We believe that our experience with the Total Joint Replacement PSH program provides solid evidence of the feasibility of this practice model to improve patient outcomes and achieve high patient
Durand, Wesley M; Johnson, Joseph R; Li, Neill Y; Yang, JaeWon; Eltorai, Adam E M; DePasse, J Mason; Daniels, Alan H
Interhospital competition has been shown to influence the adoption of surgical techniques and approaches, clinical patient outcomes, and health-care resource use for select surgical procedures. However, little is known regarding these dynamics as they relate to spine surgery. This investigation sought to examine the relationship between interhospital competitive intensity and perioperative outcomes following lumbar spinal fusion. This study used the Nationwide Inpatient Sample dataset, years 2003, 2006, and 2009. Patients were included based on the presence of the International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) codes corresponding to lumbar spinal fusion, as well as on the presence of data on the Herfindahl-Hirschman Index (HHI). The outcome measures are perioperative complications, defined using an ICD-9-CM coding algorithm. The HHI, a validated measure of competition within a market, was used to assess hospital market competitiveness. The HHI was calculated based on the hospital cachement area. Multiple regression was performed to adjust for confounding variables including patient age, gender, primary payer, severity of illness score, primary versus revision fusion, anterior versus posterior approach, national region, hospital bed size, location or teaching status, ownership, and year. Perioperative clinical outcomes were assessed based on ICD-9-CM codes with modifications. In total, 417,520 weighted patients (87,999 unweighted records) were analyzed. The mean cachement area HHI was 0.31 (range 0.099-0.724). The average patient age was 55.4 years (standard error=0.194), and the majority of patients were female (55.8%, n=232,727). The majority of procedures were primary spinal fusions (92.7%, n=386,998) and fusions with a posterior-only technique (81.5%, n=340,271). Most procedures occurred in the South (42.5%, n=177,509) or the Midwest (27.0%, n=112,758) regions. In the multiple regression analysis, increased hospital
Bruhn, Jörgen; Scheffer, Gert J; van Geffen, Geert-Jan
The experience of intense postoperative pain remains a significant problem in perioperative medicine. The mainstay of postoperative analgetic therapy is the combination of nonopioid agents (e.g. paracetamol and NSAIDs) with strong opioids (e.g. morphine) according to the WHO analgesic ladder. But as the incidence and intensity of postoperative pain remains high, the search for and evaluation of additional concepts is ongoing. This review highlights the current trends of perioperative multimodal analgesia concepts. Gabapentinoids, ketamine, dexamethasone and magnesium are effective parts of a multimodal analgesia concept without absolute contraindications and nearly without major negative side effects. Recent publications further define the role of these substances for perioperative use in terms of optimal dosing, positive side effects, relative potency and interaction. Components of well tolerated and simple advanced multimodal analgesia concepts in the perioperative period are now easy to apply and ready to become a standard in the daily clinical practice.
Fernandez-Bustamante, Ana; Hashimoto, Soshi; Serpa Neto, Ary; Moine, Pierre; Vidal Melo, Marcos F.; Repine, John E.
The perioperative use and relevance of protective ventilation in surgical patients is being increasingly recognized. Obesity poses particular challenges to adequate mechanical ventilation in addition to surgical constraints, primarily by restricted lung mechanics due to excessive adiposity, frequent
unit (ICU), were studied. All had a confirmed history of coronary artery disease or were at high risk for coronary disease. Subjects were randomly...aortic aneurysm (AAA) repair came after multiple adverse outcomes were attributed to perioperative hypothermia (Bush et al.,1995). A retrospective...aortic aneurysm repair : The high price of avoidable morbidity. Journal of Vascular Surgery, 21, 392-402. Consensus Conference on Perioperative
Breuer, J-P; Langelotz, C; Paquet, P; Weimann, A; Schwenk, W; Bosse, G; Spies, C; Bauer, H
Insufficient nutrition in surgical patients increases perioperative morbidity, mortality, length of stay and therapy costs. Therefore, guidelines declare the integration of nutrition into the overall management as one of the key aspects of perioperative care. This study was conducted to evaluate the current clinical practice of clinical nutrition in surgical departments in Germany. In 2009 German Surgical Society (DGCH) members in leading positions were surveyed with a standardised online questionnaire concerning their perioperative nutritional routines in elective surgery. From the addressed physicians n = 156 (6.24 %) answered. Of those, 86.9 % consider the nutritional status of their patients. Only 6 % use standardised nutritional screening tools. Short preoperative fasting for solid and liquid food is practiced by 65 % and 40 %, respectively. After the operation, 65 % allow intake of clear fluids on the day of surgery and 78 % initiate solid food on the day of surgery or the first postoperative day. Oral nutritional supplements are given only "sometimes" or "rarely" by 53.9 % of the respondents. The low response rate may imply the dilemma that the evidence-based benefit of perioperative nutrition does not meet sufficient interest. Even in case of a positive selection of "pro-nutrition respondents", standardised preoperative malnutrition screening is also rare. Aspects such as shorter perioperative fasting are already practiced more progressively. However, still greater efforts are needed to promote guideline-based clinical nutrition in surgical care in Germany. © Georg Thieme Verlag KG Stuttgart · New York.
Zimmermann, Frank; BEAM'07; BEAM 2007; Finalizing the Roadmap for the Upgrade of the LHC and GSI Accelerator Complex
This report contains the Proceedings of the CARE-HHH-APD Event BEAM’07, “Finalizing the Roadmap for the Upgrade of the CERN & GSI Accelerator Complex,” which was held at CERN in Geneva, Switzerland, from 1 to 5 October 2007. BEAM’07 was primarily devoted to beam dynamics limitations for the two, or three, alternative baseline scenarios of the LHC luminosity upgrade and to critical design choices for the upgrade of the LHC injector complex at CERN and for the FAIR complex at GSI. It comprised five parts: (1) a Mini-Workshop on LHC+ Beam Performance, (2) a CERN-GSI Meeting on Collective Effects, (3) the Francesco Ruggiero Memorial Symposium, (4) a Mini-Workshop on the LHC Injectors Upgrade, and (5) the BEAM’07 Summaries. Topics addressed in the first mini-workshop of BEAM’07 ranged from the luminosity performance reach of the upgraded LHC in different scenarios, over the generation and stability of the future LHC beams, the turnaround time, beam–beam effects, luminosity levelling methods, and ...
Ferrando, A; Fraile, J R; Bermejo, L; de Miguel, A; Aristegui, M; Hervías, M; Quirós, P
Surgical treatment of glomus jugulare tumors yields high rates of perioperative morbidity and mortality for several reasons, among them neuroendocrine secretory activity, a high degree of vascularization, intracranial extension, duration of surgery and cranial nerve lesion. Secretory activity (e.g. catecholamines and serotonin) should be investigated before surgery and treated appropriately. Carotid arteriography (and ball occlusion) are useful to assess vascularization of the tumor and determine the need to clamp the carotid artery during the procedure. Potential complications such as hemodynamic alterations (bleeding or endocrine response), pulmonary embolism (air or thrombotic), hypothermia, facial nerve lesion, should be monitored for during surgery. After surgery cranial nerve involvement, which can lead to dysphagia and bronchoaspiration, must be looked for; the risk of cerebro-spinal fluid fistula is also high. We report the case of a woman who underwent surgery for a non secreting glomus jugulare tumor with extradural intracranial invasion. The main complications during surgery were bleeding with hemodynamic repercussions, pulmonary embolism, lesions in the VII, VIII and X cranial nerves, and opening of the dura mater (which required insertion of an intradural drain to prevent formation of a fistula). After surgery oral intake was delayed until intestinal function was established and glottic sphincter competence was verified by fiberoptic laryngoscopy. The only complication presenting at this time was cephalea, which disappeared upon removal of the drain on day 4. The patient was released on day 10.
Boudreaux, Arthur M; Vetter, Thomas R
The movement toward value-based payment models, driven by governmental policies, federal statutes, and market forces, is propelling the importance of effectively managing the health of populations to the forefront in the United States and other developed countries. However, for many anesthesiologists, population health management is a new or even foreign concept. A primer on population health management and its potential perioperative application is thus presented here. Although it certainly continues to evolve, population health management can be broadly defined as the specific policies, programs, and interventions directed at optimizing population health. The Population Health Alliance has created a particularly cogent conceptual framework and interconnected and very useful population health process model, which together identify the key components of population health and its management. Population health management provides a useful rationale for patients, providers, payers, and policymakers to move collectively away from the traditional system of individual, siloed providers to a more integrated, coordinated, team-based approach, thus creating a holistic view of the patient population. The goal of population health management is to keep the targeted patient population as healthy as possible, thus minimizing the need for costly interventions such as emergency department visits, acute hospitalizations, laboratory testing and imaging, and diagnostic and therapeutic procedures. Population health management strategies are increasingly more important to leaders of health care systems as the health of populations for which they care, especially in a strong cost risk-sharing environment, must be optimized. Most population health management efforts rely on a patient-centric team approach, coordination of care, effective communication, robust outcomes data analysis, and continuous quality improvement. Anesthesiologists have an opportunity to help lead these efforts in
Selimen, Deniz; Andsoy, Isil Isik
Holism is the philosophy of understanding people by addressing factors that affect people in all situations. The goal of holistic nursing is to help patients integrate appropriate self-care into their lives. By providing holistic care, the perioperative nurse can help surgical patients experience fewer problems (eg, surgical trauma, pain, anesthetic complications), reach discharge more quickly, attain satisfaction with health care, and more easily resume normal activities. Holistic nursing may include the use of music, guided imagery, therapeutic massage, play therapy, touch therapy, and communication skills. Successful surgery for the patient means not only recovering but regaining physical, mental, and spiritual health as a whole. Copyright © 2011 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Lillebo, Børge; Seim, Andreas; Faxvaag, Arild
Perioperative work requires the collaborative efforts of a multitude of actors. Coordinating such collaboration is challenging, and coordination breakdowns may be very expensive and jeopardize patient safety. We studied the needs for status information and projection of future status and events for key actors in the perioperative environment. We found that information and projection needs differed significantly between actors. While just-in-time notifications sufficed for some, others were dependent on projections to provide high quality and efficient care. Finally, information on current status and support in projecting the future unfolding of events could improve actors situated coordination capabilities.
J P Attri
Full Text Available Death to most people is a major life event. Nothing in this world prepares us to face and manage the perioperative death although the majority of anesthesiologists will be involved in an intraoperative death during the course of their careers. Whether death on the table was expected or occurred when least expected or may be even later, the anesthesiologist is most likely to be affected emotionally, physically in his personal life, and as well as will have an influence on his professional career. Anesthesiologists as perioperative physicians are likely to experience death on the operating table at some time in their careers. In case of perioperative death, meticulous record keeping including time of occurrence of event and methods and medications used during resuscitation, nature of the problem, and all sequence of events should be adopted to breaking bad news with relatives and blame game should be avoided. The anesthesiologist and the relatives of the patient should also be given emotional support to come out of this untoward event. In this article, we have highlighted the various factors and causes leading on to perioperative death and if in case such an event occurs, what are the protocols to be followed, including medicolegal aspects, giving emotional support to the concerned anesthesiologist, dealing with the relatives of the patient sympathetically, etc. We have also enumerated the various precautions to be taken to prevent perioperative mortality in this article.
Nurok, Michael; Green, Douglas S T; Chisholm, Mary F; Fins, Joseph J; Liguori, Gregory A
To assess anesthesiologists' familiarity with the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) guidelines on Advance Directives in the perioperative setting. Single-center, 4-question anonymous survey. Urban academic medical center. Up to 34 subjects responded to each question. Familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting ranged from 45% to 100%. There was inadequate familiarity with components of the ASA and ACS guidelines on advance directives in the perioperative setting. Larger studies are required to assess anesthesiologists' familiarity with national society guidelines that directly affect patient care. Future work should investigate best practices for guideline implementation, and consequences of poor adherence to national guidelines. Copyright © 2014 Elsevier Inc. All rights reserved.
Mehdi, Zehra; Birns, Jonathan; Partridge, Judith; Bhalla, Ajay; Dhesi, Jugdeep
It is increasingly common for physicians and anaesthetists to be asked for advice in the medical management of surgical patients who have an incidental history of stroke or transient ischaemic attack (TIA). Advising clinicians requires an understanding of the common predictors, outcomes and management of perioperative stroke. The most important predictor of perioperative stroke is a previous history of stroke, and outcomes associated with such an event are extremely poor. The perioperative management of this patient group needs careful consideration to minimise the thrombotic risk and a comprehensive, individualised approach is crucial. Although there is literature supporting the management of such patients undergoing cardiac surgery, evidence is lacking in the setting of non-cardiac surgical intervention. This article reviews the current evidence and provides a pragmatic interpretation to inform the perioperative management of patients with a history of stroke and/or TIA presenting for elective non-cardiac surgery. © Royal College of Physicians 2016. All rights reserved.
Full Text Available It is standard practice in many institutions to routinely perform preoperative and postoperative haemoglobin level testing in association with hip joint arthroplasty procedures. It is our observation, however, that blood transfusion after uncomplicated primary hip arthroplasty in healthy patients is uncommon and that the decision to proceed with blood transfusion is typically made on clinical grounds. We therefore question the necessity and clinical value of routine perioperative blood testing about the time of hip resurfacing arthroplasty. We present analysis of perioperative blood tests and transfusion rates in 107 patients undertaking unilateral hybrid hip resurfacing arthroplasty by the senior author at a single institution over a three-year period. We conclude that routine perioperative testing of haemoglobin levels for hip resurfacing arthroplasty procedures does not assist in clinical management. We recommend that postoperative blood testing only be considered should the patient demonstrate clinical signs of symptomatic anaemia or if particular clinical circumstances necessitate.
Background: Perioperative antibiotic administration for prophylaxis of surgical site infections can increase the anaesthetists workload. However, timely administration is essential to reduce risks and improve patient outcome. Objective: This survey evaluates anaesthetists' opinion concerning perioperative antibiotic therapy ...
Aronson, Solomon; Westover, Julie; Guinn, Nicole; Setji, Tracy; Wischmeyer, Paul; Gulur, Padma; Hopkins, Thomas; Seyler, Thorsten M; Lagoo-Deendayalan, Sandhya; Heflin, Mitchell T; Thompson, Annemarie; Swaminathan, Madhav; Flanagan, Ellen
Health care delivery in the United States continues to balance on the tight rope that connects its transition from volume to value. Value in economic terms can be defined as the amount something exceeds its commodity price and is determined by extraordinary reputation, quality, and/or service, whereas its destruction can be a consequence of poor management, unfavorable policy, decreased demand, and/or increased competition. Going forward, payment for health care delivery will increasingly be based on services that contribute to improvements in individual and/or population health value, and funds to pay for health care delivery will become increasingly vulnerable to competitive market forces. Therefore, a sustainable population health strategy needs to be comprehensive and thus include perioperative medicine as an essential component of the complete cycle of patient-centered care. We describe a multidisciplinary integrated program to support perioperative medicine services that are integral to a comprehensive population health strategy.
Beatty, Nicole C; Nicholson, Wayne T; Langman, Loralie J; Curry, Timothy B; Eisenach, John H
Serotonin syndrome is gaining attention in perioperative and chronic pain settings due to the growing prevalence of multimodal therapies that increase serotonin levels and thereby heighten patient risk. A patient's genetic make-up may further increase the risk of serotonin syndrome. A case of serotonin syndrome on emergence after general anesthesia is presented. A subsequent cytochrome P4502D6 genetic test result suggested a potential alteration in metabolism. For this patient, who was taking combination antidepressant medications and receiving common perioperative medicines, additive pharmacodynamic effects converged with a pharmacogenetic predisposition, resulting in serotonin syndrome. © 2013 Elsevier Inc. All rights reserved.
Balser, J R
Intravenous amiodarone is a potentially valuable therapy for perioperative patients experiencing life-threatening ventricular arrhythmias refractory to conventional antiarrhythmic agents perioperatively. Its potential for hemodynamic and pulmonary toxicity perioperatively suggests that it should remain an alternative therapy rather than a first-line option. However, because of its impressive efficacy in nonsurgical trials, its role in perioperative arrhythmia management will dramatically expand if clinical studies become available that clarify its safety in surgical populations.
Ashwini H Ramaswamy
Full Text Available Portal hypertensive gastropathy occurs both in cirrhotic and non cirrhotic patients leading to haemetemesis secondary to oesophageal varices. The hyper dynamic circulatory state of pregnancy in these patients poses special problems necessitating specialized care preferably in a tertiary care centre. We report the perioperative anaesthetic management for elective caesarean section in a 32-year-old pregnant lady at 39 weeks gestation with portal gastropathy secondary to periportal fibrosis of the liver.
Bangalore, Sripal; Wetterslev, Jørn; Pranesh, Shruthi
American College of Cardiology and American Heart Association (ACC/AHA) guidelines on perioperative assessment recommend perioperative beta blockers for non-cardiac surgery, although results of some clinical trials seem not to support this recommendation. We aimed to critically review the evidence...... to assess the use of perioperative beta blockers in patients having non-cardiac surgery....
Flick, Randall P; Sprung, Juraj; Harrison, Tracy E; Gleich, Stephen J; Schroeder, Darrell R; Hanson, Andrew C; Buenvenida, Shonie L; Warner, David O
The objective of this study was to determine the incidence and outcome of perioperative cardiac arrest (CA) in children younger than 18 yr undergoing anesthesia for noncardiac and cardiac procedures at a tertiary care center. After institutional review board approval (Mayo Clinic, Rochester, Minnesota), all patients younger than 18 yr who had perioperative CA between November 1, 1988, and June 30, 2005, were identified. Perioperative CA was defined as a need for cardiopulmonary resuscitation or death during anesthesia care. A cardiac procedure was defined as a surgical procedure involving the heart or great vessels requiring an incision. A total of 92,881 anesthetics were administered during the study period, of which 4,242 (5%) were for the repair of congenital heart malformations. The incidence of perioperative CA during noncardiac procedures was 2.9 per 10,000, and the incidence during cardiac procedures was 127 per 10,000. The incidence of perioperative CA attributable to anesthesia was 0.65 per 10,000 anesthetics, representing 7.5% of the 80 perioperative CAs. Both CA incidence and mortality were highest among neonates (0-30 days of life) undergoing cardiac procedures (incidence: 435 per 10,000; mortality: 389 per 10,000). Regardless of procedure type, most patients who experienced perioperative CA (88%) had congenital heart disease. The majority of perioperative CAs were caused by factors not attributed to anesthesia, in distinction to some recent reports. The incidence of perioperative CA is many-fold higher in children undergoing cardiac procedures, suggesting that definition of case mix is necessary to accurately interpret epidemiologic studies of perioperative CA in children.
Murni, Indah K; MacLaren, Graeme; Morrow, Debra; Iyer, Parvathi; Duke, Trevor
Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality. A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed. Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition. The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.
The phenomenon of desensitisation was expressed as a spectrum between being dissociated from the event and disconnected from the people ..... continue working under conditions of high stress and urgency, and provide an efficient .... Gazoni FM, Durieux ME, Wells L. Life after death: the aftermath of perioperative ...
or delayed / insufficient nutrition support has also been associated with higher risk for complication rates and mortality.4 This suggests that perioperative nutrition support may positively affect outcomes.4. This review will focus on postoperative nutritional support and arginine supplementation in surgical patients. Effect of ...
Consequently, this can contribute significantly to anaesthetists' feelings of guilt and personal responsibility in the event of a perioperative death. This study set out to describe the range of reactions to such an event amongst a group of anaesthesia trainees. Employing a qualitative methodology, 10 registrars in their fourth ...
Daniel Agustín Godoy
Full Text Available Many neurosurgery patients may have unrecognized diabetes or may develop stress-related hyperglycemia in the perioperative period. Diabetes patients have a higher perioperative risk of complications and have longer hospital stays than individuals without diabetes. Maintenance of euglycemia using intensive insulin therapy (IIT continues to be investigated as a therapeutic tool to decrease morbidity and mortality associated with derangements in glucose metabolism due to surgery. Suboptimal perioperative glucose control may contribute to increased morbidity, mortality, and aggravate concomitant illnesses. The challenge is to minimize the effects of metabolic derangements on surgical outcomes, reduce blood glucose excursions, and prevent hypoglycemia. Differences in cerebral versus systemic glucose metabolism, time course of cerebral response to injury, and heterogeneity of pathophysiology in the neurosurgical patient populations are important to consider in evaluating the risks and benefits of IIT. While extremes of glucose levels are to be avoided, there are little data to support an optimal blood glucose level or recommend a specific use of IIT for euglycemia maintenance in the perioperative management of neurosurgical patients. Individualized treatment should be based on the local level of blood glucose control, outpatient treatment regimen, presence of complications, nature of the surgical procedure, and type of anesthesia administered.
Steinmetz, J; Rasmussen, L S
factors, the predominant one being age. Ignorance of the causes for postoperative cognitive dysfunction contributes to the difficulty of conducting interventional studies. Postoperative cognitive disorders are associated with increased mortality and permanent disability. Peri-operative interventions can...... reduce the rate of delirium in the elderly, but in spite of promising findings in animal experiments, no intervention reduces postoperative cognitive dysfunction in humans....
Maathuis, PGM; Neut, D; Busscher, HJ; van der Mei, HC; van Horn, [No Value
All surgical procedures have the risk of microbial contamination. However, procedures in which prosthetic materials are involved have a high risk for future infectious problems because of the protection offered by the biofilm mode of growth. Studies of perioperative contamination have been done on
Background: Perioperative myocardial infarction (PMI) is a common complication following noncardiac surgery, with a 30-day mortality of 10-20%. Effective therapeutic interventions ... Significantly more haemodynamically unstable patients received acute coronary interventions (75.8% vs. 23.1%, p-value = 0.0006). Acute ...
F. van Lier (Felix)
textabstractThe first chapter provides an overview of cardiovascular risk identification and modification in the perioperative period. In this chapter the identification of patients at risk using various risk models and biomarkers is described. Noninvasive and invasive preoperative (stress) testing
Full Text Available Angioedema is a rare condition which manifests as sudden localised, non-pitting swelling of certain body parts including skin and mucous membranes. It is vital that anaesthesiologists understand this condition, as it may present suddenly in the perioperative period with airway compromise. To identify literature for this review, the authors searched the PubMed, Medline, Embase, Scopus and Web of Science databases for English language articles covering a 10-year period, 2006 through 2016. Angioedema can be either mast-cell mediated or bradykinin-induced. Older therapies for histaminergic symptoms are well known to anaesthesiologists (e.g., adrenaline, anti-histamines and steroids, whereas older therapies for bradykinin-induced symptoms include plasma and attenuated androgens. New classes of drugs for bradykinin-induced symptoms are now available, including anti-bradykinin, plasma kallikrein inhibitor and C1 esterase inhibitors. These can be used prophylactically or as rescue medications. Anaesthesiologists are in a unique position to coordinate perioperative care for this complex group of patients.
Moore, Carolyn; Edward, Karen-Leigh; King, Karolin; Giandinoto, Jo-Ann
Despite the substantial risks posed in the surgical environment, compliance in wearing appropriate personal protective equipment (PPE) in the operating room (OR) and the post-anaesthetic care unit (PACU) amongst health care workers is considered poor globally. Lack of awareness and limited access to information about the appropriate precautions to prevent exposure contribute to continued high-risk behaviours amongst the team in the perioperative setting. The aim of this project was to assess current compliance rates of staff in the use of PPE and to develop and implement an educational program to increase staff compliance in the perioperative setting of a large, private hospital (450 beds). A convenience sample of perioperative nurses were invited to complete a questionnaire. Eighty (80) registered nurses RNs) were invited to participate response rate of 69%), giving a sample size of n = 55. Questionnaires not completed in full were not included in the final analysis, leaving n = 31 fully completed questionnaires. There was an education group (n = 14) and a control group (n = 17). Between the groups, educational background, type of work and patient contact were very similar. Of those that did respond regarding exposure, only 20% reported the incident. Both groups identified their manager and team as frequently discussing safer work practices and being supportive. PPE was identified as essential; however, participants reported not enough time to always follow standard precautions (education 15%; control 25%). Team and good leadership was identified as essential to ongoing professional knowledge and support with regard to risk minimisation in the perioperative setting.
Kwari, Y D; Bello, M R; Eni, U E
Perioperative cardiac arrests and death on the table represent the most serious complications of surgery and anaesthesia. This paper was designed to study their pattern, causes and outcomes following cardiopulmonary resuscitation (CPR) and intensive care unit (ICU) management in our institution. Three year retrospective review of perioperative cardiac arrests and death on operating table following surgical procedure under anaesthesia. For each cardiac arrest or death on the table the sequence of events leading to the arrest was evaluated using case notes, anaesthetic chart and ICU records. Study variables which include demographic data, ASA score, anaesthetic technique, causes and outcome were analysed and discussed. Fourteen perioperative cardiac arrests were encountered following 4051 anaesthetics administered over the three year study period. Twelve out of the fourteen cardiac arrests occurred following general anaesthesia, while the remaining two occurred following spinal anaesthesia. There was no cardiac arrest following local anaesthesia. Children suffered more cardiac arrest than adults. ASA class III and IV risk status suffered more arrests than ASA I and II. Hypoxia from airway problems was the commonest cause of cardiac arrest followed by septic shock. Monitoring with pulse oximeter was done in only 4 out of the 14 cardiac arrests. Only 2 (14%) out of 14 cardiac arrests recovered to home discharge, one of them with significant neurological deficit. Majority of arrests were due to hypoxia from airway problems that were not detected early There is need to improve on patient monitoring, knowledge of CPR and intensive care so as to improve the outcome of perioperative cardiac arrest.
Grabowska, Izabela; Ścisło, Lucyna; Pietruszka, Szymon; Walewska, Elzbieta; Paszko, Agata; Siarkiewicz, Benita; Richter, Piotr; Budzyński, Andrzej; Szczepanik, Antoni M
Demographic changes in contemporary society require implementation of proper perioperative care of elderly patients due to an increased risk of perioperative complications in this group. Preoperative assessment of health status identifies risks and enables preventive interventions, improving outcomes of surgical treatment. The Comprehensive Geriatric Assessment contains numerous diagnostic tests and consultations, which is expensive and difficult to use in everyday practice. The development of a simplified model of perioperative assessment of elderly patients will help identifying the group of patients who require further diagnostic workup. The aim of the study is to evaluate the usefulness of the tests used in a proposed model of perioperative risk assessment in elderly patients. In a group of 178 patients older than 64 years admitted for surgical procedures, a battery of tests was performed. The proposed model of perioperative risk assessment included: Charlson Comorbidity Index, ADL (activities of daily living), TUG test (timed "up and go" test), MNA (mini nutritional assessment), AMTS (abbreviated mental test score), spirometry measurement of respiratory muscle strength (Pimax, Pemax). Distribution of abnormal results of each test has been analysed. The Charlson Index over 6 points was recorded in 10.1% of patients (15.1% in cancer patients). Abnormal result of the TUG test was observed in 32.1%. The risk of malnutrition in MNA test has been identified in 29.7% (39.2% in cancer patients). Abnormal test results at the level of 10-30% indicate potential diagnostic value of Charlson Comorbidity Index, TUG test and MNA in the evaluation of perioperative risk in elderly patients.
Brogly, N; Alsina, E; de Celis, I; Huercio, I; Dominguez, A; Gilsanz, F
Prevention of perioperative hypothermia decreases morbidity and mortality, as well as hospital costs. This study was conducted to evaluate the level of implementation of protocols in 3 tertiary Spanish University Hospitals. A survey among anaesthesiologists assessed estimated importance and clinical practice in terms of prevention of perioperative hypothermia. Results were compared depending on their experience. Ptotal of 116 anaesthesiologists answered the survey, of whom 48 (41.3%) were residents, 32 (27.6%) were staff with less than 10 years of experience, and 36 (31.1%) staff with 10 years or more of experience, In a 0-10 importance scale, prevention of hypothermia was scored 7.49±1,79, with no difference between groups (P=.58). Younger staff were more concerned of the end surgery temperature than other colleagues (P=.02). The most usual practice was a combination warming the intravenous fluids and an electric blanket (55%). Only 20% of the anaesthesiologists monitored temperature intra-operatively, even though 75% considered it an important parameter. No unit had a written protocol for prevention of perioperative hypothermia. Despite the absence of prevention protocols, the anaesthesiologists were aware of the importance maintaining a normal peri-operative temperature, but this awareness is still not enough to influence their perioperative management to diagnose and prevent hypothermia. A harmonisation of practice at local, regional and national level could improve this practice in the future. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.
Postoperative pulmonary complications contribute considerably to morbidity and mortality, especially after major thoracic or abdominal surgery. Clinically relevant pulmonary complications include the exacerbation of underlying chronic lung disease, bronchospasm, atelectasis, pneumonia and respiratory failure with prolonged mechanical ventilation. Risk factors for postoperative pulmonary complications include patient-related risk factors (e.g., chronic obstructive pulmonary disease (COPD), tobacco smoking and increasing age) as well as procedure-related risk factors (e.g., site of surgery, duration of surgery and general vs. regional anaesthesia). Careful history taking and a thorough physical examination may be the most sensitive ways to identify at-risk patients. Pulmonary function tests are not suitable as a general screen to assess risk of postoperative pulmonary complications. Strategies to reduce the risk of postoperative pulmonary complications include smoking cessation, inspiratory muscle training, optimising nutritional status and intra-operative strategies. Postoperative care should include lung expansion manoeuvres and adequate pain control.
Ma, Hong; Tang, Jun; White, Paul F; Zaentz, Alan; Wender, Ronald H; Sloninsky, Alexander; Naruse, Robert; Kariger, Robert; Quon, Raymond; Wood, Dennis; Carroll, Brendan J
Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30-40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for "rescue" analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 +/- 30 vs 126 +/- 44 min, P outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period. Rofecoxib (50 mg per os), given before and after surgery, was effective in improving postoperative pain management, as well as the speed and quality of recovery after outpatient inguinal herniorrhaphy. However, it failed to accelerate the postdischarge resumption of normal activities of daily living.
Ellett, Justin; Prasad, Michaella M; Purves, J Todd; Stec, Andrew A
Post-surgical infections (PSIs) are a source of preventable perioperative morbidity. No guidelines exist for the use of perioperative antibiotics in pediatric urologic procedures. This study reports the rate of PSIs in non-endoscopic pediatric genitourinary procedures at our institution. Secondary aims evaluate the association of PSI with other perioperative variables, including wound class (WC) and perioperative antibiotic administration. Data from consecutive non-endoscopic pediatric urologic procedures performed between August 2011 and April 2014 were examined retrospectively. The primary outcome was the rate of PSIs. PSIs were classified as superficial skin (SS) and deep/organ site (D/OS) according to Centers for Disease Control and Prevention guidelines, and urinary tract infection (UTI). PSIs were further stratified by WC1 and WC2 and perioperative antibiotic usage. A relative risk and chi-square analysis compared PSI rates between WC1 and WC2 procedures. A total of 1185 unique patients with 1384 surgical sites were reviewed; 1192 surgical sites had follow-up for inclusion into the study. Ten total PSIs were identified, for an overall infection rate of 0.83%. Of these, six were SS, one was D/OS, and three were UTIs. The PSI rate for WC1 (885 sites) and WC2 (307 sites) procedures was 0.34% and 2.28%, respectively, p antibiotics (0.35% vs. 0.33%). All WC2 procedures received antibiotics. Post-surgical infections are associated with significant perioperative morbidity. In some studies, PSI can double hospital costs, and contribute to hospital length of stay, admission to intensive care units, and impact patient mortality. Our study demonstrates that the rate of PSI in WC1 operations is low, irrespective of whether the patient received perioperative antibiotics (0.35%) or no antibiotics (0.33%). WC2 operations were the larger source of morbidity with an infection rate of 2.28% and a 6.7 fold higher increase in relative risk. WC1 procedures have a rate of
Nielsen, Hans Jørgen
Evidence suggests that perioperative allogeneic blood transfusion increases the risk of infectious complications after major surgery and of cancer recurrence after curative operation. This has been attributed to immunosuppression. Several authors have suggested that filtered whole blood and/or red...... cell concentrate, or leucocyte- and buffy coat-reduced red cells in artificial medium or their own plasma, may reduce postoperative immunosuppression. It was also anticipated that the use of autologous blood might minimize the risk of perioperative transfusion, but studies have unexpectedly shown...... similar postoperative infectious complications and cancer recurrence and/or survival rates in patients receiving autologous blood donated before operation and those receiving allogeneic blood. Future studies should identify common risk factors associated with blood storage....
Huhmann, Maureen B; August, David A
Malnutrition and weight loss negatively affect outcomes in surgical cancer patients. Decades of research have sought to identify the most appropriate use of nutrition support in these patients. National and international guidelines help to direct clinicians' use of nutrition support in surgical patients, but a number of specific issues concerning the use of nutrition support continue to evolve. This review focuses on 5 key issues related to perioperative nutrition support in cancer patients: (1) Which perioperative cancer patients should receive nutrition support? (2) How can the nutrition status and requirements of these patients be optimally assessed? (3) What is the optimal route of administration (parenteral nutrition vs enteral nutrition) and composition of nutrition support in this setting? (4) When should feedings be initiated? (5) What is the role of glycemic control in these patients?
Alison A. Nielsen
Full Text Available Purpose : To propose an optimal perioperative pain management clinical care pathway for interstitial brachytherapy for gynecologic cancer based on our interdepartmental experience. Material and methods : We conducted a retrospective review of 23 women who underwent 32 interstitial brachytherapy procedures for gynecological cancers, analyzing patient demographics, type of anesthetic, medications, postoperative pain scores, adverse events, and delays in discharge. We measured the association of postoperative nausea and/or vomiting (PONV with hydromorphone use, and postoperative pain scores and total narcotic administration with type of anesthesia. Results : In 91% of patients postoperative pain was managed with an epidural infusion plus, as needed (PRN, IV or patient controlled analgesia (PCA narcotics. The most common postoperative adverse event was PONV (53%, followed by delirium (22%. Hospital discharge was delayed, at least by one night, in 26% of patients. Use of a basal rate on the PCA was associated with all cases of delayed discharge from over-sedation and PONV. The use of 5 mg or more of intravenous (IV hydromorphone during the first 24-hours postoperatively was associated with PONV (p = 0.01. Use of a basal PCA was associated with delirium (p = 0.03. Postoperative pain scores were not significantly associated with the type of anesthesia. Conclusions : Interstitial gynecologic brachytherapy requires a multidisciplinary effort for optimal perioperative management. Our study outlines the appropriate preoperative, intraoperative, and postoperative anesthesia clinical care pathway. Decreased narcotic use during hospitalization and utilization of a patient-directed infusion may decrease side effects and allow for a more efficient hospital discharge.
Full Text Available Alan David Kaye,1 Olutoyin J Okanlawon,2 Richard D Urman21Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, 2Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston MA, USAAbstract: Clinical performance feedback is an important component of the ongoing development and education of health care practitioners. For physicians, feedback about their clinical practice and outcomes is central to developing both confidence and competence at all stages of their medical careers. Cultural and financial infrastructures need to be in place, and the concept of feedback needs to be readily embraced and encouraged by clinical leadership and other stakeholders. The "buy-in" includes the expectation and view that feedback occurs on a routine basis, and those engaged in the process are both encouraged to participate and held accountable. Feedback must be part of an overarching quality improvement and physician education agenda; it is not meant to be an isolated, fragmented initiative that is typically undermined by lack of resources or systemic barriers to gaining improvement within programs. Effective feedback should be an integral part of clinical practice. Anesthesiologists and other perioperative physicians are identifying specialty-specific indicators that can be used when creating a broader quality improvement agenda. Placing a more immediate formal feedback strategy that focuses on goal-oriented behavior is rapidly becoming a mainstay. Physicians may use their individual feedback reports for reflection and designing personal development plans as lifelong learners and leaders in improving patient care.Keywords: physician education, outcomes measurement, performance improvement, anesthesiology
Tame, Susan L
To report perceived changes to UK perioperative nurses' relationships with medical staff following periods of formal, university-based study. Continuing professional development is considered important for nursing internationally; however, practice changes may not result following formal study. The literature did not describe perioperative nurses' experiences of formal study, and it was believed differences may exist due to hierarchical interprofessional relationships in the operating theatre. Descriptive, qualitative. Unstructured interviews (N=23) were conducted between 2006-2007 with a purposive sample of perioperative nurses who had recent experience of continuing professional education. All participants were employed by one National Health Service Trust in the North of England, UK. Audio-taped interviews were transcribed fully into the ethnograph computer-assisted qualitative data analysis programme and data coded and analysed to identify themes. Findings. The findings indicated that whilst continuing professional education did not have a direct impact on practice, development of increased knowledge and confidence facilitated participants' collaboration with and questioning of medical colleagues. Such increased interprofessional collaboration was attributed to indirectly enhancing patient care. Continuing professional education appeared to lead to intrinsic changes to practitioners rather than direct behavioural change. Nurses' increased knowledge and confidence affected the balance of power in the doctor-nurse relationship in British perioperative environments. This paper is of significance to perioperative nursing and may be transferable to other areas of care. © 2012 Blackwell Publishing Ltd.
Assistência ao paciente obeso mórbido submetido à cirurgia bariátrica: dificuldades do enfermeiro Asistencia al paciente obeso mórbido sometido a la cirugía bariátrica: dificultades del enfermero Perioperative care for morbid obese patient undergoing bariatric surgery: challenges for nurses
Denise Spósito Tanaka
Full Text Available OBJETIVO: Identificar as dificuldades de enfermeiros de centro cirúrgico ao assistir pacientes obesos mórbidos submetidos à cirurgia bariátrica no período transoperatório. MÉTODOS: A amostra constou de 70 enfermeiros com experiência em assistência ao paciente obeso mórbido. Os dados foram coletados durante o 7º Congresso Brasileiro de Enfermeiros de Centro Cirúrgico, Recuperação Anestésica e Centro de Material e Esterilização por meio de um questionário. RESULTADOS: A análise dos resultados apontou como dificuldades aquelas relacionadas ao espaço físico, materiais e equipamentos e à assistência de enfermagem específica ao paciente obeso mórbido. CONCLUSÃO: O conhecimento específico, a especialização e a experiência em Centro Cirúrgico darão o conforto, a segurança física e emocional necessárias a estes pacientes.OBJETIVO: Identificar las dificultades de enfermeros de centro quirúrgico en el cuidado a pacientes obesos mórbidos sometidos a cirugía bariátrica en el período transoperatorio. MÉTODOS: La muestra constó de 70 enfermeros con experiencia en asistencia al paciente obeso mórbido. Los datos fueron recolectados por medio de un cuestionario durante el 7º Congreso Brasileño de Enfermeros de Centro Quirúrgico, Recuperación Anestésica y Centro de Material y Esterilización. RESULTADOS: El análisis de los resultados identificó como dificultades aquellas relacionadas al espacio físico, materiales y equipos y a la asistencia de enfermería específica al paciente obeso mórbido. CONCLUSIÓN: El conocimiento específico, la especialización y la experiencia en Centro Quirúrgico darán el confort, la seguridad física y emocional que necesitan estos pacientes.OBJECTIVE: To identify the challenges for nurses during the perioperative for patients undergoing bariatric surgery. METHODS: The sample consisted of 70 nurses who had experience in providing care for morbid obese patients. Data were collected
Relacionamento terapêutico com criança no período perioperatório: utilização do brinquedo e da dramatização Relación terapéutica com el nino en el período perioperatorio Therapeutic relationship with child in perioperative nursing care
Full Text Available Este estudo de caso tem o objetivo de analisar o relacionamento terapêutico desenvolvido entre aluna de enfermagem e uma criança de 3 anos , durante o período perioperatório, utilizando o brinquedo e a dramatização para facilitar a explicação dos procedimentos e dos objetos do hospital para a criança.Ouso do brinquedo mostrou-se uma forma adequada para comunicar-se efetivamente com a criança, e para prepará-la para a intervenção cirúrgica, pois, através da dramatização, ela participou ativamente dos procedimentos, mostrando que compreendia e aceitava o que estava acontecendo,nãoapresentando em nenhum momento medo ou ansiedade diante do ambiente do hospital e dos procedimentos cirúrgicos. Ao final do relacionamento, a mãe e a equipe cirúrgica avaliaram positivamente o preparo da criança para a cirurgia.El presente estudio tiene como finalidad analizar el proceso de relación terapéutica entre alumna de enfermería y una niña de 3 años de edad durante el período perioperatorio. Utilizando técnicas de comunicación terapéutica y medidas terapéuticas de enfermería, la alumna desarrolló empatía con la niña y su madre, proponiendo ayudarlas a superar sus dificultades frente sus miedos y ansiedad debida ala hospitalización y cirugia. La madre y equipo cirúgica han evaluado la preparación para la cirugia positivamente.The purpose of this study was to analyse the therapeutic relationship between a nursing student and a 3 years old child during perioperative period . Through the use of careful development assessments, preoperative tours, and therapeutic play techniques her fears and anxiety because of hospitalization and surgery were reduced and the surgical experience was lived by the child in a constructive manner. Parents and peri-operative team have evaluated positively the preparation and assessment of the child for surgery.
Awad, Sherif; Lobo, Dileep N
To highlight recent developments in the field of perioperative nutritional support by reviewing clinically pertinent English language articles from October 2008 to December 2010, that examined the effects of malnutrition on surgical outcomes, optimizing metabolic function and nutritional status preoperatively and postoperatively. Recognition of patients with or at risk of malnutrition remains poor despite the availability of numerous clinical aids and clear evidence of the adverse effects of poor nutritional status on postoperative clinical outcomes. Unfortunately, poor design and significant heterogeneity remain amongst many studies of nutritional interventions in surgical patients. Patients undergoing elective surgery should be managed within a multimodal pathway that includes evidence-based interventions to optimize nutritional status perioperatively. The aforementioned should include screening patients to identify those at high nutritional risk, perioperative immuno-nutrition, minimizing 'metabolic stress' and insulin resistance by preoperative conditioning with carbohydrate-based drinks, glutamine supplementation, minimal access surgery and enhanced recovery protocols. Finally gut-specific nutrients and prokinetics should be utilized to improve enteral feed tolerance thereby permitting early enteral feeding. An evidence-based multimodal pathway that includes interventions to optimize nutritional status may improve outcomes following elective surgery.
Meehan, Anita J; Beinlich, Nancy R; Hammonds, Tracy L
Pressure injuries negatively affect patients physically, emotionally, and economically. Studies report that pressure injuries occur in 69% of inpatients who have undergone a surgical procedure while hospitalized. In 2012, we created a nurse-initiated, perioperative pressure injury risk assessment measure for our midwestern, urban, adult teaching hospital. We retrospectively applied the risk assessment to a random sample of 350 surgical patients which validated the measure. The prospective use of the risk assessment and prevention measures in 350 surgical patients resulted in a 60% reduction in pressure injuries compared with the retrospective group. Our findings support the use of a multipronged approach for the prevention of health care-associated pressure injuries in the surgical population, which includes assessment of risk, implementation of evidence-based prevention interventions for at-risk patients, and continuation of prevention beyond the perioperative setting to the nursing care unit. Copyright Â© 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Full Text Available Mohamed Adnane Berdai, Smael Labib, Mustapha HarandouChild and Mother Intensive Care Unit, University Hospital Hassan II, Fes, MoroccoBackground: Transfusion-related acute lung injury (TRALI is one of the leading causes of transfusion-related morbidity and mortality. Although it is a serious complication of blood transfusion, it is still underestimated because of underrecognition and misdiagnosis, which can lead to inappropriate management.Case report: We report the case of a 34-year-old female, who presented with hemorrhagic shock during cesarean section and was transfused with packed red blood cells and fresh frozen plasma. Three hours after the end of transfusion, while still intubated, the patient developed acute respiratory failure, with diffuse crackles at auscultation and bilateral lung infiltrations on chest radiography. The ratio of the arterial partial pressure of O2 and the fraction of inspired O2 (PaO2/FiO2 was 51. The diagnosis of TRALI was made after excluding other possible causes of acute lung injury. She was managed symptomatically with ventilatory support and vasopressors. The patient later died secondary to multiple organ failure.Conclusion: The diagnosis of TRALI relies on the exclusion of other causes of acute pulmonary edema following transfusion. All plasma-containing blood products have been involved in the genesis of this syndrome. This is a relatively common and serious adverse transfusion reaction that requires prompt diagnosis and management. Challenges are ahead as preventive strategies have reduced but not eliminated the onset of TRALI.Keywords: acute lung injury, transfusion related acute lung injury, anti-human leukocyte antigen antibody, pulmonary edema, transfusion accident
Bergman, Gert J D; Winter, Jan C; van Tulder, Maurits W; Meyboom-de Jong, Betty; Postema, Klaas; van der Heijden, Geert J M G
Shoulder complaints are common in primary care and have unfavourable long term prognosis. Our objective was to evaluate the clinical effectiveness of manipulative therapy of the cervicothoracic spine and the adjacent ribs in addition to usual medical care (UMC) by the general practitioner in the treatment of shoulder complaints. This economic evaluation was conducted alongside a randomized trial in primary care. Included were 150 patients with shoulder complaints and a dysfunction of the cervicothoracic spine and adjacent ribs. Patients were treated with UMC (NSAID's, corticosteroid injection or referral to physical therapy) and were allocated at random (yes/no) to manipulative therapy (manipulation and mobilization). Patient perceived recovery, severity of main complaint, shoulder pain, disability and general health were outcome measures. Data about direct and indirect costs were collected by means of a cost diary. Manipulative therapy as add-on to UMC accelerated recovery on all outcome measures included. At 26 weeks after randomization, both groups reported similar recovery rates (41% vs. 38%), but the difference between groups in improvement of severity of the main complaint, shoulder pain and disability sustained. Compared to the UMC group the total costs were higher in the manipulative group (€1167 vs. €555). This is explained mainly by the costs of the manipulative therapy itself and the higher costs due sick leave from work. The cost effectiveness ratio showed that additional manipulative treatment is more costly but also more effective than UMC alone. The cost-effectiveness acceptability curve shows that a 50%-probability of recovery with AMT within 6 months after initiation of treatment is achieved at €2876. Manipulative therapy in addition to UMC accelerates recovery and is more effective than UMC alone on the long term, but is associated with higher costs. INTERNATIONAL STANDARD RANDOMIZED CONTROLLED TRIAL NUMBER REGISTER: ISRCTN11216.
Bergman Gert JD
Full Text Available Abstract Background Shoulder complaints are common in primary care and have unfavourable long term prognosis. Our objective was to evaluate the clinical effectiveness of manipulative therapy of the cervicothoracic spine and the adjacent ribs in addition to usual medical care (UMC by the general practitioner in the treatment of shoulder complaints. Methods This economic evaluation was conducted alongside a randomized trial in primary care. Included were 150 patients with shoulder complaints and a dysfunction of the cervicothoracic spine and adjacent ribs. Patients were treated with UMC (NSAID's, corticosteroid injection or referral to physical therapy and were allocated at random (yes/no to manipulative therapy (manipulation and mobilization. Patient perceived recovery, severity of main complaint, shoulder pain, disability and general health were outcome measures. Data about direct and indirect costs were collected by means of a cost diary. Results Manipulative therapy as add-on to UMC accelerated recovery on all outcome measures included. At 26 weeks after randomization, both groups reported similar recovery rates (41% vs. 38%, but the difference between groups in improvement of severity of the main complaint, shoulder pain and disability sustained. Compared to the UMC group the total costs were higher in the manipulative group (€1167 vs. €555. This is explained mainly by the costs of the manipulative therapy itself and the higher costs due sick leave from work. The cost effectiveness ratio showed that additional manipulative treatment is more costly but also more effective than UMC alone. The cost-effectiveness acceptability curve shows that a 50%-probability of recovery with AMT within 6 months after initiation of treatment is achieved at €2876. Conclusion Manipulative therapy in addition to UMC accelerates recovery and is more effective than UMC alone on the long term, but is associated with higher costs. International Standard
Gao, Weili; Plummer, Virginia; Williams, Allison
To explore and evaluate perioperative nurses' experience of organ procurement. Organ procurement is part of the organ donation process, and is typically performed in the perioperative setting. This experience may contribute to perioperative nurses' feelings of distress and negative attitudes towards organ donation. Systematic review of the literature. Primary research studies, published in the English language between 1990-2014 were identified, screened and appraised using Joanna Briggs Institute appraisal tools. Data extraction and analysis followed. The quality assessment resulted in seven qualitative and three quantitative research studies. The main findings were: (1) Perioperative nurses reported feeling emotionally distressed, challenged, lonely and physically drained throughout the entire organ procurement procedure. (2) Perioperative nurses reported finding their own unique self-coping strategies and ways of eliciting support. (3) Perioperative nurses had positive and negative attitudes towards organ donation. Perioperative nurses reported feelings of sadness, feeling challenged and physically drained through the entire organ procurement procedure, which were influenced by differing factors in the preoperative, intraoperative and postoperative stages. It is acknowledged that personal coping strategies and support are important to help perioperative nurses improve their psychological well-being, and their experiences and attitudes towards organ procurement and donation. The meaningfulness of these findings for practice policy and research is described. Perioperative nurses play a vital role in the organ procurement procedure and require ongoing support to ensure their psychological welfare, in particular, newly qualified or inexperienced nurses' participating in organ procurement. © 2016 John Wiley & Sons Ltd.
Full Text Available Background. Perioperative aneurysm rupture (PAR is one of the most dreaded complications of intracranial aneurysms, and approximately 80% of nontraumatic SAHs are related to such PAR aneurysms. The literature is currently scant and even controversial regarding the issues of various contributory factors on different phases of perioperative period. Thus this paper highlights the current understanding of various risk factors, variables, and outcomes in relation to PAR and try to summarize the current knowledge. Method. We have performed a PubMed search (1 January 1991–31 December 2012 using search terms including “cerebral aneurysm,” “intracranial aneurysm,” and “intraoperative/perioperative rupture.” Results. Various risk factors are summarized in relation to different phases of perioperative period and their relationship with outcome is also highlighted. There exist many well-known preoperative variables which are responsible for the highest percentage of PAR. The role of other variables in the intraoperative/postoperative period is not well known; however, these factors may have important contributory roles in aneurysm rupture. Preoperative variables mainly include natural course (age, gender, and familial history as well as the pathophysiological factors (size, type, location, comorbidities, and procedure. Previously ruptured aneurysm is associated with rupture in all the phases of perioperative period. On the other hand intraoperative/postoperative variables usually depend upon anesthesia and surgery related factors. Intraoperative rupture during predissection phase is associated with poor outcome while intraoperative rupture at any step during embolization procedure imposes poor outcome. Conclusion. We have tried to create such an initial categorization but know that we cannot scale according to its clinical importance. Thorough understanding of various risk factors and other variables associated with PAR will assist in better
I describe the future accelerator facilities that are currently foreseen for electroweak scale physics, neutrino physics, and nuclear structure. I will explore the physics justification for these machines, and suggest how the case for future accelerators can be made.
Aliasgar V Moiyadi
Full Text Available Background: Perioperative outcomes following surgery for brain tumors are an important indicator of the safety as well as efficacy of surgical intervention. Perioperative morbidity not only has implications on direct patient care, but also serves as an indicator of the quality of care provided, and enables objective documentation, for comparision in various clinical trials. We document our experience at a tertiary care referral, a dedicated neuro-oncology center in India. Materials and Methods: One hundred and ninety-six patients undergoing various surgeries for intra-axial brain tumors were analyzed. Routine microsurgical techniques and uniform antibiotic policy were used. Navigation/ intraoperative electrophysiological monitoring was not available. The endpoints assessed included immediate postoperative neurological status, neurological outcome at discharge, regional complications, systemic complications, overall morbidity, and mortality. Various risk factors assessed included clinico-epidemiological factors, tumor-related factors, and surgery-related factors. Univariate and multivariate analysis were performed. Results: Median age was 38 years. 72% had tumors larger than 4 cm. Neurological morbidity, and regional and systemic complications occurred in 16.8, 17.3, and 10.7%, respectively. Overall, major morbidity occurred in 18% and perioperative mortality rate was 3.6%. Although a few of the known risk factors were found to be significant on univariate analysis, none achieved significance on multivariate analysis. Conclusions: Our patients were younger and had larger tumors than are generally reported. Despite the unavailability of advanced intraoperative aids we could achieve acceptable levels of morbidity and mortality. Objective recording of perioperative events is crucial to document outcomes after surgery for brain tumors.
Rothman, Brian S; Gupta, Rajnish K; McEvoy, Matthew D
Throughout the history of medicine, physicians have relied upon disruptive innovations and technologies to improve the quality of care delivered, patient outcomes, and patient satisfaction. The implementation of mobile technology in health care is quickly becoming the next disruptive technology. We first review the history of mobile technology over the past 3 decades, discuss the impact of hardware and software, explore the rapid expansion of applications (apps), and evaluate the adoption of mobile technology in health care. Next, we discuss how technology serves as the vehicle that can transform traditional didactic learning into one that adapts to the learning behavior of the student by using concepts such as the flipped classroom, just-in-time learning, social media, and Web 2.0/3.0. The focus in this modern education paradigm is shifting from teacher-centric to learner-centric, including providers and patients, and is being delivered as context-sensitive, or semantic, learning. Finally, we present the methods by which connected health systems via mobile devices increase information collection and analysis from patients in both clinical care and research environments. This enhanced patient and provider connection has demonstrated benefits including reducing unnecessary hospital readmissions, improved perioperative health maintenance coordination, and improved care in remote and underserved areas. A significant portion of the future of health care, and specifically perioperative medicine, revolves around mobile technology, nimble learners, patient-specific information and decision-making, and continuous connectivity between patients and health care systems. As such, an understanding of developing or evaluating mobile technology likely will be important for anesthesiologists, particularly with an ever-expanding scope of practice in perioperative medicine.
Søndergaard, Susanne F; Lorentzen, Vibeke; Sørensen, Erik E; Frederiksen, Kirsten
Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses' level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses' documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses' documentation practices and that a tailored EHR may improve documentation practices. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Rio, E; Bardet, E; Peuvrel, P; Martinet, L; Perrot, P; Baraer, F; Loirat, Y; Sartre, J-Y; Malard, O; Ferron, C; Dreno, B
Evaluation of the results of perioperative interstitial brachytherapy with low dose-rate (LDR) Ir-192 in the treatment of keloid scars. We performed a retrospective analysis of 73 histologically confirmed keloids (from 58 patients) resistant to medicosurgical treated by surgical excision plus early perioperative brachytherapy. All lesions were initially symptomatic. Local control was evaluated by clinical evaluation. Functional and cosmetic results were assessed in terms of patient responses to a self-administered questionnaire. Median age was 28 years (range 13-71 years). Scars were located as follows: 37% on the face, 32% on the trunk or abdomen, 16% on the neck, and 15% on the arms or legs. The mean delay before loading was four hours (range, 1-6h). The median dose was 20Gy (range, 15-40Gy). Sixty-four scars (from 53 patients) were evaluated. Local control was 86% (follow-up, 44.5 months; range, 14-150 months). All relapses occurred early - within 2 years posttreatment. At 20 months, survival without recurrence was significantly lower when treated lengths were more than 6cm long. The rate was 100% for treated scars below 4.5cm in length, 95% (95% CI: 55-96) for those 4.5-6cm long, and 75% (95% CI: 56-88) beyond 6cm (p=0.038). Of the 35 scars (28 patients) whose results were reassessed, six remained symptomatic and the esthetic results were considered to be good in 51% (18/35) and average in 37% (13/35) (median follow-up, 70 months; range, 16-181 months). Early perioperative LDR brachytherapy delivering 20Gy at 5mm reduced the rate of recurrent keloids resistant to other treatments and gave good functional results. 2009 Société française de radiothérapie oncologique (SFRO). Published by Elsevier SAS. All rights reserved.
Henry, D A; Moxey, A J; Carless, P A; O'Connell, D; McClelland, B; Henderson, K M; Sly, K; Laupacis, A; Fergusson, D
Public concerns regarding the safety of transfused blood have prompted re-consideration of the use of allogeneic (from an unrelated donor) red blood cell (RBC) transfusion, and a range of techniques designed to minimise transfusion requirements. To examine the evidence for the efficacy of desmopressin (1-deamino-8-D-arginine-vasopressin), in reducing perioperative blood loss and the need for red cell transfusion in patients who do not have congenital bleeding disorders. Articles were identified by: computer searches of OVID MEDLINE, EMBASE, and Current Contents (to August 2000) and web sites of international health technology assessment agencies (to May 1998). References in the identified trials and review articles were checked and authors contacted to identify additional studies. Randomised controlled parallel group trials in which adult patients, scheduled for non-urgent surgery, were randomised to DDAVP, or to a control group, who did not receive the intervention. Trial quality was assessed using criteria proposed by Schulz et al. (1995) and Jadad et al. (1996). The principal outcomes were: the number of patients exposed to red cells, and the amount of blood transfused. Other clinical outcomes are detailed in the review. Fourteen trials of DDAVP (N=1034) reported data on the proportion of patients exposed to allogeneic RBC transfusion. In subjects treated with DDAVP the relative risk of exposure to peri-operative allogeneic blood transfusion was 0.98 (95%CI: 0.88 to 1.10) compared with control. In DDAVP-treated patients the relative risk of requiring re-operation due to bleeding was 0.56 (95%CI: 0.18 to 1.73). There was no statistically significant effect overall for mortality and non-fatal myocardial infarction in DDAVP-treated patients compared with control (RR=1.53: 95%CI: 0.58 to 4.05) and (RR=1.52: 95%CI: 0.67 to 3.49) respectively. There is no convincing evidence that desmopressin minimises perioperative allogeneic RBC transfusion in patients who do not
Kilbourne, Amy M; Elwy, A Rani; Sales, Anne E; Atkins, David
Since 1998, the Veterans Health Administration (VHA) Quality Enhancement Research Initiative (QUERI) has supported more rapid implementation of research into clinical practice. With the passage of the Veterans Access, Choice and Accountability Act of 2014 (Choice Act), QUERI further evolved to support VHA's transformation into a Learning Health Care System by aligning science with clinical priority goals based on a strategic planning process and alignment of funding priorities with updated VHA priority goals in response to the Choice Act. QUERI updated its strategic goals in response to independent assessments mandated by the Choice Act that recommended VHA reduce variation in care by providing a clear path to implement best practices. Specifically, QUERI updated its application process to ensure its centers (Programs) focus on cross-cutting VHA priorities and specify roadmaps for implementation of research-informed practices across different settings. QUERI also increased funding for scientific evaluations of the Choice Act and other policies in response to Commission on Care recommendations. QUERI's national network of Programs deploys effective practices using implementation strategies across different settings. QUERI Choice Act evaluations informed the law's further implementation, setting the stage for additional rigorous national evaluations of other VHA programs and policies including community provider networks. Grounded in implementation science and evidence-based policy, QUERI serves as an example of how to operationalize core components of a Learning Health Care System, notably through rigorous evaluation and scientific testing of implementation strategies to ultimately reduce variation in quality and improve overall population health.
The WHO Safe Surgery Checklist (2008) patient safety focus and communication prompts are widely accepted. In many low-income regions (as defined by the World Bank and accepted by the World Health Organization) perioperative nurses have little or no formal training; continuing and in-service education are virtually unknown; nor does an articulated "culture of safety" exist. In 2009 the Canadian Network for International Surgery (CNIS) piloted a two-day perioperative nursing course, in Addis Ababa, Ethiopia, using lectures, case studies, skills sessions, and role-play exercises based on the SSSL Checklist outline and protocols. Canadian instructors (who are certified after taking the Canadian Network for International Surgery-sponsored Instructor's Course) have since returned and taught at additional sites in Ethiopia and Uganda. Course participants now include perioperative nurses, anaesthetists, and junior surgical residents--mirroring the interdisciplinary teamwork that is crucial to safe perioperative patient care. The course's facilitated discussions focus on workplace and practice issues in order to allow for appropriate evaluation and planning of future educational initiatives. Participants complete pre- and post-course questionnaires, which evaluate baseline and post-course knowledge, and further follow-up is completed four months after course completion. This article explains the need for aiding in the expansion of perioperative nursing knowledge and skill in low-income settings and provides the author's personal perspective and experience in responding to this need. Her experience as facilitator in a pilot project and subsequent course development described. The objective is to discuss ways that other perioperative nurses can work to make a positive difference on professional practice and patient care in low-income regions.
Hazendonk, H C A M; Lock, J; Mathôt, R A A; Meijer, K; Peters, M; Laros-van Gorkom, B A P; van der Meer, F J M; Driessens, M H E; Leebeek, F W G; Fijnvandraat, K; Cnossen, M H
ESSENTIALS: Targeting of factor VIII values is a challenge during perioperative replacement therapy in hemophilia. This study aims to identify the extent and predictors of factor VIII underdosing and overdosing. Blood group O predicts underdosing and is associated with perioperative bleeding. To increase quality of care and cost-effectiveness of treatment, refining of dosing is obligatory. Perioperative administration of factor VIII (FVIII) concentrate in hemophilia A may result in both underdosing and overdosing, leading to respectively a risk of bleeding complications and unnecessary costs. This retrospective observational study aims to identify the extent and predictors of underdosing and overdosing in perioperative hemophilia A patients (FVIII levels < 0.05 IU mL(-1)). One hundred nineteen patients undergoing 198 elective, minor, or major surgical procedures were included (median age 40 years, median body weight 75 kg). Perioperative management was evaluated by quantification of perioperative infusion of FVIII concentrate and achieved FVIII levels. Predictors of underdosing and (excessive) overdosing were analyzed by logistic regression analysis. Excessive overdosing was defined as upper target level plus ≥ 0.20 IU mL(-1). Depending on postoperative day, 7-45% of achieved FVIII levels were under and 33-75% were above predefined target ranges as stated by national guidelines. A potential reduction of FVIII consumption of 44% would have been attained if FVIII levels had been maintained within target ranges. Blood group O and major surgery were predictive of underdosing (odds ratio [OR] 6.3, 95% confidence interval [CI] 2.7-14.9; OR 3.3, 95% CI 1.4-7.9). Blood group O patients had more bleeding complications in comparison to patients with blood group non-O (OR 2.02, 95% CI 1.00-4.09). Patients with blood group non-O were at higher risk of overdosing (OR 1.5, 95% CI 1.1-1.9). Additionally, patients treated with bolus infusions were at higher risk of excessive
Paavilainen, E; Seppanen, S; Astedt-Kurki, P
The purpose of this study was to describe how adult patients undergoing emergency surgery experience family centredness in perioperative nursing practice. The central aim was to generate knowledge to be used while developing the practice, education and management of perioperative nursing. Data were collected using a questionnaire with emergency surgical patients in five regional hospitals in Southern Finland. The number of distributed questionnaires was 132. The response rate was 85% (n = 112). The results were mainly described as frequencies and percentages. The open-ended sections of the answers were analysed using qualitative content analysis. The findings from the open-ended questions were used for deepening and complementing the quantitative description of the results. In the preoperative phase, ascertaining the family situation and informing the family member chosen by the patient were not achieved systematically. Family situation was also rarely examined in the intraoperative and postoperative phases, although it is central to coping after surgery, especially in home care. The results support the view of earlier research about the importance of individuality of patients and their families during the perioperative care process and hence enhance the endeavour to develop nursing based on families' real needs.
White, Klane K; Bompadre, Viviana; Goldberg, Michael J; Bober, Michael B; Cho, Tae-Joon; Hoover-Fong, Julie E; Irving, Melita; Mackenzie, William G; Kamps, Shawn E; Raggio, Cathleen; Redding, Gregory J; Spencer, Samantha S; Savarirayan, Ravi; Theroux, Mary C
Patients with skeletal dysplasia frequently require surgery. This patient population has an increased risk for peri-operative complications related to the anatomy of their upper airway, abnormalities of tracheal-bronchial morphology and function; deformity of their chest wall; abnormal mobility of their upper cervical spine; and associated issues with general health and body habitus. Utilizing evidence analysis and expert opinion, this study aims to describe best practices regarding the peri-operative management of patients with skeletal dysplasia. A panel of 13 multidisciplinary international experts participated in a Delphi process that included a thorough literature review; a list of 22 possible care recommendations; two rounds of anonymous voting; and a face to face meeting. Those recommendations with more than 80% agreement were considered as consensual. Consensus was reached to support 19 recommendations for best pre-operative management of patients with skeletal dysplasia. These recommendations include pre-operative pulmonary, polysomnography; cardiac, and neurological evaluations; imaging of the cervical spine; and anesthetic management of patients with a difficult airway for intubation and extubation. The goals of this consensus based best practice guideline are to provide a minimum of standardized care, reduce perioperative complications, and improve clinical outcomes for patients with skeletal dysplasia. © 2017 Wiley Periodicals, Inc.
Torossian, Alexander; Van Gerven, Elke; Geertsen, Karin; Horn, Bengt; Van de Velde, Marc; Raeder, Johan
Incidence of inadvertent perioperative hypothermia is still high; therefore, present guidelines advocate "prewarming" for its prevention. Prewarming means preoperative patient skin warming, which minimizes redistribution hypothermia caused by induction of anesthesia. In this study, we compared the new self-warming BARRIER EasyWarm blanket with passive thermal insulation regarding mean perioperative patient core body temperature. Multinational, multicenter randomized prospective open-label controlled trial. Surgical ward, operation room, postanesthesia care unit at 4 European hospitals. A total of 246 adult patients, American Society of Anesthesiologists class I to III undergoing elective orthopedic; gynecologic; or ear, nose, and throat surgery scheduled for 30 to 120 minutes under general anesthesia. Patients received warmed hospital cotton blankets (passive thermal insulation, control group) or BARRIER EasyWarm blanket at least 30 minutes before induction of general anesthesia and throughout the perioperative period (intervention group). The primary efficacy outcome was the perioperative mean core body temperature measured by a tympanic infrared thermometer. Secondary outcomes were hypothermia incidence, change in core body temperature, length of stay in postanesthesia care unit, thermal comfort, patient satisfaction, ease of use, and adverse events related to the BARRIER EasyWarm blanket. The BARRIER EasyWarm blanket significantly improved perioperative core body temperature compared with standard hospital blankets (36.5°C, SD 0.4°C, vs 36.3, SD 0.3°C; Pthermal comfort scores, preoperatively and postoperatively. No serious adverse effects were observed in either group. Perioperative use of the new self-warming blanket improves mean perioperative core body temperature, reduces the incidence of inadvertent perioperative hypothermia, and improves patients' thermal comfort during elective adult surgery. Copyright © 2016 The Authors. Published by Elsevier Inc
Levin, Rona F; Wright, Fay; Pecoraro, Kathleen; Kopec, Wendy
Unintentional perioperative hypothermia has been shown to cause serious patient complications and, thus, to increase health care costs. In 2009, an evidence-based practice improvement project produced a significant decrease in unintentional perioperative hypothermia in colorectal surgical patients through monitoring of OR ambient room temperature. Project leaders engaged all interdisciplinary stakeholders in the original project, which facilitated the sustainability of the intervention method. An important aspect of sustainability is ongoing monitoring and evaluation of a new intervention method. Therefore, continued evaluation of outcomes of the protocol developed in 2009 was scheduled at specific time points after the initial small test of change with colorectal patients. This article focuses on how attention to sustainability factors during implementation of an improvement project led to the sustainability of a protocol for monitoring OR ambient room temperature with all types of surgical patients five years after the initial project. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Muñoz, M; Acheson, A G; Auerbach, M
the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency...... in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace......Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed...
Full Text Available Aim: The aim of the study was to describe how the basic concepts, human being, health, suffering, caring and culture appear in perioperative practice in order to obtain an understanding of the concepts in practice.Methods: A hermeneutic text interpretation of results from ten previous studies and reports from perioperative research meetings with co-researchers was conducted in order to gain an understanding ofthe concepts in practice.Results: The basic concepts were understood as; The human being–the patient and the nurse. Patient is a suffering human being who has been betrayed by the body; a body that needs to undergo surgery. Nurse-the caring human being, whose ethos is embedded in human dignity and emerges in their caring acts. Health–to be a unique human being:someone who wants to be taken seriously wants to become involved,to be considered a resource and to establish a communion. Suffering–a struggle between good and evil: Suffering exists in different forms. Suffering in care can be a result of the staff behaviour towards the patient and towards each other, how caring/the work is organized, or how the nurses’ time with the patients is planned. Caring–to be there for the patient; the nurses’ care for the patient, taking the patient seriously and safeguarding the patient’s dignity.The culture–material and spiritual culture: human dignity is the ethos of the perioperative culture and appears as confirmed or violated dignity and value conflicts.
Phillips, Anthony George; Hongaard-Andersen, Peter; Moscicki, Richard A; Sahakian, Barbara; Quirion, Rémi; Krishnan, K Ranga Rama; Race, Tim
Central nervous system (CNS) diseases and, in particular, mental health disorders, are becoming recognized as the health challenge of the 21(st) century. Currently, at least 10% of the global population is affected by a mental health disorder, a figure that is set to increase year on year. Meanwhile, the rate of development of new CNS drugs has not increased for many years, despite unprecedented levels of investment. In response to this state of affairs, the Collegium Internationale Neuro-Psychopharmacologicum (CINP) convened a summit to discuss ways to reverse this disturbing trend through new partnerships to accelerate CNS drug discovery. The objectives of the Summit were to explore the issues affecting the value chain (i.e. the chain of activities or stakeholders that a company engages in/with to deliver a product to market) in brain research, thereby gaining insights from key stakeholders and developing actions to address unmet needs; to identify achievable objectives to address the issues; to develop action plans to bring about measurable improvements across the value chain and accelerate CNS drug discovery; and finally, to communicate recommendations to governments, the research and development community, and other relevant stakeholders. Summit outputs include the following action plans, aligned to the pressure points within the brain research-drug development value chain: Code of conduct dealing with conflict of interest issues, Prevention, early diagnosis, and treatment, Linking science and regulation, Patient involvement in trial design, definition of endpoints, etc., Novel trial design, Reproduction and confirmation of data, Update of intellectual property (IP) laws to facilitate repurposing and combination therapy (low priority), Large-scale, global patient registries, Editorials on nomenclature, biomarkers, and diagnostic tools, and Public awareness, with brain disease advocates to attend G8 meetings and World Economic Forum (WEF) Annual meetings in
Gandhi, Gunjan Y; Murad, M Hassan; Flynn, Errol David
To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of perioperative insulin infusion on outcomes important to patients.......To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of perioperative insulin infusion on outcomes important to patients....
Sep 14, 2010 ... Abstract. This article presents the perioperative anaesthetic management of a patient with Bernard-Soulier syndrome. (BSS). A literature search was conducted to examine the perioperative haemostatic management of BSS, with particular focus on the developing role of recombinant factor VIIa. The early ...
Surgery patients are at risk for iatrogenic malnutrition and subsequent deleterious effects. The benefits of nutrition support on patient outcomes have been demonstrated and the possible benefit of perioperative nutrition support thus implied. Enhanced recovery after surgery (ERAS) protocols, including perioperative nutrition ...
Based on the findings of this systematic review and the recently published Clopidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT), it can be concluded that the prevention of peri-operative myocardial ischaemia with a betablocker is clinically more important to peri-operative cardioprotection than whether the ...
Beloeil, H; Sulpice, L
Recent advances in the management of peri-operative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain pre-operatively, pre-operative opioid use, and the intensity of post-operative pain. Ideal management of peri-operative pain in 2015 aims to optimize post-operative pain management, to detect the risk of pain chronicity begins pre-operatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in post-operative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer , and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intra-operative and post-operative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications. Copyright Â© 2016. Published by Elsevier Masson SAS.
Asher, Daniel I; Avery, Edwin G
Hypertension affects approximately one third of the U.S. population and is the most common preventable medical reason that surgical cases are postponed or cancelled. However, subtypes of hypertension and their perioperative risks are poorly studied and understood. We will review the natural history and pathophysiology of essential hypertension and discuss the perioperative significance of diastolic blood pressure elevation. There is evidence that elevated preoperative diastolic blood pressures are associated with an increased perioperative risk of cardiovascular and cerebrovascular events and increased postoperatively 30-day mortality. However, lower preoperative diastolic blood pressures were found, in one study, to be associated with renal injury. Diastolic hypertension and hypotension both carry perioperative risk. Further study needs to be dedicated to elucidating the risks and developing strategies for acute and chronic management of diastolic blood pressure changes in order to improve perioperative safety.
Kent, Michael L; Hsia, Hung-Lun John; Van de Ven, Thomas J; Buchheit, Thomas E
To review acute pain management strategies in patients undergoing amputation with consideration of preoperative patient factors, pharmacologic/interventional modalities, and multidisciplinary care models to alleviate suffering in the immediate post-amputation setting. Regardless of surgical indication, patients undergoing amputation suffer from significant residual limb pain and phantom limb pain in the acute postoperative phase. Most studies have primarily focused on strategies to prevent persistent pain with inclusion of immediate postoperative outcomes as secondary measures. Pharmacologic agents, including gabapentin, ketamine, and calcitonin, and interventional modalities such as neuraxial and perineural catheters, have been examined in the perioperative period. Focused Literature Review. Pharmacologic agents (gabapentin, ketamine, calcitonin) have not shown consistent efficacy. Neuraxial analgesia has demonstrated both an opioid sparing and analgesic benefit while results have been mixed regarding perineural catheters in the immediate post-amputation setting. However, several early studies of perineural catheters employed sub-optimal techniques (distal surgical placement), and prolonged use of perineural catheters may provide a sustained benefit. Regardless of analgesic technique, a multidisciplinary approach is necessary for optimal care. Patient-tailored analgesic regimens utilizing catheter-based techniques are essential in the acute post-amputation phase and should be implemented in all patients undergoing amputation. Future research should focus on improved measurement of acute pain and comparisons of effective analgesic regimens instead of single techniques.
The principle of electrostatic accelerators is presented. We consider Cockcroft Walton, Van de Graaff and Tandem Van de Graaff accelerators. We resume high voltage generators such as cascade generators, Van de Graaff band generators, Pelletron generators, Laddertron generators and Dynamitron generators. The speci c features of accelerating tubes, ion optics and methods of voltage stabilization are described. We discuss the characteristic beam properties and the variety of possible beams. We ...
The principle of electrostatic accelerators is presented. We consider Cockcroft Walton, Van de Graaff and Tandem Van de Graaff accelerators. We resume high voltage generators such as cascade generators, Van de Graaff band generators, Pelletron generators, Laddertron generators and Dynamitron generators. The speci c features of accelerating tubes, ion optics and methods of voltage stabilization are described. We discuss the characteristic beam properties and the variety of possible beams. We sketch possible applications and the progress in the development of electrostatic accelerators.
Jonsson, Eythor Ivar
accelerator programs. Microsoft runs accelerators in seven different countries. Accelerators have grown out of the infancy stage and are now an accepted approach to develop new ventures based on cutting-edge technology like the internet of things, mobile technology, big data and virtual reality. It is also...... an approach to facilitate implementation and realization of business ideas and is a lucrative approach to transform research into ventures and to revitalize regions and industries in transition. Investors have noticed that the accelerator approach is a way to increase the possibility of success by funnelling...... with the traditional audit and legal universes and industries are examples of emerging potentials both from a research and business point of view to exploit and explore further. The accelerator approach may therefore be an Idea Watch to consider, no matter which industry you are in, because in essence accelerators...
Gimbler Berglund, Ingalill; Huus, Karina; Enskär, Karin; Faresjö, Maria; Björkman, Berit
The overall aim of this study was to describe the current set of guidelines for the preparation and care for children with autism spectrum disorder (ASD) in the perioperative setting across Sweden and explore the content of these guidelines in detail. An online questionnaire was distributed to the chairpersons of all anesthesia departments (n = 68) and pediatric departments (n = 38) throughout Sweden. Follow-up phone calls were made to those departments that did not return the questionnaire. The presence of guidelines was analyzed through descriptive statistics. These guidelines and comments on routines used in these departments were analyzed inspired by conventional content analysis. Seven of the 68 anesthesia departments and none of the 38 pediatric departments across Sweden have guidelines for preparing and/or administering care to children with ASD within the perioperative setting. From the guidelines and routines used, 3 categories emerge: "lacking the necessary conditions," "no extra considerations needed," and "care with specific consideration for children with ASD." These 3 categories span a continuum in the care. In the first category, the anesthesia induction could result in the child with ASD being physically restrained. In the last category, the entire encounter with the health care service would be adapted to the specific needs of the child. There is a lack of evidence-based guidelines specifically designed to meet the needs of children with ASD in the preoperative period in Sweden. Further research is needed to understand if children with ASD would benefit from evidence-based guidelines.
The prototype module of LIBO, a linear accelerator project designed for cancer therapy, has passed its first proton-beam acceleration test. In parallel a new version - LIBO-30 - is being developed, which promises to open up even more interesting avenues.
Dumancić, Jelena; Marković, Asja Stipić
A large number of individuals experiencing anaphylactic reaction to neuromuscular blocking agents have not previously been in contact with them. The search for a substance inducing sensitization to muscle relaxants has led Norwegian and Swedish scientists to pholcodine, a cough suppressant, which is widely used in Europe and worldwide. Ammonium ion is an epitope common to pholcodine and neuromuscular blocking agents and it is the basis of their cross-reactivity. Based on the results of published studies that pointed to a connection of the use of pholcodine and perioperative anaphylactic reaction, pholcodine was withdrawn from the Norwegian market and subsequent research revealed a reduction of anaphylactic reactions in that country. In its latest report, the European Medicines Agency made a decision not to withdraw pholcodine mixtures from the market but it urged further research with the aim to clarify the cross-reactivity between pholcodine and neuromuscular blocking agents.
Carry, P Y; Dubost, J; Roche, C; Baud, A V; Breton, P; Freidel, M; Gueugniaud, P Y
To describe per and postoperative medical complications. Prospective, observational study. Between July and December 1999, 59 patients scheduled for programmed orthognathic surgery were included. Anaesthetic and surgical procedures were standardised including patient information and training of surgical ward' nurses. During perioperative periods (in operative and recovery theater and in surgical ward), all the events were qualified on an anaesthetic spreadsheet for a qualitative analysis (description of events and treatment procedures). Two main complications were described 1) one atelectasia due to blood inhalation during the recovery period and 2) local sepsis in surgical ward. These two events were medically treated and recovered. No need of blood transfusion or stay in ICU were noted. Anaesthetic and surgical cooperation is associated with poor morbidity of this functional surgery performed in young subjects.
Andersen, Cheme; Afshari, Arash
For more than 50 years, hypotonic fluids (crystalloids) have been the standard for maintenance fluid used in children. In the last decade, several studies have evaluated the risk of hyponatremia associated with the use of hypotonic vs isotonic fluids, which has lead to an intense debate. Children...... hyponatremia is higher in children than in adults. It represents an emergency condition, and early diagnosis, prompt treatment and close monitoring are essential to reduce morbidity and mortality. The widespread use of hypotonic fluids in children undergoing surgery is a matter of concern and more focus...... on this topic is urgently needed. In this paper, we review the literature and describe the impact of perioperative hyponatremia in children....
CERN has been involved in the dissemination of scientific results since its early days and has continuously updated the distribution channels. Currently, Inspire hosts catalogues of articles, authors, institutions, conferences, jobs, experiments, journals and more. Successful orientation among this amount of data requires comprehensive linking between the content. Inspire has lacked a system for linking experiments and articles together based on which accelerator they were conducted at. The purpose of this project has been to create such a system. Records for 156 accelerators were created and all 2913 experiments on Inspire were given corresponding MARC tags. Records of 18404 accelerator physics related bibliographic entries were also tagged with corresponding accelerator tags. Finally, as a part of the endeavour to broaden CERN's presence on Wikipedia, existing Wikipedia articles of accelerators were updated with short descriptions and links to Inspire. In total, 86 Wikipedia articles were updated. This repo...
A broad class of accelerators rests on the induction principle whereby the accelerating electrical fields are generated by time-varying magnetic fluxes. Particularly suitable for the transport of bright and high-intensity beams of electrons, protons or heavy ions in any geometry (linear or circular) the research and development of induction accelerators is a thriving subfield of accelerator physics. This text is the first comprehensive account of both the fundamentals and the state of the art about the modern conceptual design and implementation of such devices. Accordingly, the first part of the book is devoted to the essential features of and key technologies used for induction accelerators at a level suitable for postgraduate students and newcomers to the field. Subsequent chapters deal with more specialized and advanced topics.
Miguel L. Tedde
Full Text Available OBJECTIVE: The standard therapy for patients with high-level spinal cord injury is long-term mechanical ventilation through a tracheostomy. However, in some cases, this approach results in death or disability. The aim of this study is to highlight the anesthetics and perioperative aspects of patients undergoing insertion of a diaphragmatic pacemaker. METHODS: Five patients with quadriplegia following high cervical traumatic spinal cord injury and ventilator-dependent chronic respiratory failure were implanted with a laparoscopic diaphragmatic pacemaker after preoperative assessments of their phrenic nerve function and diaphragm contractility through transcutaneous nerve stimulation. ClinicalTrials.gov: NCT01385384. RESULTS: The diaphragmatic pacemaker placement was successful in all of the patients. Two patients presented with capnothorax during the perioperative period, which resolved without consequences. After six months, three patients achieved continuous use of the diaphragm pacing system, and one patient could be removed from mechanical ventilation for more than 4 hours per day. CONCLUSIONS: The implantation of a diaphragmatic phrenic system is a new and safe technique with potential to improve the quality of life of patients who are dependent on mechanical ventilation because of spinal cord injuries. Appropriate indication and adequate perioperative care are fundamental to achieving better results.
Friend, Tynan H; Jennings, Samantha J; Copenhaver, Martin S; Levine, Wilton C
In the hospital, fast and efficient communication among clinicians and other employees is paramount to ensure optimal patient care, workflow efficiency, patient safety and patient comfort. The implementation of the wireless Vocera® Badge, a hands-free wearable device distributed to perioperative team members, has increased communication efficiency across the perioperative environment at Massachusetts General Hospital (MGH). This quality improvement project, based upon identical pre- and post-implementation surveys, used qualitative and quantitative analysis to determine if and how the Vocera system affected the timeliness of information flow, ease of communication, and operating room noise levels throughout the perioperative environment. Overall, the system increased the speed of information flow and eased communication between coworkers yet was perceived to have raised the overall noise level in and around the operating rooms (ORs). The perceived increase in noise was outweighed by the closed-loop communication between clinicians. Further education of the system's features in regard to speech recognition and privacy along with expected conversation protocol are necessary to ensure hassle-free communication for all staff.
Full Text Available Flaminia Coluzzi,1 Francesca Bifulco,2 Arturo Cuomo,2 Mario Dauri,3 Claudio Leonardi,4 Rita Maria Melotti,5 Silvia Natoli,3 Patrizia Romualdi,6 Gennaro Savoia,7 Antonio Corcione8 1Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anaesthesia, Intensive Care and Pain Medicine, Sapienza University of Rome, Polo Pontino, Latina, 2National Cancer Institute “G Pascale” Foundation, Unit of Anaesthesia, Intensive Care and Pain Medicine, Naples, 3Department of Clinical Science and Translational Medicine, Tor Vergata University of Rome, 4Addiction Disease Department, Local Health Unit (ASL Rome 2, Rome, 5Department of Medical and Surgical Sciences, 6Department of Pharmacy and Biotechnology, Alma Mater Studiorum University of Bologna, Bologna, 7Department Anesthesia, Fatebenefratelli Hospital, Naples, 8Unit of Anaesthesia and Intensive Care, Dei Colli Hospital, V. Monaldi, Naples, Italy Abstract: The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioid-tolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and
Godfrey, Marjorie M; Oliver, Brant J
The Learning and Leadership Collaborative (LLC) supports cystic fibrosis (CF) centres' responses to the variation in CF outcomes in the USA. Between 2002 and 2013, the Cystic Fibrosis Foundation (CFF) designed, tested and modified the LLC to guide front line staff efforts in these efforts. This paper describes the CFF LLC evolution and essential elements that have facilitated increased improvement capability of CF centres and improved CF outcomes. CF centre improvement teams across the USA have participated in 11 LLCs of 12 months' duration since 2002. Based on the Dartmouth Microsystem Improvement Curriculum, the original LLC included face to face meetings, an email listserv, conference calls and completion of between learning session task books. The LLCs evolved over time to include internet based learning, an electronic repository of improvement resources and examples, change ideas driven by evidence based clinical practice guidelines, benchmarking site visits, an applied QI measurement curriculum and team coaching. Over 90% of the CF centres in the USA have participated in the LLCs and have increased their improvement capabilities. Ten essential elements were identified as contributors to the successful LLCs: LLC national leadership and coordination, local leadership, people with CF and families involvement, registry data transparency, standardised improvement curriculum with evidence based change ideas, internet resources with reminders, team coaching, regular progress reporting and tracking, benchmarking site visits and applied improvement measurement. The LLCs have contributed to improved medical and process outcomes over the past 10 years. Ten essential elements of the LLCs may benefit improvement efforts in other chronic care populations and health systems.
Onorati, Francesco; Renzulli, Attilio; De Feo, Marisa; Galdieri, Nicola; Santè, Pasquale; Mastroroberto, Pasquale; Bilotta, Massimo; Cotrufo, Maurizio
To assess whether routine postoperative enoximone infusion compared with dobutamine improved clinical and biochemical results after coronary artery bypass grafting with cardiopulmonary bypass. Prospective nonrandomized study. Data collection was blinded to the choice of inotrope. Double-institutional clinical investigation. Two hundred sixteen consecutive patients undergoing myocardial revascularization between May 2000 and December 2002. Seventy-two patients underwent myocardial revascularization and were treated with enoximone, 5 microg/kg/min (group A). They were compared in a ratio of 1:2 to 144 patients treated with dobutamine at the same dose (group B) after aortic cross-clamp removal. The groups proved to be homogenous in preoperative and intraoperative characteristics. Hospital outcome, electrocardiogram, echocardiography, further inotropic support, and biochemical markers of ischemia were compared. Subsets of patients with comorbidities and total arterial revascularization were analyzed. Perioperative myocardial infarction, postoperative low-output syndrome, intra-aortic balloon pump, atrial fibrillation, ST-segment changes, postoperative echocardiographic findings, and intensive care and hospital durations were similar between groups. In the postoperative course, more patients belonging to group A maintained low-dose inotropic support, whereas more patients belonging to group B required higher doses. Troponin I and creatine kinase-MB values were higher in patients of group B, especially when subgroups with diabetes, left ventricular hypertrophy, or total arterial revascularization were included. Postoperative enoximone reduced troponin I release and need for inotropic support in patients undergoing on-pump myocardial revascularization. Subgroup data were confirmed in diabetes, left ventricular hypertrophy, and total arterial revascularization.
Competence to practise in the perioperative environment requires specialist knowledge (Gillespie and Hamlin, 2009). Newly qualified staff in this environment can experience difficulty in making the transition into practice (Stratton, 2011) and often feel overwhelmed by the skills required (Callaghan, 2010). Simulation-based learning techniques are increasingly used by practice educators specifically within these environments (Cato and Murray, 2010) to aid with acquisition of skills, emergency care delivery, general post-registration development and also as a standardised indicator of 'competence' (Bullock et al, 2008; Cato and Murray, 2010). This article will consider the impact of this educational strategy on the learner's lifelong development following registration, and its position in relation to the widely accepted learning paradigms of Benner's 'Novice to Expert' and Maslow's 'Hierarchy of Needs'. Through discussion of the nature of education in the practice setting, the reader will be prompted to reconsider the actual value of simulation-based learning in the post-registration arena and how this may be used to redefine simulation in the clinical setting.
More than 500,000 health care workers are exposed to surgical smoke every year. Toxic gases create an offensive odor, small particulate matter causes respiratory complications, and pathogens may be transmitted in the surgical smoke to the surgical team. Previous research notes that perioperative nurses do not consistently follow smoke evacuation recommendations. The purpose of this study was to determine key indicators that are associated with compliance with smoke evacuation recommendations. Data from a web-based survey completed by 777 nurse members of AORN were analyzed to examine the relationship between the key indicators and compliance with smoke evacuation recommendations. Major findings were that specific key indicators influencing compliance include increased knowledge and training, positive perceptions about the complexity of the recommendations, and increased specialization, interconnectedness, and leadership support in larger facilities. Education programs can be developed that directly address these key predictors so that a surgical environment free from surgical smoke is promoted. 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.
In this series of lectures we review observational evidence for, and theoretical investigations into, cosmic acceleration and dark energy. The notes are in four sections. First I review the basic cosmological formalism to describe the expansion history of the universe and how distance measures are defined. The second section covers the evidence for cosmic acceleration from cosmic distance measurements. Section 3 discusses the theoretical avenues being considered to explain the cosmological observations. Section 4 discusses how the growth of inhomogeneities and large scale structure observations might help us pin down the theoretical origin of cosmic acceleration.
Kamiyoshihara, Mitsuhiro; Igai, Hitoshi; Ibe, Takashi; Kawatani, Natsuko; Uchiyama, Toshio; Gomi, Akinori; Takahashi, Sayako; Otake, Hiroaki; Shimizu, Kimihiro; Mogi, Akira; Kuwano, Hiroyuki
To prevent oral problems in lung cancer patients, dental intervention should be performed in conjunction with cancer treatment in cancer base hospitals. This paper reports on the perioperative oral care management of lung cancer patients. From January 2013 to August 2015, perioperative oral management was performed in 123 patients undergoing pulmonary lobectomy. We ensure cooperation between the departments of medicine and dentistry. First, the dentist plans oral management based on the patient's individual oral status. Then, the actual oral management is performed by an in-hospital dentist and at the regional dental clinic. The patients comprised 70 males and 53 females with an average age of 69.4 years;118 had primary lung cancer and 5 had metastatic lung cancer. Abnormal findings were detected in approximately 50% of the patients, of whom 6 received oral treatment before starting their cancer treatment. Two patients(1.3%)had postoperative complications. In all cases, the oral care support team provided both tooth and oral mucosal care. About half of the referred patients required oral treatment. There were no serious adverse events due to the oral care intervention. Further investigation is necessary to establish appropriate treatment policy guidelines for dental disease requiring oral maintenance.
Jones, Emma; Lees, Nicholas; Martin, Graham; Dixon-Woods, Mary
Quality improvement (QI) methods are widely used in surgery in an effort to improve care, often using techniques such as Plan-Do-Study-Act cycles to implement specific interventions. Explicit definition of both the QI method and quality intervention is necessary to enable the accurate replication of effective interventions in practice, facilitate cumulative learning, reduce research waste and optimise benefits to patients. This systematic review aims to assess quality of reporting of QI methods and quality interventions in perioperative care. Studies reporting on quality interventions implemented in perioperative care settings will be identified. Searches will be conducted in the Ovid SP version of Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Effective Practice and Organisation of Care database and the related articles function of PubMed. The journal BMJ Quality will be searched separately. Search strategy terms will relate to (i) surgery, (ii) QI and (iii) evaluation methods. Explicit exclusion and inclusion criteria will be applied. Data from studies will be extracted using a data extraction form. The Template for Intervention Description and Replication (TIDieR) checklist will be used to evaluate quality of reporting, together with additional items aimed at assessing QI methods specifically. PROSPERO http://CRD42014012845.
Sukhminder Jit Singh Bajwa
Full Text Available Anesthesiologists and intensivists are encountering increasing number of diabetic patients in daily clinical practice. Majority of such patients may require insulin injections for control of hyperglycemia. Advancements in diabetes management have led to usage of newer insulin injections ranging from human insulin and insulin analogs to glucagon-like peptides-1 analogs. The adequacy of glycemic control and successful outcome with such therapeutic interventions depends upon the adoption of correct injection techniques and procedures. Peri-operative and critically ill diabetic patients are highly prone to develop acute complications of diabetes if appropriate therapeutic strategies are not formulated and implemented. As such, the in-depth knowledge and awareness about various injection technique guidelines is essential from the patient care and healthcare provider′s perspective in the operative and critical care settings. This description is an abridged version of the Forum for Injection Techniques, India: The first Indian recommendations for best practice in insulin injection technique and their significance in peri-operative period and critically ill patients in intensive care units (ICU. These insulin injection techniques are based on evidence-based recommendations and are meant to improve the management of diabetes by the attending staff and physicians in operative and critical care arenas.
Federal Laboratory Consortium — The Horizontal Accelerator (HA) Facility is a versatile research tool available for use on projects requiring simulation of the crash environment. The HA Facility is...
Accelerated Construction Technology Transfer (ACTT) is a strategic process that uses various innovative techniques, strategies, and technologies to minimize actual construction time, while enhancing quality and safety on today's large, complex multip...
Mariana A. Aquafredda
Full Text Available The surgery of brain tumours is not free from complications, above all taking into account that today the patients operated are even older and with multiple comorbidities associated. The multidisciplinary preoperative evaluation aims at minimising the risks; nevertheless this evaluation has not yet been defined and is not based on a strong evidence. The detailed clinical history, the physical examination including functional status and the neuroimaging are the fundamental pillars.The more critical complications occur in the immediate postoperative period: cerebral oedema, postoperative haemorrhage, intracranial hypertension and convulsions; other complications, such as pulmonary thromboembolism or infections, develop lately but are not less severe. Every surgical approach has its own complications in addition to the ones common to the whole neurosurgery.
I.R.A.M. Mertens Zur Borg (Ingrid)
textabstractA successful renal transplant for patients with kidney failure reduces mortality rate when compared to patients who continue dialysis. Organ donation from living donors has significant better results over organ donation from deceased donors. Traditionally the surgical
May 3, 2004 ... Key words: Pregnancy, trauma, abdominal trauma, head injury, cervical spine injury, fetal injury, gun shot wounds, blunt trauma, motor vehicle accidents, falls, violent assaults, .... ventilation for both, the airway control and control of the in- tracranial pressure. However, trauma victims with “good”. GCS's can ...
We present the case of a nine-year-old with UCMD who required operative intervention for progressive scoliosis. In these patients, anaesthetic issues relate to difficulties with endotracheal intubation, as well as the potential for postoperative respiratory failure, given early diaphragmatic involvement. As with other types of ...
Full Text Available Pregnant Females require special perioperative consideration as females react differently to treatment from physiologic and behavioural standpoints. Thus a standard perioperative assessment plays a crucial role for successful accomplishment of intraoperative and postoperative phase as well as to resist complications due to pregnancy. Each physiologic system is affected in such a way that may or may not have clinical significance for the surgeons. Thus affect of Pregnancy on cardiovascular, respiratory, gastrointestinal, renal and endocrinal system have been reviewed. Moreover to decrease the hazards to the developing child, impact of surgery/treatment on the fetus has also been discussed. It was concluded that the goal of the perioperative evaluation of pregnant females is to identify its physiological effects on various systems and provide for the best efficacious perioperative treatment algorithm that shall minimize the patient morbidity.
Taylor, David L
The personal leadership of the perioperative director is a critical factor in the success of any change management initiative. This article presents an approach to perioperative nursing leadership that addresses obstacles that prevent surgical departments from achieving high performance in clinical and financial outcomes. This leadership approach consists of specific insights, priorities, and tools: key insights include self-understanding of personal barriers to leadership and accuracy at understanding economic and strategic considerations related to the OR environment; key priorities include creating a customer-centered organization, focusing on process improvement, and concentrating on culture change; and key tools include using techniques (e.g., direct engagement, collaborative leadership) to align surgical organizations with leadership priorities and mitigate specific perioperative management risks. Included in this article is a leadership development plan for perioperative directors. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Dyke, Cornelius; Aronson, Solomon; Dietrich, Wulf; Hofmann, Axel; Karkouti, Keyvan; Levi, Marcel; Murphy, Gavin J; Sellke, Frank W; Shore-Lesserson, Linda; von Heymann, Christian; Ranucci, Marco
.... We propose a universal definition for perioperative bleeding (UDPB) in adult cardiac surgery in an attempt to precisely describe and quantify bleeding and to facilitate future investigation into this difficult clinical problem...
A. Yu. Yakovlev
Full Text Available Objective: to reveal the features of perioperative metabolic disturbances in patients with lung cancer after pulmonectomy and a possibility of their correction with perioperative «Standard» formula sipping and with postoperative intravenous cytoflavin. Subjects and methods. The paper presents the results of a prospective randomized study of the efficiency of correction of metabolic disturbances in patients with lung cancer with perioperative enteral «Standard» formula sipping (5 days before surgery and 12 days after surgery. The study was conducted in 326 men aged 36 to 68 years. Arterial blood metabolic parameters (glucose, lactate, and pyruvate and daily urine urea were estimated. Results. There was an association of preoperative metabolic disturbances with body mass index (BMI. Inclusion of sipping into perioperative therapy did not exert a considerable impact on the cause of postoperative metabolic disturbances. Key words: lung cancer, pul-monectomy, body mass index, sipping, cytoflavin.
Christofilos, N.C.; Polk, I.J.
Improvements in linear particle accelerators are described. A drift tube system for a linear ion accelerator reduces gap capacity between adjacent drift tube ends. This is accomplished by reducing the ratio of the diameter of the drift tube to the diameter of the resonant cavity. Concentration of magnetic field intensity at the longitudinal midpoint of the external sunface of each drift tube is reduced by increasing the external drift tube diameter at the longitudinal center region.
Ruminjo, Joseph K; Frajzyngier, Veronica; Bashir Abdullahi, Muhammad; Asiimwe, Frank; Barry, Thierno Hamidou; Bello, Abubakar; Danladi, Dantani; Ganda, Sanda Oumarou; Idris, Sa'ad; Inoussa, Maman; Lynch, Maura; Mussell, Felicity; Podder, Dulal Chandra; Wali, Abba; Barone, Mark A
Treatment and care for female genital fistula have become increasingly available over the last decade in countries across Africa and South Asia. Before the International Federation of Gynaecology and Obstetrics (FIGO) and partners published a global fistula training manual in 2011 there was no internationally recognized, standardized training curriculum, including perioperative care. The community of fistula care practitioners and advocates lacks data about the prevalence of various perioperative clinical procedures and practices and their potential programmatic implications are lacking. Data presented here are from a prospective cohort study conducted between September 2007 and September 2010 at 11 fistula repair facilities supported by Fistula Care in five countries. Clinical procedures and practices used in the routine perioperative management of over 1300 women are described. More than two dozen clinical procedures and practices were tabulated. Some of them were commonly used at all sites (e.g., vaginal route of repair, 95.3% of cases); others were rare (e.g., flaps/grafts, 3.4%) or varied widely depending on site (e.g. for women with urinary fistula, the inter-quartile range for median duration of post-repair bladder catheterization was 14 to 29 days). These findings show a wide range of clinical procedures and practices with different program implications for safety, efficacy, and cost-effectiveness. The variability indicates the need for further research so as to strengthen the evidence base for fistula treatment in developing countries.
Full Text Available Aim: The aim of this study was to describe our institutional experience, primarily with general anesthesiologists consulting with cardiac anesthesiologists, caring for left ventricular assist device (LVAD patients undergoing noncardiac surgery. Materials and Methods: This is a retrospective review of the population of patients with LVADs at a single institution undergoing noncardiac procedures between 2009 and 2014. Demographic, perioperative, and procedural data collected included the type of procedure performed, anesthetic technique, vasopressor requirements, invasive monitors used, anesthesia provider type, blood product management, need for postoperative intubation, postoperative disposition and length of stay, and perioperative complications including mortality. Statistical Analysis: Descriptive statistics for categorical variables are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation and range when applicable. Results: During the study, 31 patients with LVADs underwent a total of 74 procedures. Each patient underwent an average of 2.4 procedures. Of the total number of procedures, 48 (65% were upper or lower endoscopies. Considering all procedures, 81% were performed under monitored anesthesia care (MAC. Perioperative care was provided by faculty outside of the division of cardiac anesthesia in 62% of procedures. Invasive blood pressure monitoring was used in 27 (36% procedures, and a central line, peripherally inserted central catheter or midline was in place preoperatively and used intraoperatively for 38 (51% procedures. Vasopressors were not required in the majority (65; 88% of procedures. There was one inhospital mortality secondary to multiorgan failure; 97% of patients survived to discharge after their procedure. Conclusion: At our institution, LVAD patients undergoing noncardiac procedures most frequently require endoscopy. These procedures can frequently be done
Garvey, Lene Heise
Perioperative hypersensitivity reactions are rare, often life-threatening events, and subsequent investigations to identify the culprit are important to avoid re-exposure. All exposures in the perioperative setting may potentially be the cause of a hypersensitivity reaction, but drugs administered intravenously such as neuromuscular blocking agents (NMBA), induction agents and antibiotics have traditionally been reported to be implicated most commonly. It has recently become apparent that there are geographical differences in sensitization patterns related to variation in exposures, referral patterns and performance and interpretation of investigations. Differences in sensitization to NMBAs are partly explained by cross sensitization to pholcodine, an ingredient in cough-medicines available in some countries. While NMBAs are the most common causes of perioperative hypersensitivity in some countries, this may not necessarily be the case in all countries. New and hidden allergens have emerged as causes of perioperative hypersensitivity such as blue dyes, chlorhexidine and excipients. Detailed knowledge of the events at the time of reaction is necessary to identify potential culprits including rare and hidden allergens. Cooperation between allergists and anaesthetists, or other staff present perioperatively, is often needed to identify hidden or even undocumented exposures. The objectives of this review are to provide an overview of the history of investigation of perioperative hypersensitivity, to describe the differences in causes of perioperative hypersensitivity emerging over time and to increase awareness about the "hidden allergens" in the perioperative setting. Some practical advice on how to approach the patient testing negative on all initial investigations is also included. Copyright© Bentham Science Publishers; For any queries, please email at email@example.com.
Battié, Renae N
Changes in the current health care system have rendered the system unprepared to support new demands. Similarly, nursing education both before and after licensure is no longer adequate. Four of the eight recommendations in the Institute of Medicine's Future of Nursing report involve changes to nursing education and pose significant goals to achieve. This makes creating innovative ways to meet the demand for educating RNs a necessity. This article discusses the Institute of Medicine's recommendations, how they relate to perioperative nursing, and ways in which nurses and educators can help promote expectations. Copyright © 2013 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Gustin, Allen N; Aslakson, Rebecca A
Many seriously ill geriatric patients are at higher risk for perioperative morbidity and mortality, and incorporating proactive palliative care principles may be appropriate. Advanced care planning is a hallmark of palliative care in that it facilitates alignment of the goals of care between the patient and the health care team. When these goals conflict, perioperative dilemmas can occur. Anesthesiologists must overcome many cultural and religious barriers when managing the care of these patients. Palliative care is gaining ground in several perioperative populations where integration with certain patient groups has occurred. Geriatric anesthesiologists must be aware of how palliative care and hospice influence and enhance the care of elderly patients. Copyright © 2015 Elsevier Inc. All rights reserved.
Davis, Sean; Babidge, Wendy; Kiermeier, Andreas; Aitken, Robert; Maddern, Guy
Bariatric surgery is the most effective method of sustainable weight loss for the treatment of morbid obesity. Low mortality associated with these procedures has been reported internationally; however, Australian outcomes are yet to be published. Despite its efficacy, limited access to bariatric surgery exists in Australian public hospitals. This retrospective data analysis was conducted for two reasons. Firstly, to determine the perioperative mortality rate (POMR) associated with bariatric procedures in Australia, and secondly, to compare public and private hospital bariatric surgery admission demographics and outcomes. A retrospective review of de-identified patient data from the National Hospital Morbidity Database, held by the Australian Institute of Health and Welfare (AIHW), was conducted using codes relating to bariatric procedures. POMR calculations were established using AIHW admission data from 1 July 2005 to 30 June 2013. From 1 July 2005 to 30 June 2013, 113,929 patient admissions occurred for patients undergoing a bariatric procedure. Thirty-nine deaths occurred nationally, with an overall average POMR of 0.03%. A higher POMR was associated with public admissions and secondary procedures. A higher proportion of secondary procedures were performed in public hospitals. Primary bariatric procedure incidence increased throughout the study period while secondary bariatric procedure incidence decreased. This study demonstrates the Australian bariatric procedure POMR to be substantially lower than internationally reported figures. Public hospitals were shown to perform far fewer bariatric procedures at a higher POMR than private hospitals. Public hospitals performed a higher proportion of secondary revision procedures.
Piriou, V; Aouifi, A; Lehot, J J
To review the pharmacologic and pathophysiologic information necessary to prescribe beta-blockers (BB) in perioperative medicine. Manual retrieval and electronic research of the literature using MEDLINE (key-words: anesthesia and beta- blocker; surgery and beta-blocker). Cardioselective BB inhibit preferentially beta-1 receptors, inducing a decrease in heart rate and cardiac inotropism leading to reduction of oxygen myocardial consumption. Non-cardioselective BB inhibit also beta-2 receptors, increasing bronchial and peripheral vascular resistances and uterine contractions. However, some BB are also vasodilators (carvedilol, celiprolol, labetalol). Contraindications to BB result logically from their pharmacological effects. Treatment with BB increases membrane beta-receptor density; this explains sympathetic overactivity observed during weaning of treatment. Since the discovery of propranolol in 1964, the use of BB has been controversial in anesthesia. Formerly, the adverse effects of partial sympatholysis during anesthesia and surgery were feared. However, since 1973, experimental and clinical data have suggested a protective hemodynamic effect. Continued administration of BB up to the time of anesthesia has been encouraged except in patients with signs of intolerance such as hypotension or excessive bradycardia.
V. N. Amirdzhanova
Full Text Available The paper considers the joint management of rheumatoid arthritis patients needing endoprosthetic replacement of the large joints of the lower extremities by rheumatologists and orthopedic traumatologists.Due to the fact that there are no conventional standards or guidelines for the perioperative management of patients with rheumatic diseases, adopted by international rheumatology associations, the authors generalize their experience in managing the patients in terms of international approaches and guidelines from different countries. The medical assessment and reduction of cardiovascular risks, the prevention of infectious complications, hemorrhages, and lower extremity deep vein thrombosis, and the specific features of management of patients with osteoporosis are under consideration. The authors' experience in managing the patients receiving antirheumatic therapy with nonsteroidal antiinflammatory and disease-modifying antirheumatic drugs, such as methotrexate, leflunomide, sulfasalazine, and hydroxychloroquine, is detailed. Recommendations for managing patients taking glucocorticoids and biologic agents (tumor necrosis factor-α inhibitors, anti-B-cell therapy, and interleukin-6 receptor inhibitors in the preoperative andpostoperative periods are given.
Rapoport, Yury; Fox, Charles J; Khade, Parth; Fox, Mary E; Urman, Richard D; Kaye, Alan David
Dextrocardia, a term used to describe all varieties of developmental malformations resulting in the positioning of the heart in the right hemithorax, is linked to a number of highly significant cardiac disorders. Current estimates vary tremendously in the literature. Only about 10 % of patients with diagnosed dextroversion show no substantial cardiac pathology; however, the incidence of congenital heart defects associated with dextrocardia is close to 100 %. The majority of studies previously reported include dextrocardia associated with situs inversus and cases of Kartagener syndrome. There is complex embryology and pathogenesis that results in dextrocardia. Physical examinations of the heart, such as percussion and palpation during routine exams, are vitally important initial diagnostic instruments. X-ray, CT scan, echocardiography (ECHO), and MRI are all invaluable imaging modalities to confirm and classify the diagnosis of dextrocardia. In summary, heart malposition is a group of complex pathologic associations within the human body, rather than just a single congenital defect. Clinicians such as anesthesiologists have unique challenges managing patients with dextrocardia. An appreciation of associated pathogenesis, appropriate diagnosis, and management is paramount in ensuring the best outcome for these patients perioperatively.
Full Text Available Background: The short term outcome of patients undergoing surgery for Moyamoya disease can be affected by various perioperative factors. However, due to lesser prevalence of this disease in our country, data relating the effect of perioperative factors on the overall neurological outcomes of these patients is lacking. Aims: To analyze the effect of perioperative factors on the duration of postoperative hospital stay in patients undergoing surgery for Moyamoya disease. Settings and Design: It is a retrospective study analyzing various perioperative factors influencing the overall outcome of patients undergoing surgery for Moyamoya disease at a tertiary care centre in North India. Methods and Material: The medical records of all patients who underwent revascularization surgeries for Moyamoya disease from 2007 to till January 2014 were included for retrospective analysis. Various preoperative, intraoperative, and postoperative data were recorded. The data was statistically compared for short and prolonged hospital stay for various perioperative factors. The duration of post operative hospital stay was categorized as short (5 days. Statistical Analysis: Kolmogrov Smirnov test was applied to see the normality of continuous data. The association of various categorically classified data with 2 groups was found using Fisher Exact test. The trends in intraoperative hemodynamics were analysed using 2 way repeated measure Anova test. T-test was used for comparing two group means for various parameters. Results: A total of 15 patients were included in the study. One patient underwent surgery twice on two different occasions. Thirteen patients belonged to paediatric age group (<18 years. The type of anaesthetics used for induction and maintenance had no effect on patient outcome. Mean duration of anaesthesia was 2.45 (1.3-4.0 hours. The mean duration of hospital stay was 5.13 (3-10 days. Most of the parameters did not have significant effect on postoperative
Aguilar-Nascimento, José Eduardo de; Salomão, Alberto Bicudo; Caporossi, Cervantes; Diniz, Breno Nadaf
Multimodal protocol of perioperative care may enhance recovery after surgery. Based on evidence these new routines of perioperative care changed conventional prescriptions in surgery. To evaluate the results of a multimodal protocol (ACERTO protocol) in elderly patients. Non-randomized historical cohort study was performed at the surgical ward of a tertiary university hospital. One hundred seventeen patients aged 60 and older were submitted to elective abdominal operations under either conventional (n = 42; conventional group, January 2004-June 2005) or a fast-track perioperative protocol named ACERTO (n = 75; ACERTO group, July 2005-December 2007). Main endpoints were preoperative fasting time, postoperative day of re-feeding, volume of intravenous fluids, length of hospital stay and morbidity. The implantation of the ACERTO protocol was followed by a decrease in both preoperative fasting (15 [8-20] vs 4 [2-20] hours, P<0.001) and postoperative day of refeeding (1st [1st-10th] vs 0 [0-5th] PO day; P<0.01), and intravenous fluids (10.7 [2.5-57.5] vs 2.5 [0.5-82] L, P<0.001). The changing of protocols reduced the mean length of hospital stay by 4 days (6[1-43] vs 2[1-97] days; P = 0.002) and surgical site infection rate by 85.7% (19%; 8/42 vs 2.7%; 2/75, P<0.001; relative risk = 1.20; 95% confidence interval = 1.03-1.39). Per-protocol analysis showed that hospital stay in major operations diminished only in patients who completed the protocol (P<0.01). The implementation of multidisciplinary routines of the ACERTO protocol diminished both hospitalization and surgical site infection in elderly patients submitted to abdominal operations.
Full Text Available The authors have investigated the perioperative complications after donor nephrectomy integrating the US transplant registry with administrative records from an academic hospital consortium (97 centers, 2008-2012. 14.964 patients were verified as live donors through linkage with the Organ Procurement and Transplantation Network registry. Overall, 16.8% of donors experienced a perioperative complication, including Clavien grade 2 or higher events in 8.8%, Clavien grade 3 or higher in 7.3%, and Clavien grade 4 or higher events in 2.5%. The most common complications were gastrointestinal (4.4%, bleeding (3.0%, respiratory (2.5%, and surgical/anesthesia-related injuries (2.4%. After adjustment for demographic and clinical factors, African American donors were 26% more likely to experience any perioperative complication and 56% more likely to experience the most severe complications. Other factors associated with increased risk of any perioperative complication, and with the most severe complications included predonation hematologic and psychiatric conditions and more recent years of donation. Donation at centers with the highest annual volume of living donor nephrectomies (>50 cases/year was associated with approximately 45% lower risk of any perioperative complication and of the most severe complications. Donors who underwent robotic nephrectomy were twice as likely to experience severe perioperative complications (adjusted odds ratio 2.07 for Clavien grade 4 or higher events. To conclude, the authors found that while one in six US living kidney donors experienced a perioperative complication, the most severe complications were infrequent, affecting only 2.5% of donors.
Background The role of peri-operative chemotherapy in patients with resected stage IV colorectal cancer (CRC) remains to be defined. This study was aimed at evaluating the effectiveness of peri-operative chemotherapy in patients with resected stage IV CRC by performing a meta-analysis of relevant trials. Methods We performed a literature search to identify trials comparing patients with stage IV CRC receiving peri-operative chemotherapy and surgery with patients undergoing surgery alone. The hazard ratio (HR) was estimated to assess any survival advantage of peri-operative chemotherapy. Results Eight trials conducted on a total of 1174 patients were identified by a literature search. In these trials, HR estimates suggested that peri-operative chemotherapy yielded no survival advantage over surgery alone (HR, 0.94; 95%CI, 0.8-1.10; p = 0.43). In a subset analysis on intra-arterial chemotherapy alone, no survival benefit was evident (HR, 1.0; 95% CI, 0.84-1.21; p = 0.96; I2 = 30%), whereas in the trials involving systemic chemotherapy, the difference between the groups approached statistical significance (HR, 0.74; 95% CI, 0.53-1.04; p = 0.08; I2 = 0%). Both peri-operative treatment groups had a significant recurrence-free survival benefit (HR, 0.78; 95% CI, 0.65-0.95; P = 0.01 for hepatic arterial infusion; and HR, 0.75; 95% CI, 0.62-0.91; p = 0.003 for systemic therapy). The toxicities of chemotherapy were acceptable in most trials. Conclusions This is the first meta-analysis demonstrating the importance of peri-operative chemotherapy in the treatment of resected stage IV CRC. Although the results must be carefully interpreted because of some limitations, critical issues were identified that must be resolved by future studies. PMID:20565923
Vipul Krishen Sharma
Full Text Available Background: Pulmonary hypertension (PHT, if present, can be a significant cause of increased morbidity and mortality in children undergoing surgery for congenital heart diseases (CHD. Various techniques and drugs have been used perioperatively to alleviate the effects of PHT. Intravenous (IV sildenafil is one of them and not many studies validate its clinical use. Aims and Objectives: To compare perioperative PaO 2 - FiO 2 ratio peak filling rate (PFR, systolic pulmonary artery pressure (PAP - systolic aortic pressure (AoP ratio, extubation time, and Intensive Care Unit (ICU stay between two groups of children when one of them is administered IV sildenafil perioperatively during surgery for CHDs. Materials and Methods: Patients with ventricular septal defects and proven PHT, <14 years of age, all American Society of Anesthesiologists physical status III, undergoing cardiac surgery, were enrolled into two groups - Group S (IV sildenafil and Group C (control - over a period of 14 months, starting from October 2013. Independent t-test and Mann-Whitney U-test were used to compare the various parameters between two groups. Results: PFR was higher throughout, perioperatively, in Group S. PAP/AoP was 0.3 and 0.4 in Group S and Group C, respectively. In Group S, mean group extubation time was 7 ± 7.34 h, whereas in Group C it was 22.1 ± 10.6. Postoperative ICU stay in Group S and Group C were 42.3 ± 8.8 h and 64.4 ± 15.9 h, respectively. Conclusion: IV sildenafil, when used perioperatively, in children with CHD having PHT undergoing corrective surgery, improves not only PaO 2 - FiO 2 ratio and PAP - AoP ratio but also reduces extubation time and postoperative ICU stay.
Rozec, B; Cinotti, R; Le Teurnier, Y; Marret, E; Lejus, C; Asehnoune, K; Blanloeil, Y
Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature. Systematic review. Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters. In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients. Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality. Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.
Bräuer, A; Perl, T; Uyanik, Z; English, M J M; Weyland, W; Braun, U
Reduction of heat losses from the skin by thermal insulation is used to avoid perioperative hypothermia. However, there is little information about the physical properties of various insulating materials used in the operating room. The following insulation materials were tested using a validated manikin: cotton surgical drape tested in two and four layers; Allegiance drape; 3M Steri-Drape; metallized plastic sheet; Thermadrape Barkey thermcare 1 tested in one and two layers; hospital duvet tested in one and two layers. Heat loss from the surface of the manikin can be described as: Q(*);= h.DeltaT.A where Q(*); is heat flux, h is the heat exchange coefficient, DeltaT is the temperature gradient between the environment and surface and A is the area covered. The heat flux per unit area (Q(*); A(-1)) and surface temperature were measured with nine calibrated heat-flux transducers. The environmental temperature was measured using a thermoanemometer. DeltaT was varied and h was determined by linear regression analysis as the slope of DeltaT vs Qdot; A(-1). The reciprocal of h defines the insulation. The insulation value of air was 0.61 Clo. The insulation values of the materials varied between 0.17 Clo (two layers of cotton surgical drapes) to 2.79 Clo (two layers of hospital duvet). There are relevant differences between various insulating materials. The best commercially available material designed for use in the operating room (Barkey thermcare 1) can reduce heat loss from the covered area by 45% when used in two layers. Given the range of insulating materials available for outdoor activities, significant improvement in insulation of patients in the operating room is both possible and desirable.
Full Text Available Xiaopeng Zhang,1 Xiaowei Yan,2 Jennifer Gorman,2 Stuart N Hoffman,3 Li Zhang,1 Joseph A Boscarino2 1Department of Anesthesiology, Geisinger Medical Center, 2Center for Health Research, Geisinger Clinic, 3Department of Neurology, Geisinger Medical Center, Danville, PA, USA Objective: Neurocognitive disorders commonly occur following cardiac surgery. However, the underlying etiology of these disorders is not well understood. The current study examined the association between perioperative glucose levels and other risk factors and the onset of neurocognitive disorders in adult patients following coronary artery bypass and/or valvular surgery. Methods: Adult patients who underwent their first cardiac surgery at a large tertiary care medical center were identified and those with neurocognitive disorders prior to surgery were excluded. Demographic, perioperative, and postoperative neurocognitive outcome data were extracted from the Society for Thoracic Surgery database, and from electronic medical records, between January 2004 and June 2009. Multiple clinical risk factors and measures associated with insulin resistance, such as hyperglycemia, were assessed. Multivariable Cox competing risk survival models were used to assess hyperglycemia and postoperative neurocognitive disorders at follow up, adjusting for other risk factors and confounding variables. Results: Of the 855 patients included in the study, 271 (31.7% had new onset neurocognitive disorders at follow-up. Age, sex, New York Heart Failure (NYHF Class, length of postoperative intensive care unit stay, perioperative blood product transfusion, and other key factors were identified and assessed as potential risk factors (or confounders for neurocognitive disorders at follow-up. Bivariate analyses suggested that new onset neurocognitive disorders were associated with NYHF Class, cardiopulmonary bypass, history of diabetes, intraoperative blood product use, and number of diseased coronary vessels
Zoghbi, Veronica; Caskey, Robert C; Dumon, Kristoffel R; Soegaard Ballester, Jacqueline M; Brooks, Ari D; Morris, Jon B; Dempsey, Daniel T
The ability to use electronic medical records (EMR) is an essential skill for surgical residents. However, frustration and anxiety surrounding EMR tasks may detract from clinical performance. We created a series of brief, 1-3 minutes "how to" videos demonstrating 7 key perioperative EMR tasks: booking OR cases, placing preprocedure orders, ordering negative-pressure wound dressing supplies, updating day-of-surgery history and physical notes, writing brief operative notes, discharging patients from the postanesthesia care unit, and checking vital signs. Additionally, we used "Cutting Insights"-a locally developed responsive mobile application for surgical trainee education-as a platform for providing interns with easy access to these videos. We hypothesized that exposure to these videos would lead to increased resident efficiency and confidence in performing essential perioperative tasks, ultimately leading to improved clinical performance. Eleven surgery interns participated in this initiative. Before watching the "how to" videos, each intern was timed performing the aforementioned 7 key perioperative EMR tasks. They also underwent a simulated perioperative emergency requiring the performance of 3 of these EMR tasks in conjunction with 5 other required interventions (including notifying the chief resident, the anesthesia team, and the OR coordinator; and ordering fluid boluses, appropriate laboratories, and blood products). These simulations were scored on a scale from 0 to 8. The interns were then directed to watch the videos. Two days later, their times for performing the 7 tasks and their scores for a similar perioperative emergency simulation were once again recorded. Before and after watching the videos, participants were surveyed to assess their confidence in performing each EMR task using a 5-point Likert scale. We also elicited their opinions of the videos and web-based mobile application using a 5-point scale. Statistical analyses to assess for
Tolstrup, Rikke; Funder, Jonas Amstrup; Lundbech, Liselotte; Thomassen, Niels; Iversen, Lene Hjerrild
In order to improve the surgical treatment of rectal cancer, robot-assisted laparoscopy has been introduced. The robot has gained widespread use; however, the scientific basis for treatment of rectal cancer is still unclear. The aim of this study was to investigate whether robot-assisted laparoscopic rectal resection cause less perioperative pain than standard laparoscopic resection measured by the numerical rating scale (NRS score) as well as morphine consumption. Fifty-one patients were randomized to either laparoscopic or robot-assisted rectal resection at the Department of Surgery at Aarhus University Hospital in Denmark. The intra-operative analgetic consumption was recorded prospectively and registered in patient records. Likewise all postoperative medicine administration including analgesia was recorded prospectively at the hospital medical charts. All morphine analogues were converted into equivalent oral morphine by a converter. Postoperative pain where measured by numeric rating scale (NRS) every hour at the postoperative care unit and three times a day at the ward. Opioid consumption during operation was significantly lower during robotic-assisted surgery than during laparoscopic surgery (p=0.0001). However, there were no differences in opioid consumption or NRS in the period of recovery. We found no differences in length of surgery between the two groups; however, ten patients from the laparoscopic group underwent conversion to open surgery compared to one from the robotic group (p=0.005). No significant difference between groups with respect to complications where found. In the present study, we found that patients who underwent rectal cancer resection by robotic technique needed less analgetics during surgery than patients operated laparoscopically. We did, however, not find any difference in postoperative pain score or morphine consumption postoperatively between the robotic and laparoscopic group.
Gin, Greg E; Ruel, Nora H; Kardos, Steven V; Sfakianos, John P; Uchio, Edward; Lau, Clayton S; Yuh, Bertram E
Evidence for the use of perioperative chemotherapy (PC) in upper tract urothelial carcinoma (UTUC) is largely derived from level I evidence for invasive urothelial carcinoma of the bladder (UCB). There has been an increase in PC for urothelial carcinoma of the bladder, as it has disseminated into clinical practice. Therefore, we sought to not only analyze trends in the utilization of PC in UTUC, but also assess factors associated with its use in a large cancer registry database. The National Cancer Database was queried for patients with UTUC who underwent extirpative surgery from 2004 to 2013. Predictors of receiving PC were identified using univariate and multivariate logistic regression. Temporal trends in the utilization of PC were also analyzed using a general analysis of variance linear model. From 2004 to 2013, there was significant increase in PC for UTUC from 9.6% to 13.8% (P = 0.0003). Neoadjuvant chemotherapy increased from 0.7% to 2.1% (P = 0.0018), whereas adjuvant chemotherapy remained relatively stable at 11.3%. Significant predictors of receiving PC on multivariate analysis were private insurance, ureter as the primary site, poorly differentiated and undifferentiated grade, lymphovascular invasion, positive margins, clinical T3 or T4 disease, nodal metastasis, and reporting from an academic research program. Patients who were≥70 years old,>50 miles to treatment center, had tumor in the kidney, or had an increased Charlson-Deyo Score were significantly less likely to receive PC. Over the time period studied, there has been an increase in the use of PC, primarily from increased administration of neoadjuvant chemotherapy. Its use is mostly associated with advanced pathologic characteristics. The study also highlights key demographic and socioeconomic differences that can help identify barriers to receiving PC and aid in making improvements in delivery of health care to patients with UTUC. Published by Elsevier Inc.
Whittemore, Kenneth R; Dornan, Briana K; Dargie, Jenna M; Zhou, Guangwei
Obtaining hearing thresholds is an important step in the evaluation of a child with otitis media because decreased hearing in the presence of a chronic middle ear effusion factors into the decision to place tympanostomy tubes (TTs). To provide evidence regarding appropriate use of perioperative hearing evaluations in conjunction with TTs. Case series with medical record review of all patients aged 0 to 24 years who received TTs at a tertiary pediatric care facility from June 1, 2010, through June 1, 2011. Medical records were abstracted by 1 researcher for surgical, audiometric, tympanometric, clinical, and patient demographic data. The data analysis was performed between December 1, 2014, and June 1, 2015. Audiometric data were examined to determine the number of patients with hearing loss preoperatively and postoperatively, with the intention to describe the population with no prior hypothesis regarding results. Of 2274 patients identified, 910 (40.0%) were female. Median (interquartile range) age at TT placement was 2.62 (1.48-4.94) years. A total of 1757 (77.3%) underwent audiometric evaluation preoperatively, 1742 (76.6%) postoperatively, and 1395 (61.3%) both preoperatively and postoperatively; 170 (7.5%) had no audiometric testing. Within 1 year after surgery, 271 (11.9%) of patients had evidence of nonfunctional tubes. Postoperatively, 19.9% (347 of the 1742 patients who received a postoperative evaluation) had hearing loss. In all, 89 (3.9%) patients had a permanent sensorineural hearing loss, and 15 (0.66%) had a persistent conductive hearing loss. A postoperative audiometric examination should be performed in children who have hearing loss when evaluated before TT placement to determine whether resolution of the hearing loss was obtained.
Burkitt, Kelly H; Mor, Maria K; Jain, Rajiv; Kruszewski, Matthew S; McCray, Ellesha E; Moreland, Michael E; Muder, Robert R; Obrosky, David Scott; Sevick, Mary Ann; Wilson, Mark A; Fine, Michael J
To assess the role of a Toyota production system (TPS) quality improvement (QI) intervention on appropriateness of perioperative antibiotic therapy and in length of hospital stay (LOS) among surgical patients. Pre-post quasi-experimental study using local and national retrospective cohorts. We used TPS methods to implement a multifaceted intervention to reduce nosocomial methicillin-resistant Staphylococcus aureus infections on a Veterans Affairs surgical unit, which led to a QI intervention targeting appropriate perioperative antibiotic prophylaxis. Appropriate perioperative antibiotic therapy was defined as selection of the recommended antibiotic agents for a duration not exceeding 24 hours from the time of the operation. The local computerized medical record system was used to identify patients undergoing the 25 most common surgical procedures and to examine changes in appropriate antibiotic therapy and LOS over time. Overall, 2550 surgical admissions were identified from the local computerized medical records. The proportion of surgical admissions receiving appropriate perioperative antibiotics was significantly higher (P <.01) in 2004 after initiation of the TPS intervention (44.0%) compared with the previous 4 years (range, 23.4%-29.8%) primarily because of improvements in compliance with antibiotic therapy duration rather than appropriate antibiotic selection. There was no statistically significant decrease in LOS over time. The use of TPS methods resulted in a QI intervention that was associated with an increase in appropriate perioperative antibiotic therapy among surgical patients, without affecting LOS.
Partridge, Judith S L; Collingridge, Geraint; Gordon, Adam Lee; Martin, Finbarr C; Harari, Danielle; Dhesi, Jugdeep K
national reports have highlighted deficiencies in care provided to older surgical patients and suggested a role for innovative, collaborative, inter-specialty models of care. The extent of geriatrician-led perioperative services in the UK (excluding orthogeriatric services) has not previously been described. This survey describes current services and explores barriers to further development. an electronic survey was sent to clinical leads for geriatric medicine at all 161 acute NHS health care trusts in the UK. Reminders were sent on three occasions over an 8-week period. The survey examined preoperative and postoperative care and organisational issues. Responses were analysed descriptively. there were 130 respondents (80.7%). One-third (38) of respondents described providing some geriatric medicine input in older surgical patients. Preoperative services existed in 15 (12%), where 14 provided risk assessment and 13 preoperative optimisation. Twenty-six respondents (20%) delivered care postoperatively, of them 10 took a reactive approach, 11 a proactive approach and 5 provided a combination of reactive and proactive care. Barriers to establishing perioperative geriatric medicine services included funding, workforce issues and a lack of inter-specialty collaboration. a national appetite exists to provide geriatrician-led services to older surgical patients yet the majority of existing services remain reactive and do not use comprehensive geriatric assessment as an organising principle. This survey suggests that funding for geriatricians in perioperative care has not yet been universally established. Future efforts should focus on dissemination of experiential knowledge and published resources, collaboration with commissioners and empirical research to overcome the barriers described. © The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: firstname.lastname@example.org.
Simpson, Melanie H; Bruckenthal, Patricia
Achievement of adequate postoperative pain management is a critical challenge in health care, with an estimated three out of four adult surgical patients reporting moderate to extreme pain after surgery. Overreliance on opioids in acute care settings has persisted, despite well-known adverse side effects frequently associated with this class of drugs. Furthermore, patients with a history of chronic opioid use present additional challenges in terms of postsurgical pain management. Advances in the development of newer analgesic agents and anesthetic techniques may be useful in surgical patients with a history of chronic opioid use and in the overall surgical patient population. Systemic inefficiencies and problematic medical practice patterns can also have negative effects on perioperative pain management. As the surgical patient's primary advocate, perioperative nurses play an important role in overcoming these diverse challenges and addressing the problems associated with inadequately controlled postsurgical pain. Copyright Â© 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Perioperative care in an animal model for training in abdominal surgery: is it necessary a preoperative fasting? Cuidados perioperatórios em modelo animal de treinamento em cirurgia abdominal: é necessário jejum pré-operatório?
José Roberto Alves
Full Text Available PURPOSE: Demonstrate that the rabbit may be used in the training of surgery, in addition to present its perioperative care. METHODS: Thirty two animals, with age and weight, respectively, from 3 to 5.5 months old and 3000 to 4200 grams, were undergone different periods of pre-operative fasting, exclusive intramuscular anesthesia (ketamine+xylazine, laparotomy with total gastrectomy and total splenectomy. It was dosed the pre-operative (initial and post-surgical (end serum blood glucose, in addition to quantify the gastric content after the resection of the part. RESULTS: The anesthetical-surgical procedure presented a mortality rate of 3.125% (1:32 and a morbidity rate of 6.25% (2:32. It was evidenced an initial mean blood glucose = 199.4 mg/dl and the end = 326.1 mg/dl. In spite of extended fasting (minimum of 2 hours for the absolute fasting and maximum of 8.5 hours for liquids, and 20.5 hours for solids all animals presented at the end of the surgical procedure any gastric content and a blood glucose increase. Those with fasting for liquids and solids when compared to the quantity of solid gastric content, presented a moderate negative degree of correlation. CONCLUSION: The rabbit is a good model to be used in training of surgery, with a low morbi-mortality, able to be anesthetized intramuscularly, with no need of pre-operative fasting and does not present hypoglycemia even with the extended fasting period.OBJETIVO: Demonstrar que o coelho pode ser utilizado no treinamento em cirurgia, além de apresentar seus cuidados perioperatórios. MÉTODOS: Trinta e dois animais, com idade e peso respectivamente, entre 3 a 5,5 meses e 3000 a 4200 gramas, foram submetidos a variados tempos de jejum pré-operatório, anestesia intramuscular exclusiva (quetamina+xilasina, laparotomia com gastrectomia e esplenectomia totais. Dosou-se a glicemia sérica pré-operatória (inicial e pós-cirúrgica (final, além de quantificado o conteúdo gástrico p
Merkel, M J; von Dossow, V; Zwißler, B
Clear and consistent communication is pivotal for well-functioning teamwork, in operating theatres as well as intensive care units. However, patient handovers significantly vary between specialties and locations. If communication is not well structured, it might increase the risk for mishaps and malpractice. Therefore, implementing structured handover protocols is pivotal. The perioperative setting is a high-risk environment that is prone to communication failures due to operational design (frequent change of shift due to working time restrictions) and a high work load and multitasking (operating room management, short surgery times, concurrent emergencies). Hence teamwork in the operating room and intensive care unit requires clear and consistent communication. In the perioperative setting, the patient is transferred several times: from the ward to operating room, to recovery, intermediate care/intensive care unit and back to normal ward. This necessitates multiple handovers. Since 2005, the World Health Organization (WHO) requests a structured handover concept that processes all relevant information in a predefined order. The SBAR concept (situation, background, assessment, recommendation) is an intuitive communication concept that can improve quality of patient handovers. This underlines the clinical relevance of a structured handover concept that leads to improved outcomes for every patient.In this review, basic measures for a clear and consistent communication are presented. These are pivotal for an effective teamwork and for ensuing patient safety. Furthermore, we will focus on possibilities to implement structured approaches but also on potential barriers of implementation. Communication failure among different health care providers can be identified more easily and hopefully can be eliminated.
Culp, Jeffrey A; Palis, Ross I; Castells, Mariana C; Lucas, Sean R; Borish, Larry
This article presents a case report of perioperative anaphylaxis in a previously nonallergic 44-year-old man undergoing cervical spine surgery. After receiving general anesthesia with midazolam, propofol, lidocaine, fentanyl, rocuronium, and sevoflurane and cefazolin for prophylaxis, the patient developed hypotension, tachycardia, bronchospasm, and generalized erythema. A serum tryptase concentration was markedly elevated 2 hours after the anaphylactic episode. Initial prick and intradermal skin tests (excluding skin testing for unavailable benzylpenicilloyl polylysine) and IgE immunoassays for penicillin and cefazolin were negative. However, repeat prick skin testing for cefazolin 6 weeks after anaphylaxis was positive. Although anaphylaxis to cephalosporins is rare, it remains a potential cause of perioperative anaphylaxis. All cases of perioperative anaphylaxis require a workup to identify the offending agent and to avoid future reactions. Skin testing regimens for several commonly implicated drugs used for general anesthesia are available and are described.
Juan V Llau
Full Text Available Juan V Llau1, Raquel Ferrandis1, Pilar Sierra2, Aurelio Gómez-Luque31Department of Anaesthesiology and Critical Care Medicine, Hospital Clínic Universitari, València, Spain; 2Department of Anaesthesiology, Fundació Puigvert, Barcelona, Spain; 3Department of Anaesthesiology and Critical Care Medicine, Hospital Clínico Universitario, Málaga, SpainAbstract: The management of patients scheduled for surgery with a coronary stent, and receiving 1 or more antiplatelet drugs, has many controversies. The premature discontinuation of antiplatelet drugs substantially increases the risk of stent thrombosis (ST, myocardial infarction, and cardiac death, and surgery under an altered platelet function could also lead to an increased risk of bleeding in the perioperative period. Because of the conflict in the recommendations, this article reviews the current antiplatelet protocols after positioning a coronary stent, the evidence of increased risk of ST associated with the withdrawal of antiplatelet drugs and increased bleeding risk associated with its maintenance, the different perioperative antiplatelet protocols when patients are scheduled for surgery or need an urgent operation, and the therapeutic options if excessive bleeding occurs.Keywords: stent thrombosis, antiplatelet agents, aspirin, clopidogrel, surgical bleeding, perioperative management
Tajima, T.; Nakajima, K.; Mourou, G.
The fundamental idea of Laser Wakefield Acceleration (LWFA) is reviewed. An ultrafast intense laser pulse drives coherent wakefield with a relativistic amplitude robustly supported by the plasma. While the large amplitude of wakefields involves collective resonant oscillations of the eigenmode of the entire plasma electrons, the wake phase velocity ˜ c and ultrafastness of the laser pulse introduce the wake stability and rigidity. A large number of worldwide experiments show a rapid progress of this concept realization toward both the high-energy accelerator prospect and broad applications. The strong interest in this has been spurring and stimulating novel laser technologies, including the Chirped Pulse Amplification, the Thin Film Compression, the Coherent Amplification Network, and the Relativistic Mirror Compression. These in turn have created a conglomerate of novel science and technology with LWFA to form a new genre of high field science with many parameters of merit in this field increasing exponentially lately. This science has triggered a number of worldwide research centers and initiatives. Associated physics of ion acceleration, X-ray generation, and astrophysical processes of ultrahigh energy cosmic rays are reviewed. Applications such as X-ray free electron laser, cancer therapy, and radioisotope production etc. are considered. A new avenue of LWFA using nanomaterials is also emerging.
Yeh, Lu; Montealegre-Gallegos, Mario; Mahmood, Feroze; Hess, Philip E; Shnider, Marc; Mitchell, John D; Jones, Stephanie B; Mashari, Azad; Wong, Vanessa; Matyal, Robina
Understanding of the workflow of perioperative ultrasound (US) examination is an integral component of proficiency. Workflow consists of the practical steps prior to executing an US examination (eg, equipment operation). Whereas other proficiency components (ie, cognitive knowledge and manual dexterity) can be tested, workflow understanding is difficult to define and assess due to its contextual and institution-specific nature. The objective was to define the workflow components of specific perioperative US applications using an iterative process to reach a consensus opinion. Expert consensus, survey study. Tertiary university hospital. This study sought expert consensus among a focus group of 9 members of an anesthesia department with experience in perioperative US. Afterward, 257 anesthesia faculty members from 133 academic centers across the United States were surveyed. A preliminary list of tasks was designed to establish the expectations of workflow understanding by an anesthesiology resident prior to clinical exposure to perioperative US. This list was modified by a focus group through an iterative process. Afterwards, a survey was sent to faculty members nationwide, and Likert scale ratings for each task were obtained and reviewed during a second round. Consensus among members of the focus group was reached after 2 iterations. 72 participants responded to the nationwide survey (28%), and consensus was reached after the second round (Cronbach's α = 0.99, ICC = 0.99) on a final list of 46 workflow-related tasks. Specific components of perioperative US workflow were identified. Evaluation of workflow understanding may be combined with cognitive knowledge and manual dexterity testing for assessing proficiency in perioperative US. Copyright © 2017 Elsevier Inc. All rights reserved.
Hulst, A. H.; Hermanides, J.; DeVries, J. H.; Preckel, B.
We thank Dr Brown and Dr Paul for their insightful commentary on our study(1) and the subject of perioperative continuation of metformin, stressing again the importance of perioperative hyperglycaemia and treatment of diabetes mellitus (DM)
Mebazaa, Alexandre; Pitsis, Antonis A.; Rudiger, Alain; Toller, Wolfgang; Longrois, Dan; Ricksten, Sven-Erik; Bobek, Ilona; de Hert, Stefan; Wieselthaler, Georg; Schirmer, Uwe; von Segesser, Ludwig K.; Sander, Michael; Poldermans, Don; Ranucci, Marco; Karpati, Peter Cj; Wouters, Patrick; Seeberger, Manfred; Schmid, Edith R.; Weder, Walter; Follath, Ferenc
Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, signifi cant
A. Mebazaa (Alexandre); A.A. Pitsis (Antonis); A. Rudiger (Alain); W. Toller (Wolfgang); D. Longrois (Dan); S.E. Ricksten; I. Bobek (Ilona); S. de Hert (Stefan); G. Wieselthaler (Georg); U. Schirmer (Uwe); L.K. von Segesser (Ludwig); M. Sander (Michael); D. Poldermans (Don); M. Ranucci (Marco); P.C.J. Karpati (Peter); P.J. Wouters (Pieter); M. Seeberger (Manfred); E.R. Schmid (Edith); W. Weder (Walter); F. Follath
textabstractAcute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF,
Elizabeth A. Martinez
Full Text Available Although the evidence strongly supports perioperative glycemic control among cardiac surgical patients, there is scant literature to describe the practical application of such a protocol in the complex ICU environment. This paper describes the use of the Lean Six Sigma methodology to implement a perioperative insulin protocol in a cardiac surgical intensive care unit (CSICU in a large academic hospital. A preintervention chart audit revealed that fewer than 10% of patients were admitted to the CSICU with glucose <200 mg/dL, prompting the initiation of the quality improvement project. Following protocol implementation, more than 90% of patients were admitted with a glucose <200 mg/dL. Key elements to success include barrier analysis and intervention, provider education, and broadening the project scope to address the intraoperative period.
Martinez, Elizabeth A.; Chavez-Valdez, Raul; Holt, Natalie F.; Grogan, Kelly L.; Khalifeh, Katherine W.; Slater, Tammy; Winner, Laura E.; Moyer, Jennifer; Lehmann, Christoph U.
Although the evidence strongly supports perioperative glycemic control among cardiac surgical patients, there is scant literature to describe the practical application of such a protocol in the complex ICU environment. This paper describes the use of the Lean Six Sigma methodology to implement a perioperative insulin protocol in a cardiac surgical intensive care unit (CSICU) in a large academic hospital. A preintervention chart audit revealed that fewer than 10% of patients were admitted to the CSICU with glucose <200 mg/dL, prompting the initiation of the quality improvement project. Following protocol implementation, more than 90% of patients were admitted with a glucose <200 mg/dL. Key elements to success include barrier analysis and intervention, provider education, and broadening the project scope to address the intraoperative period. PMID:22091218
Full Text Available Statins belong to a specific group of drugs that have been described for their ability to control hyperlipidemia as well as for other pleiotropic effects such as improving vascular endothelial function, inhibition of oxidative stress pathways, and anti-inflammatory actions. Accumulating clinical evidence strongly suggests that statins also have a beneficial effect on perioperative morbidity and mortality. Therefore, this review aims to present all recent and pooled data on statin treatment in the perioperative setting as well as to highlight considerations regarding their indications and therapeutic application.
Jørgensen, B G; Qvist, N
Allogenic blood transfusion carries the risk of immunological and non-immunological adverse effects. Consequently, blood transfusion should be limited to situations where alternatives are not available. This article reviews current by available alternative strategies that reduce the need...... for perioperative allogenic blood transfusion. The effectiveness of a number of these alternatives needs to be documented and potential adverse effects clarified. The acceptance of a lower haemoglobin level as the transfusion trigger value is perhaps the most important factor in reducing the need for peri......-operative allogenic blood transfusion...
Schlitt, Axel; Jámbor, Csilla; Spannagl, Michael; Gogarten, Wiebke; Schilling, Tom; Zwissler, Bernhard
When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use. We selectively searched for relevant publications that appeared from 2003 to February 2013, with particular consideration of the guidelines of the European Society of Cardiology, the Association of Scientific Medical Societies in Germany (AWMF), the American College of Cardiology, and the American Heart Association. Vitamin K antagonists (VKA), low molecular weight heparins, and fondaparinux are the established anticoagulants. The past few years have seen the introduction of orally administered selective inhibitors of the clotting factors IIa (dabigatran) and Xa (rivaroxaban, apixaban). The timing of perioperative interruption of anticoagulation is based on pharmacokinetic considerations rather than on evidence from clinical trials. Recent studies have shown that substituting short-acting anticoagulants for VKA before a procedure increases the risk of bleeding without lowering the risk of periprocedural thromboembolic events. The therapeutic spectrum of acetylsalicylic acid and clopidogrel has been broadened by the newer platelet aggregation inhibitors prasugrel and ticagrelor. Patients with drug eluting stents should be treated with dual platelet inhibition for 12 months because of the risk of in-stent thrombosis. Anticoagulants and platelet aggregation inhibitors are commonly used drugs, but the evidence for their perioperative management is limited. The risks of thrombosis and of hemorrhage must be balanced against each other in the individual case. Anticoagulation need not be stopped for minor
Conlin, Frederick; Connelly, Neil R; Eaton, Michael P; Broderick, Patrick J; Friderici, Jennifer; Adler, Adam C
The advent of portable ultrasound machines in recent years has led to greater availability of focused cardiac ultrasound (FoCUS) in the perioperative and critical care setting. To our knowledge, its use in the perioperative setting among anesthesiologists remains undefined. We sought to assess the use of FoCUS by members of the Society of Cardiovascular Anesthesiologists (SCA) in clinical practice, to identify variations in its application, to outline limits to its use, and to understand the level of training of physicians using this technology. A 26-question anonymous and voluntary online survey assessing the participants' training level with FoCUS, frequency of use, and opinions regarding incorporating it into residency training and developing a pathway to basic certification. The survey was distributed to the members of the SCA via email. The survey was completed by 379 of 3660 members of the SCA (10%). Of the respondents, the majority (67%) had completed a cardiovascular anesthesiology fellowship with 58% identifying their practice as academic, while 37% stated they were in private practice, and 6% were military/Veterans Administration. Most (84%) of the respondents practiced in North America. Eighty-one percent reported familiarity with FoCUS, while 47% stated they use it in their clinical practice. Those practicing in North America were significantly less likely to utilize FoCUS in their practice as compared to other respondents. With regard to training and certification, 88% believe FoCUS education should be integrated into residency training programs and 74% believe there should be a pathway to basic certification for FoCUS. While most cardiovascular anesthesiologists are familiar with FoCUS, a minority have integrated it into their practice. Roadblocks such as lack of training, the fear of missing diagnoses, lack of resources, and the lack of a formal certification process must be addressed to allow for more widespread use of perioperative cardiac
Busti, Anthony J; Hooper, Justin S; Amaya, Christopher J; Kazi, Salahuddin
Patients with various rheumatologic and inflammatory disease states commonly require drugs known to decrease the inflammatory or autoimmune response for adequate control of their condition. Such drugs include nonsteroidal antiinflammatory drugs (NSAIDs), cyclooxygenase (COX)-2 inhibitors, corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers. These drugs affect inflammation and local immune responses, which are necessary for proper wound healing in the perioperative setting, thereby potentially resulting in undesirable postoperative complications. Such complications include wound dehiscence, infection, and impaired collagen synthesis. The end result is delayed healing of soft tissue and bone wounds. The current literature provides insight into the effect of some of these drugs on wound healing. For certain drugs, such as methotrexate, trials have been conducted in humans and direct us on what to do during the perioperative period. Whereas with other drugs, we must rely on either small-animal studies or extrapolation of data from human studies that did not specifically look at wound healing. Unfortunately, no clear consensus exists on the need and optimum time for withholding therapy before surgery. Likewise, clinicians are often uncertain of the appropriate time to resume therapy after the procedure. For those drugs with limited or no data in this setting, the use of pharmacokinetic properties and biologic effects of each drug should be considered individually. In some cases, discontinuation of therapy may be required up to 4 weeks before surgery because of the long half-lives of the drugs. In doing so, patients may experience an exacerbation or worsening of disease. Clinicians must carefully evaluate individual patient risk factors, disease severity, and the pharmacokinetics of available therapies when weighing the risks and benefits of discontinuing therapy in the perioperative setting.
Levy, J K; Bard, K M; Tucker, S J; Diskant, P D; Dingman, P A
High volume spay-neuter (spay-castration) clinics have been established to improve population control of cats and dogs to reduce the number of animals admitted to and euthanazed in animal shelters. The rise in the number of spay-neuter clinics in the USA has been accompanied by concern about the quality of animal care provided in high volume facilities, which focus on minimally invasive, time saving techniques, high throughput and simultaneous management of multiple animals under various stages of anesthesia. The aim of this study was to determine perioperative mortality for cats and dogs in a high volume spay-neuter clinic in the USA. Electronic medical records and a written mortality log were used to collect data for 71,557 cats and 42,349 dogs undergoing spay-neuter surgery from 2010 to 2016 at a single high volume clinic in Florida. Perioperative mortality was defined as deaths occurring in the 24h period starting with the administration of the first sedation or anesthetic drugs. Perioperative mortality was reported for 34 cats and four dogs for an overall mortality of 3.3 animals/10,000 surgeries (0.03%). The risk of mortality was more than twice as high for females (0.05%) as for males (0.02%) (P=0.008) and five times as high for cats (0.05%) as for dogs (0.009%) (P=0.0007). High volume spay-neuter surgery was associated with a lower mortality rate than that previously reported in low volume clinics, approaching that achieved in human surgery. This is likely to be due to the young, healthy population of dogs and cats, and the continuous refinement of techniques based on experience and the skills and proficiency of teams that specialize in a limited spectrum of procedures. Copyright © 2017 Elsevier Ltd. All rights reserved.
John, M; Crook, D; Dasari, K; Eljelani, F; El-Haboby, A; Harper, C M
Forced-air warming is a commonly used warming modality, which has been shown to reduce the incidence of inadvertent perioperative hypothermia (resistive heating mattresses offer a potentially cheaper alternative, however, and one of the research recommendations from the National Institute for Health and Care Excellence was to evaluate such devices formally. We conducted a randomized single-blinded study comparing perioperative hypothermia in patients receiving resistive heating or forced-air warming. A total of 160 patients undergoing non-emergency surgery were recruited and randomly allocated to receive either forced-air warming (n=78) or resistive heating (n=82) in the perioperative period. Patient core temperatures were monitored after induction of anaesthesia until the end of surgery and in the recovery room. Our primary outcome measures included the final intraoperative temperature and incidence of hypothermia at the end of surgery. There was a significantly higher rate of hypothermia at the end of surgery in the resistive heating group compared with the forced-air warming group (P=0.017). Final intraoperative temperatures were also significantly lower in the resistive heating group (35.9 compared with 36.1°C, P=0.029). Hypothermia at the end of surgery in both warming groups was common (36% forced air warming, 54% resistive heating). Our results suggest that forced-air warming is more effective than resistive heating in preventing postoperative hypothermia. NCT01056991. © The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: email@example.com.
Ousey, K; Edward, K-L; Lui, S; Stephenson, J; Walker, K; Duff, J; Leaper, D
Surgical site infection (SSI) is a common cause of postoperative morbidity. Perioperative hypothermia may contribute to surgical complications including increased risk of SSI. In this systematic review and meta-analysis, the effectiveness of active and passive perioperative warming interventions to prevent SSI was compared with standard (non-warming) care. Ovid MEDLINE; Ovid EMBASE; EBSCO CINAHL Plus; The Cochrane Wounds Specialised Register, and The Cochrane Central Register of Controlled Trials were searched, with no restrictions on language, publication date or study setting for randomised controlled trials (RCTs) and cluster RCTs. Adult patients undergoing elective or emergency surgery under general anaesthesia, receiving any active or passive warming intervention perioperatively were included. Selection, risk of bias assessment and data extraction were performed by two review authors, independently. Outcomes studied were SSI (primary outcome), inpatient mortality, hospital length of stay and pain (secondary outcomes). We identified four studies, including 769 patients. The risk ratio (RR) for SSI in warming groups was 0.36 [95% confidence interval (CI): 0.23, 0.56; p<0. 001]. Length of hospitalisation was 1.13 days less in warming groups [95% CI: -3.07, 5.33; p=0.600]. The RR for mortality in the warming groups was 0.77 [95% CI: 0.17, 3.43; p=0.730]. A meta-analysis for pain outcome could not be conducted. This review provides evidence in favour of active warming to prevent SSI, but insufficient evidence of active warming to reduce length of hospital stay and mortality. Benefits of passive warming remain unclear and warrant further research.
de Amorim, Ana Carolina Ribeiro; Costa, Milena Damasceno de Souza; Nunes, Francisca Leide da Silva; da Silva, Maria da Guia Bezerra; de Souza Leão, Cristiano; Gadelha, Patrícia Calado Ferreira Pinheiro
many factors can have a negative influence over surgical results, such as a compromised nutritional status and the extension of the perioperative fasting time. to evaluate the influence of the nutritional status and the perioperative fasting time over the occurrence of surgical complications and over hospital stay, in patients who have undergone surgery of the gastrointestinal tract and/or abdominal wall, and who were subjected to a nutritional care protocol. cohort study, conducted with 84 patients, from June to November 2014. Data collection was performed by applying a structured questionnaire, search over the records and medical and/or nutritional prescription. Statistical analysis was performed using STATA/SE 12.0 and significance level of 5%. nutritional risk was present in 26.2%, and from these 45.4% carried out preoperative nutritional therapy, having an average of 6.6 ± 2.79 days. The preoperative fasting was 4.5 (3.66; 5.50) hours and the postoperative fasting 5.1 (2.5; 20.5) hours. No associations were found between the parameters for assessing body composition and the presence of complications. A negative correlation was observed between the length of hospital stay and the BMI (p = 0.017),while a positive correlation was observed between weight loss and the length of hospital stay (p = 0.036). Patients with higher postoperative fasting time had a higher occurrence of complications (p = 0.021). the compromised nutritional status and the extension of perioperative fasting time are associated with the occurrence of surgical complications and increased length of hospital stay. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.
Maker, Ajay V; Sheikh, Raashid; Bhagia, Vinita
infusion, and glucagon rescue therapy has greatly improved management in the modern era and constitute the current standard of care. A simple immediate post-operative algorithm was constructed. Successful perioperative surgical management of total pancreatectomy and resulting pancreatogenic diabetes is critical to achieve acceptable post-operative outcomes, and we review the pertinent literature and provide a simple, evidence-based algorithm for immediate post-resection glycemic control.
Tengberg, L. T.; Bay-Nielsen, M.; Bisgaard, T.
Background: Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery....... Methods: The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included...... after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high...
Malamud, Ernest; Sessler, Andrew
In this paper, standing back--looking from afar--and adopting a historical perspective, the field of accelerator science is examined. How it grew, what are the forces that made it what it is, where it is now, and what it is likely to be in the future are the subjects explored. Clearly, a great deal of personal opinion is invoked in this process.
ten Broecke, P. W. C.; de Hert, S. G.; Mertens, E.; Adriaensen, H. F.
BACKGROUND: Many preoperative factors can influence perioperative mortality in cardiac surgery. Because the perioperative use of beta-blocking agents may reduce perioperative cardiac complications in non-cardiac surgery, we considered the possibility that beta-blocking agents could improve survival
On the inside of the cavity there is a layer of niobium. Operating at 4.2 degrees above absolute zero, the niobium is superconducting and carries an accelerating field of 6 million volts per metre with negligible losses. Each cavity has a surface of 6 m2. The niobium layer is only 1.2 microns thick, ten times thinner than a hair. Such a large area had never been coated to such a high accuracy. A speck of dust could ruin the performance of the whole cavity so the work had to be done in an extremely clean environment.
TOPGEAR: a randomised phase III trial of perioperative ECF chemotherapy versus preoperative chemoradiation plus perioperative ECF chemotherapy for resectable gastric cancer (an international, intergroup trial of the AGITG/TROG/EORTC/NCIC CTG).
Leong, Trevor; Smithers, B Mark; Michael, Michael; Gebski, Val; Boussioutas, Alex; Miller, Danielle; Simes, John; Zalcberg, John; Haustermans, Karin; Lordick, Florian; Schuhmacher, Christoph; Swallow, Carol; Darling, Gail; Wong, Rebecca
The optimal management of patients with resectable gastric cancer continues to evolve in Western countries. Following publication of the US Intergroup 0116 and UK Medical Research Council MAGIC trials, there are now two standards of care for adjuvant therapy in resectable gastric cancer, at least in the Western world: postoperative chemoradiotherapy and perioperative epirubicin/cisplatin/fluorouracil (ECF) chemotherapy. We hypothesize that adding chemoradiation to standard perioperative ECF chemotherapy will achieve further survival gains. We also believe there are advantages to administering chemoradiation in the preoperative rather than postoperative setting. In this article, we describe the TOPGEAR trial, which is a randomised phase III trial comparing control arm therapy of perioperative ECF chemotherapy with experimental arm therapy of preoperative chemoradiation plus perioperative ECF chemotherapy. Eligible patients with resectable adenocarcinoma of the stomach or gastroesophageal junction will be randomized to receive either perioperative chemotherapy alone (3 preoperative and 3 postoperative cycles of ECF) or perioperative chemotherapy plus preoperative chemoradiation. In the chemoradiation arm, patients receive 2 cycles of ECF plus chemoradiation prior to surgery, and then following surgery 3 further cycles of ECF are given. The trial is being conducted in two Parts; Part 1 (phase II component) has recruited 120 patients with the aim of assessing feasibility, safety and preliminary efficacy of preoperative chemoradiation. Part 2 (phase III component) will recruit a further 632 patients to provide a total sample size of 752 patients. The primary endpoint of the phase III trial is overall survival. The trial includes quality of life and biological substudies, as well as a health economic evaluation. In addition, the trial incorporates a rigorous quality assurance program that includes real time central review of radiotherapy plans and central review of
Desborough, Michael J; Oakland, Kathryn; Brierley, Charlotte; Bennett, Sean; Doree, Carolyn; Trivella, Marialena; Hopewell, Sally; Stanworth, Simon J; Estcourt, Lise J
Background Blood transfusion is administered during many types of surgery, but its efficacy and safety are increasingly questioned. Evaluation of the efficacy of agents, such as desmopressin (DDAVP; 1-deamino-8-D-arginine-vasopressin), that may reduce perioperative blood loss is needed. Objectives To examine the evidence for the efficacy of DDAVP in reducing perioperative blood loss and the need for red cell transfusion in people who do not have inherited bleeding disorders. Search methods We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2017, issue 3) in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1937), the Transfusion Evidence Library (from 1980), and ongoing trial databases (all searches to 3 April 2017). Selection criteria We included randomised controlled trials comparing DDAVP to placebo or an active comparator (e.g. tranexamic acid, aprotinin) before, during, or immediately after surgery or after invasive procedures in adults or children. Data collection and analysis We used the standard methodological procedures expected by Cochrane. Main results We identified 65 completed trials (3874 participants) and four ongoing trials. Of the 65 completed trials, 39 focused on adult cardiac surgery, three on paediatric cardiac surgery, 12 on orthopaedic surgery, two on plastic surgery, and two on vascular surgery; seven studies were conducted in surgery for other conditions. These trials were conducted between 1986 and 2016, and 11 were funded by pharmaceutical companies or by a party with a commercial interest in the outcome of the trial. The GRADE quality of evidence was very low to moderate across all outcomes. No trial reported quality of life. DDAVP versus placebo or no treatment Trial results showed considerable heterogeneity between surgical settings for total volume of red cells transfused (low
Study Objective: Surgical paients have been known to benefit immensely from psychological interventions. This study set out to assess the pre and postoperative anxiety levels and depression and the effect of cognitive therapy among Nigerian surgical patients. The effects of gender and educational status on perioperative ...
the acute onset of short-lived severe depression following her third exposure to ondansetron for doxorubicin-induced nausea while concurrently taking a selective 5-HT3 or serotonin selective re-uptake inhibitor (SSRI), fluoxetine. The following is a report of a severe depressive incident following peri-operative ondansetron ...
Chwalisz, Bart; Gilbert, Aubrey L; Gittinger, John W
Perioperative vision loss (POVL) may cause devastating visual morbidity. A prompt anatomical and etiologic diagnosis is paramount to guide management and assess prognosis. Where possible, steps should be undertaken to minimize risk of POVL for vulnerable patients undergoing high-risk procedures. We review the specific risk factors, pathophysiology, and management and prevention strategies for various etiologies of POVL.
Objective: Intraoperative cardiac arrests are not uncommon and are related to both surgical and anaesthetic factors. This study aimed to examine the factors which predispose to a periopeartive cardiac arrest, to assess the appropriateness of therapy and the outcome. Materials and Methods: All perioperative cardiac arrests ...
Bevinetto, Cara M; Kaye, Alan D
Angelman syndrome arises by one of 4 genetic mechanisms. Patients often have craniofacial abnormalities, vagal hypertonia, skeletal muscle atrophy or underdevelopment, a history of seizure disorders, and pharmacodynamic unpredictability. Its pathogenesis, clinical manifestations, diagnosis and treatment options, and perioperative anesthetic considerations are presented. Copyright © 2014 Elsevier Inc. All rights reserved.
Shah, Shilpa; Szmuszkovicz, Jacqueline R.
The perioperative period is an extremely tenuous time for the pediatric patient with pulmonary arterial hypertension. This article will discuss a multidisciplinary approach to preoperative planning, the importance of early identification of pulmonary hypertensive crises, and practical strategies for postoperative management for this unique group of children. PMID:29064445
Operating a diabetic patient presents a challenge to both the surgeons and the Anaesthetists alike. Perioperative morbidity and mortality are greater in diabetic than non-diabetic patients. The problems of managing diabetics who undergo surgery are associated with its attendant period of starvation and the metabolic effects ...
Using methylene blue for perioperative localization of the hydrocele sac in boys. O. A. Sowande, T. A. Olajide. Paediatric Surgery Unit, Obafemi Awolowo University/Obafemi Awolowo University Teaching Hospital, Ile Ife,. Osun State, Nigeria. Correspondence to: Dr. O. A. Sowande, Paediatric Surgery Unit, Obafemi Awolowo ...
Wetterslev, Jørn; Juul, Anne Benedicte
randomized trials. However, confidence intervals of the intervention effects in the meta-analyses are wide, leaving room for both benefits and harms. The largest observational study performed suggests that perioperative beta-blockade is associated with higher mortality in patients with low cardiac risk...
Gillespie, Brigid M; Chaboyer, Wendy; Lingard, Shirley; Ball, Sharon
Nurses' recognition of their own level of skills and abilities (ie perceived competence) is a prerequisite for ensuring they can practice in a safe manner. The demand for competence, in the operating room, may vary between clinical environments. It is, however, unclear what competency levels migrating nurses need in order to be deemed safe. This paper describes Canadian and Australian nurses' levels of perceived perioperative competence and discusses these results in the context of nurse migration. A survey was distributed to operating room nurses in six hospital sites (three in Canada and three in Australia). Perioperative competence was measured with a 40-item self-report survey which consisted of six domain subscales: foundational knowledge and skills; leadership; collaboration; proficiency; empathy; and professional development. Non-parametric tests were used to describe differences between groups based on country of origin, years of experience and specialty qualifications. Canadian and Australian nurses reported their overall competency levels as high across all domains. Significant differences were found, between countries, in three of the six competency domains; foundational knowledge and skills (p < .001), collegiality (p = .023), and empathy (p < .0001). Describing perioperative competence cross-nationally represents the first step in generating international dialogue around educational preparation for migrating nurses. The increasing global mobility of nurses makes it imperative to further standardise, with an international perspective, knowledge and practice expectations in perioperative settings.
Christiansen, I S; Krøigaard, M; Mosbech, H
INTRODUCTION: The Danish Anaesthesia Allergy Centre (DAAC) investigated 89 adult patients with suspected perioperative cefuroxime-associated hypersensitivity reactions between 2004 and 2013. The goals were to determine if the time to index reaction after cefuroxime exposure could be used to impli...
perioperative anxiety and depression among Nigerian surgical patients. *H. 0. ... surgery."2 The recognition of this factor has culminated in an increased research in this area.“ Preoperatively, many surgical patients manifest a heightened level of anxiety} 6 They are often - ..... of postoperative cosmetic surgery patients. Plasj.
Garvey, Lene Heise
and performance and interpretation of investigations. Differences in sensitization to NMBAs are partly explained by cross sensitization to pholcodine, an ingredient in cough-medicines available in some countries. While NMBAs are the most common causes of perioperative hypersensitivity in some countries, this may...
Gentry, Melanie B
ANNUAL PERFORMANCE evaluations can be difficult to prepare and may rely, in part, on anecdotal information. PERIOPERATIVE RNs at CHRISTUS St Patrick Hospital, Lake Charles, La, developed and implemented a peer evaluation as part of nurses' annual performance evaluations. THE EVALUATION FORMS created were considered to be useful and fair by both staff members and managers.
Background: Airway-related problems account for the majority of anaesthetic morbidity in paediatric anaesthesia, but more so for cleft lip and palate repair. The aim of this study was to assess the frequency, pattern, management and outcome of adverse airway events during the perioperative period in cleft lip and palate ...
management of hypertension and post myocardial infarction.4-6. Are lipophilic beta-blockers preferable for peri-operative cardioprotection? Implications from a limited systematic review of the efficacy of atenolol and metoprolol in preventing in-hospital ventricular fibrillation following acute myocardial infarction.
van Haelst, I.M.M.
Intraoperative hemodynamic changes and loss of blood with the associated risk of allogeneic blood transfusion are risk factors for complications in surgical patients. The use of medication in the perioperative period may influence these risk factors and consequently the frequency of complications.
Full Text Available The perioperative period is an extremely tenuous time for the pediatric patient with pulmonary arterial hypertension. This article will discuss a multidisciplinary approach to preoperative planning, the importance of early identification of pulmonary hypertensive crises, and practical strategies for postoperative management for this unique group of children.
Hah, Jennifer M; Bateman, Brian T; Ratliff, John; Curtin, Catherine; Sun, Eric
Physicians, policymakers, and researchers are increasingly focused on finding ways to decrease opioid use and overdose in the United States both of which have sharply increased over the past decade. While many efforts are focused on the management of chronic pain, the use of opioids in surgical patients presents a particularly challenging problem requiring clinicians to balance 2 competing interests: managing acute pain in the immediate postoperative period and minimizing the risks of persistent opioid use after the surgery. Finding ways to minimize this risk is particularly salient in light of a growing literature suggesting that postsurgical patients are at increased risk for chronic opioid use. The perioperative care team, including surgeons and anesthesiologists, is poised to develop clinical- and systems-based interventions aimed at providing pain relief in the immediate postoperative period while also reducing the risks of opioid use longer term. In this paper, we discuss the consequences of chronic opioid use after surgery and present an analysis of the extent to which surgery has been associated with chronic opioid use. We follow with a discussion of the risk factors that are associated with chronic opioid use after surgery and proceed with an analysis of the extent to which opioid-sparing perioperative interventions (eg, nerve blockade) have been shown to reduce the risk of chronic opioid use after surgery. We then conclude with a discussion of future research directions.
Full Text Available Objective: During the perioperative period, oral ingestion is changed considerably in esophagectomy patients. The aim of this study was to investigate oral environment modifications in patients undergoing esophageal cancer treatments due to changes in dietary intake and swallowing functions. Material and Methods: Thirty patients who underwent operation for removal of esophageal cancer in Tokushima University Hospital were enrolled in this study. Results: It was found that 1 the flow rate of resting saliva decreased significantly at postoperative period by deprived feeding for one week, although it did not recover several days after oral ingestion began, 2 the accumulation of dental plaque and the number of mutans streptococci in saliva decreased significantly after operation, while both increased relatively quick when oral ingestion began, and 3 the swallowing function decreased significantly in the postoperative period. Conclusions: These results suggest that dental professionals should emphasize the importance of oral health care and provide instructions on plaque control to patients during the perioperative period of esophageal cancer treatment.
O'Brien, Brid; Graham, Margaret M; Kelly, Sile Mary
To explore nurses' use of the World Health Organization safety checklist in the perioperative setting. Promoting quality and safety in health care has received worldwide attention. The World Health Organization surgical safety checklist (2009) is promoted for reducing postoperative morbidity and mortality. The checklist has been introduced in Irish perioperative settings. A descriptive, qualitative approach was utilised. A purposeful sample of ten nurses participated in individual, semi-structured interviews. Participants were committed to promoting safety in navigating challenges in introducing, complying and accepting the value of the World Health Organization surgical safety checklist in concordance with best practice. Participants moved from task completion to embracing the checklist as an effective surgical safety checking tool. Challenges were identified around roles and responsibilities in overseeing the completion of the checklist. The management of processes is critical when implementing any safety initiative. This paper highlights the complexity and challenges in implementing the World Health Organization surgical safety checklist, contributing to global discussions around translating policy into practice. The effective implementation of a checklist requires a coordinated management approach in collaboration with team members. These approaches will support learning experiences contributing to a shared understanding of the change being implemented by all team members. © 2016 John Wiley & Sons Ltd.
Maeda, Hiromichi; Okabayashi, Takehiro; Yatabe, Tomoaki; Yamashita, Koichi; Hanazaki, Kazuhiro
Perioperative glycemic control is important for reducing postoperative infectious complications. However, clinical trials have shown that efforts to maintain normoglycemia in intensive care unit patients result in deviation of glucose levels from the optimal range, and frequent attacks of hypoglycemia. Tight glycemic control is even more challenging in those undergoing pancreatic resection. Removal of lesions and surrounding normal pancreatic tissue often cause hormone deficiencies that lead to the destruction of glucose homeostasis, which is termed pancreatogenic diabetes. Pancreatogenic diabetes is characterized by the occurrence of hyperglycemia and iatrogenic severe hypoglycemia, which adversely effects patient recovery. Postoperatively, a variety of factors including surgical stress, inflammatory cytokines, sympathomimetic drug therapy, and aggressive nutritional support can also affect glycemic control. This review discusses the endocrine aspects of pancreatic resection and highlights postoperative glycemic control using a closed-loop system or artificial pancreas. In previous experiments, we have demonstrated the reliability of the artificial pancreas in dogs with total pancreatectomy, and its postoperative clinical use has been shown to be effective and safe, without the occurrence of hypoglycemic episodes, even in patients after total pancreatectomy. Considering the increasing requirement for tight perioperative glycemic control and the recognized risk of hypoglycemia, we propose the use of an artificial endocrine pancreas that is able to monitor continuously blood glucose concentrations with proven accuracy, and administer automatically substances to return blood glucose concentration to the optimal narrow range. PMID:19725142
Kreth, Simone; Hübner, Max; Hinske, Ludwig Christian
Over the past decade, evolutionarily conserved, noncoding small RNAs-so-called microRNAs (miRNAs)-have emerged as important regulators of virtually all cellular processes. miRNAs influence gene expression by binding to the 3'-untranslated region of protein-coding RNA, leading to its degradation and translational repression. In medicine, miRNAs have been revealed as novel, highly promising biomarkers and as attractive tools and targets for novel therapeutic approaches. miRNAs are currently entering the field of perioperative medicine, and they may open up new perspectives in anesthesia, critical care, and pain medicine. In this review, we provide an overview of the biology of miRNAs and their potential role in human disease. We highlight current paradigms of miRNA-mediated effects in perioperative medicine and provide a survey of miRNA biomarkers in the field known so far. Finally, we provide a perspective on miRNA-based therapeutic opportunities and perspectives.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
Song, Jin Soo A; Wozney, Lori; Chorney, Jill; Ishman, Stacey L; Hong, Paul
Parents can struggle while providing perioperative tonsillectomy care for their children at home. Short message service (SMS) technology is an accessible and direct modality to communicate timely, evidence-based recommendations to parents across the perioperative period. This study focused on validating a SMS protocol, Tonsil-Text-To-Me (TTTM), for parents of children undergoing tonsillectomy. This study used a modified Delphi expert consensus method. Participants were an international sample of 27 clinicians/researchers. Participants rated level of agreement with recommendations across seven perioperative domains, derived systematically from scientific and lay literature. A priori consensus analysis was conducted using threshold criterion. A multidisciplinary team of local clinicians were also individually interviewed to consolidate text messages and implement recurrent suggestions. In the modified Delphi panel, 30 statements reached threshold agreement (>3.0 of 4.0); recommendations surrounding diet (3.87) and hygiene (3.83) had the highest level of consensus, while recommendations regarding activity (3.42) and non-pharmacologic pain management (3.55) had the lowest consensus. The 30 statements reconfigured into 12 concise text messages. After further interviews with local clinicians, 14 final text messages were included in the SMS protocol to be sent two weeks preoperatively to one week postoperatively. This study illustrates the development of TTTM which is designed to deliver key sequential text messages at the optimal time during the perioperative setting to parents caring for their children who are undergoing tonsillectomy. Copyright © 2017 Elsevier B.V. All rights reserved.
A case of an aggressive thymoma with intracardiac invasion in a child is presented. The management plan involved ... and it is recommended that it be considered routinely in these patients. Keywords: echocardiography ... referred to oncology for chemo-radiotherapy and palliative care. Subsequent histology showed Type ...
Leung, Alexander A; McAlister, Finlay A; Finlayson, Samuel R G; Bates, David W
The prognostic implications of preoperative hypernatremia are unknown. We sought to determine whether preoperative hypernatremia is a predictor of 30-day perioperative morbidity and mortality. We conducted a cohort study using the American College of Surgeons-National Surgical Quality Improvement Program and identified 908,869 adult patients undergoing major surgery from approximately 300 hospitals from the years 2005 to 2010. We followed the patients for 30-day perioperative outcomes, which included death, major coronary events, wound infections, pneumonia, and venous thromboembolism. Multivariable logistic regression was used to estimate the odds of 30-day perioperative outcomes. The 20,029 patients (2.2%) with preoperative hypernatremia (>144 mmol/L) were compared with the 888,840 patients with a normal baseline sodium (135-144 mmol/L). Hypernatremia was associated with a higher odds for 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% confidence interval [CI], 1.33-1.56), and this finding was consistent in all subgroups. The odds increased according to the severity of hypernatremia (P 148 mmol/L] categories). Furthermore, hypernatremia was associated with a greater odds for perioperative major coronary events (1.6% vs 0.7%; aOR, 1.16; 95% CI, 1.03-1.32), pneumonia (3.4% vs 1.5%; aOR, 1.23; 95% CI, 1.13-1.34), and venous thromboembolism (1.8% vs 0.9%; OR, 1.28; 95% CI, 1.14-1.42). Preoperative hypernatremia is associated with increased perioperative 30-day morbidity and mortality. Copyright © 2013 Elsevier Inc. All rights reserved.
Full Text Available OBJECTIVE: To develop a convenient screening method that can predict perioperative venous thromboembolism (VTE and identify patients at risk of fatal perioperative pulmonary embolism (PE. METHODS: Patients hospitalized for gynecological abdominal surgery (n = 183 underwent hematology tests and multidetector computed tomography (MDCT to detect VTE. All statistical analyses were carried out using the SPSS software program (PASWV19.0J. RESULTS: The following risk factors for VTE were identified by univariate analysis: plasmin-alpha2-plasmin inhibitor complex (PIC, thrombin-antithrombin III complex (TAT, and prolonged immobility (all p<0.001; age, neoadjuvant chemotherapy (NAC, malignancy, hypertension, past history of VTE, and hormone therapy (all p<0.01; and hemoglobin, transverse tumor diameter, ovarian disease, and menopause (all p<0.05. Multivariate analysis using these factors revealed that PIC, age, and transverse tumor diameter were significant independent determinants of the risk of VTE. We then calculated the incidence rate of perioperative VTE using PIC and transverse tumor diameter in patient groups stratified by age. In patients aged ≤40 years, PIC ≥1.3 µg/mL and a transverse tumor diameter ≥10 cm identified the high-risk group for VTE with an accuracy of 93.6%. For patients in their 50 s, PIC ≥1.3 µg/mL identified a high risk of VTE with an accuracy of 78.2%. In patients aged ≥60 years, a transverse tumor diameter ≥15 cm (irrespective of PIC or PIC ≥1.3 µg/mL identified the high-risk group with an accuracy of 82.4%. CONCLUSIONS: We propose new screening criteria for VTE risk that are based on PIC, transverse tumor diameter, and age. Our findings suggest the usefulness of these criteria for predicting the risk of perioperative VTE and for identifying patients with a high risk of fatal perioperative PE.
Full Text Available Postoperative pneumonia (POP is common and results in prolonged hospital stays, higher costs, increased morbidity and mortality. However, data on the incidence and risk factors of POP after oral and maxillofacial surgery are rare. This study aims to identify perioperative risk factors for POP after major oral cancer (OC surgery.Perioperative data and patient records of 331 consecutive subjects were analyzed in the period of April 2014 to March 2016. We individually traced each OC patient for a period to discharge from the hospital or 45 days after surgery, whichever occur later.The incidence of POP after major OC surgery with free flap construction or major OC surgery was 11.6% or 4.5%, respectively. Patient-related risk factors for POP were male sex, T stage, N stage, clinical stage and preoperative serum albumin level. Among the investigated procedure-related variables, incision grade, mandibulectomy, free flap reconstruction, tracheotomy, intraoperative blood loss, and the length of the operation were shown to be associated with the development of POP. Postoperative hospital stay was also significantly related to increased incidence of POP. Using a multivariable logistic regression model, we identified male sex, preoperative serum albumin level, operation time and postoperative hospital stay as independent risk factors for POP.Several perioperative risk factors can be identified that are associated with POP. At-risk oral cancer patients should be subjected to intensified postoperative pulmonary care.
Egner, W; Cook, T; Harper, N; Garcez, T; Marinho, S; Kong, K L; Nasser, S; Thomas, M; Warner, A; Hitchman, J; Floss, K
Guidelines for investigation of perioperative drug allergy exist, but the quality of services is unknown. Specialist perioperative anaphylaxis services were surveyed through the Royal College of Anaesthetists 6th National Audit Project. We compare self-declared UK practice in specialist perioperative allergy services with national recommendations. A SurveyMonkey™ questionnaire was distributed to providers of allergy services in the UK. Responses were assessed for adherence to the best practice recommendations of the British Society for Allergy and Clinical Immunology (BSACI), the Association of Anaesthetists of Great Britain and Ireland and the National Institute for Health and Care Excellence (NICE) Guidance on Drug Allergy-CG183. Over 1200 patients were evaluated in 44 centres annually. Variation in workload, waiting times, access, staffing and diagnostic approach was noted. Paediatric centres had the longest routine waiting times (most wait >13 weeks) in contrast to adult centres (most wait clinic and 5/44 (11%) sign-posted support groups]. Most centres were able to provide diagnostic challenges to antibiotics [40/44 (91%]) and local anaesthetics [41/44 (93%)]. Diagnostic testing is not harmonized, with marked variability in the NMBA panels used to identify safe alternatives. Chlorhexidine and latex are not part of routine testing in many centres. Poor access to services and patient information provision require attention. Harmonization of diagnostic approach is desirable, particularly with regard to a minimum NMBA panel for identification of safe alternatives. © 2017 John Wiley & Sons Ltd.
Stöckli, M; Müller, B; Wagner, M
In our division, highly qualified enterostomal therapists treat approximately 300 patients each year Patient care consists of extensive preoperative information, localization of the ideal stoma position and providing patient-education in stoma handling. A regular ambulatory consultation allows early recognition of typical stoma related complications and their effective treatment in a timely manner. Another important issue of our consulting service includes patients concerns, such as social integration and physical independence. The creation of a specialized center provides an efficient and continuous care of enterostomy patients and their relatives. Thus, initial fears and emotional crisis can be addressed and minimalized. It is our goal to provide individual and comprehensive service in order to accommodate our patients needs.
Johnson, Brenda; Raymond, Shirley; Goss, Judith
The ambient noise of monitors, other patients, and staff in the postanesthesia care unit/operating room may elevate levels of anxiety. The purpose of our study was to determine the effect of music versus noise-blocking headphones on the level of anxiety in women undergoing gynecologic same-day surgery. Institutional Review Board approval was obtained. The women were approached for consent and randomized to usual care, music with headphones, or headphones only. Preoperative and postoperative anxiety was rated on a scale of 0 to 10. Music/headphones were continued throughout surgery and removed when Aldrete level of consciousness equaled 2. The 119 women had a mean age of 38.8 (standard deviation=2.2) years. Of interest, 51 (45%) reported very low preoperative anxiety (0-3/10) and were excluded. All groups experienced a drop in anxiety from pre- to postoperative status, but the usual care group had the least improvement (Panxiety scores; the headphone group had a greater change overall. Music is a relatively inexpensive intervention, easy to administer, and noninvasive. Copyright © 2012 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Dexter, Franklin; Blake, John T; Penning, Donald H; Sloan, Brian; Chung, Patricia; Lubarsky, David A
Administrators at hospitals with a fixed annual budget may want to focus surgical services on priority areas to ensure its community receives the best health services possible. However, many hospitals lack the detailed managerial accounting data needed to ensure that such a change does not increase operating costs. The authors used a detailed hospital cost database to investigate by how much a change in allocations of operating room (OR) time among surgeons can increase perioperative variable costs. The authors obtained financial data for all patients who underwent outpatient or same-day admit surgery during a year. Linear programming was used to determine by how much changing the mix of surgeons can increase total variable costs while maintaining the same total hours of OR time for elective cases. Changing OR allocations among surgeons without changing total OR hours allocated will likely increase perioperative variable costs by less than 34%. If, in addition, intensive care unit hours for elective surgical cases are not increased, hospital ward occupancy is capped, and implant use is tracked and capped, perioperative costs will likely increase by less than 10%. These four variables predict 97% of the variance in total variable costs. The authors showed that changing OR allocations among surgeons without changing total OR hours allocated can increase hospital perioperative variable costs by up to approximately one third. Thus, at hospitals with fixed or nearly fixed annual budgets, allocating OR time based on an OR-based statistic such as utilization can adversely affect the hospital financially. The OR manager can reduce the potential increase in costs by considering not just OR time, but also the resulting use of hospital beds and implants.
Siracusa, Carlo; Manteca, Xavier; Cuenca, Rafaela; del Mar Alcalá, Maria; Alba, Aurora; Lavín, Santiago; Pastor, Josep
To study the effects of a synthetic, dog-appeasing pheromone (sDAP) on the behavioral, neuroendocrine, immune, and acute-phase perioperative stress responses in dogs undergoing elective orchiectomy or ovariohysterectomy. Randomized, controlled clinical trial. 46 dogs housed in animal shelters and undergoing elective orchiectomy or ovariohysterectomy. Intensive care unit cages were sprayed with sDAP solution or sham treated with the carrier used in the solution 20 minutes prior to use. Dogs (n = 24 and 22 in the sDAP and sham treatment exposure groups, respectively) were placed in treated cages for 30 minutes before and after surgery. Indicators of stress (ie, alterations in behavioral, neuroendocrine, immune, and acute-phase responses) were evaluated perioperatively. Behavioral response variables, salivary cortisol concentration, WBC count, and serum concentrations of glucose, prolactin, haptoglobin, and C-reactive protein were analyzed. Behavioral response variables and serum prolactin concentration were influenced by sDAP exposure. Dogs exposed to sDAP were more likely to have alertness and visual exploration behaviors after surgery than were dogs exposed to sham treatment. Decreases in serum prolactin concentrations in response to perioperative stress were significantly smaller in dogs exposed to sDAP, compared with findings in dogs exposed to the sham treatment. Variables examined to evaluate the hypothalamic-pituitary-adrenal axis, immune system, and acute-phase responses were unaffected by treatment. sDAP appeared to affect behavioral and neuroendocrine perioperative stress responses by modification of lactotropic axis activity. Use of sDAP in a clinical setting may improve the recovery and welfare of dogs undergoing surgery.
ICU) can provide an insight into the standard of peri-operative management in operating theatres and ICU resource management,1 including quality of anaesthetic care.1,2 Assessing anaesthetic-related mortality and morbidity ...
Machi, Sueo [Japan Atomic Industrial Forum, Inc., Tokyo (Japan)
Electron accelerator is an important radiation source for radiation technology, which covers broad fields such as industry, health care, food and environmental protection. There are about 1,000 electron accelerators for radiation processing worldwide. Electron accelerator has advantage over Co-60 irradiator in term of high dose rate and power, assurance of safety, and higher economic performance at larger volume of irradiation. Accelerator generating higher energy in the range of 10 MeV and high power electron beam is now commercially available. There is a trend to use high-energy electron accelerator replacing Co-60 in case of large through-put of medical products. Irradiated foods, in particular species, are on the commercial market in 35 countries. Electron accelerator is used efficiently and economically for production of new or modified polymeric materials through radiation-induced cross-linking, grafting and polymerization reaction. Another important application of electron beam is the curing of surface coatings in the manufacture of products. Electron accelerators of large capacity are used for cleaning exhaust gases in industrial scale. Economic feasibility studies of this electron beam process have shown that this technology is more cost effective than the conventional process. It should be noted that the conventional limestone process produce gypsum as a by-product, which cannot be used in some countries. By contrast, the by-product of the electron beam process is a valuable fertilizer. (Y. Tanaka)
Full Text Available Abstract Background Perioperative pain management has recently been revolutionized with the recognition of novel mechanisms and introduction of newer drugs. Many randomized trials have studied the use of the gabapentinoid anti-epileptic, pregabalin, in acute pain. Published systematic reviews suggest that using pregabalin for perioperative pain management may decrease analgesic requirements and pain scores, at the expense of troublesome side effects. A major limitation of the extant reviews is the lack of rigorous investigation of clinical characteristics that would maximize the benefit harms ratio in favor of surgical patients. We posit that effects of pregabalin for perioperative pain management vary by the type of surgical pain model and propose this systematic review protocol to update previous systematic reviews and investigate the heterogeneity in findings across subgroups of surgical pain models. Methods/Design Using a peer-reviewed search strategy, we will search key databases for clinical trials on perioperative pregabalin use in adults. The electronic searches will be supplemented by scanning the reference lists of included studies. No limits of language, country or year will be imposed. Outcomes will include pain; use of co-analgesia, particularly opioids; enhanced recovery; and drug-related harms. We will focus on the identification of surgical models and patient characteristics that have shown benefit and adverse effects from pregabalin. Two clinical experts will independently screen the studies for inclusion using eligibility criteria established a priori. Data extracted by the reviewers will then be verified. Publication bias will be assessed, as will risk of bias using the Cochrane Risk of Bias tool. Meta-analysis and meta-regression are planned if the studies are deemed statistically, methodologically and clinically homogenous. Evidence will be graded for its strength for a select number of outcomes. Discussion We will explore
Background Perioperative pain management has recently been revolutionized with the recognition of novel mechanisms and introduction of newer drugs. Many randomized trials have studied the use of the gabapentinoid anti-epileptic, pregabalin, in acute pain. Published systematic reviews suggest that using pregabalin for perioperative pain management may decrease analgesic requirements and pain scores, at the expense of troublesome side effects. A major limitation of the extant reviews is the lack of rigorous investigation of clinical characteristics that would maximize the benefit harms ratio in favor of surgical patients. We posit that effects of pregabalin for perioperative pain management vary by the type of surgical pain model and propose this systematic review protocol to update previous systematic reviews and investigate the heterogeneity in findings across subgroups of surgical pain models. Methods/Design Using a peer-reviewed search strategy, we will search key databases for clinical trials on perioperative pregabalin use in adults. The electronic searches will be supplemented by scanning the reference lists of included studies. No limits of language, country or year will be imposed. Outcomes will include pain; use of co-analgesia, particularly opioids; enhanced recovery; and drug-related harms. We will focus on the identification of surgical models and patient characteristics that have shown benefit and adverse effects from pregabalin. Two clinical experts will independently screen the studies for inclusion using eligibility criteria established a priori. Data extracted by the reviewers will then be verified. Publication bias will be assessed, as will risk of bias using the Cochrane Risk of Bias tool. Meta-analysis and meta-regression are planned if the studies are deemed statistically, methodologically and clinically homogenous. Evidence will be graded for its strength for a select number of outcomes. Discussion We will explore the findings of perioperative
Ogonowska-Kobusiewicz, Maria; Rutyna, Rafał; Nestorowicz, Andrzej
Patients with upper airway obstruction during sleep are at constant risk of hypoxic and hypercarbic episodes and are especially vulnerable during anaesthesia and sedation as the abnormal anatomy is compounded by drug-related respiratory depression. Elective procedures in patients with the obstructive sleep apnoea (OSA) should be usually delayed, allowing for the preoperative home treatment (diet, alcohol abstinence, nasal CPAP/BiPAP during night). Respiratory supportive techniques, started at home, should be continued in the hospital, both in preoperative and postoperative periods. Patients with OSA should be also thoroughly examined for possible anatomic abnormalities of the upper airway that may complicate laryngoscopy and/or intubation. Heavy premedication should be avoided; in special cases of very nervous patients oral clonidine may be used. Careful preoxygenation is mandatory, opioids should be used sparingly. Muscle relaxant should be calculated for an ideal body weight. Isoflurane should be avoided. The OPS and obese patients are usually extubated in the sitting or lateral positions to avoid limitation of FRC by elevated diaphragm. In selected cases, prolonged intubation and/or ventilation are recommended. Regional anaesthesia are usually safe in these patients, however, opioids should be used carefully. When sedation is required, ketamine or dexmedetomidine may be used.
Vitin Alexander A.
Full Text Available Lactic acidosis (LA in end-stage liver disease (ESLD patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia- and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.
Clayton, Judy; Isaacs, Anton Neville; Ellender, Isabel
To explore the lived experiences of perioperative nurses in a multicultural operating theatre in Melbourne, Australia. Multiculturalism has become the norm in the health workforce of several developed countries due mostly to immigration. Within an operating theatre setting where good communication is paramount, the presence of nurses and doctors from multiple cultures and different training backgrounds could pose a major challenge. Using a qualitative research methodology underpinned by phenomenology, we interviewed fourteen nurses from different sections of an operating theatre. From the lived experiences of the participants, difficulties in communication emerged as the major theme. Difficulties in communication affected patient care and the working atmosphere. In addition, social integration appeared to improve communication. Addressing the needs of patients from culturally and linguistically diverse backgrounds in the operating theatre continues to be challenging. However, developing a sense of camaraderie and fostering good relationships between staff through regular social gatherings can improve communication and the working atmosphere. Copyright © 2014 Elsevier Ltd. All rights reserved.
Bergman, Gert J. D.; Winter, Jan C.; van Tulder, Maurits W.; Meyboom-de Jong, Betty; Postema, Klaas; van der Heijden, Geert J. M. G.
Background: Shoulder complaints are common in primary care and have unfavourable long term prognosis. Our objective was to evaluate the clinical effectiveness of manipulative therapy of the cervicothoracic spine and the adjacent ribs in addition to usual medical care (UMC) by the general
Andersen, L P H; Werner, M U; Rosenberg, J
; and safety. Compared with placebo, melatonin reduced the standardised mean difference (95% CI) pre-operative anxiety score by 0.88 (0.44-1.33) and postoperative pain score by 1.06 (0.23-1.88). The magnitude of effect was unreliable due to substantial statistical heterogeneity, with I(2) 87% and 94......We systematically reviewed randomised controlled trials of peri-operative melatonin. We included 24 studies of 1794 participants that reported eight peri-operative outcomes: anxiety; analgesia; sleep quality; oxidative stress; emergence behaviour; anaesthetic requirements; steal induction......%, respectively. Qualitative reviews suggested the melatonin improved sleep quality and emergence behaviour, and might be capable of reducing oxidative stress and anaesthetic requirements....
Shim, Hongjin; Cheong, Jae Ho; Lee, Kang Young; Lee, Hosun; Noh, Sung Hoon
Purpose The presence of gastrointestinal (GI) cancer and its treatment might aggravate patient nutritional status. Malnutrition is one of the major factors affecting the postoperative course. We evaluated changes in perioperative nutritional status and risk factors of postoperative severe malnutrition in the GI cancer patients. Materials and Methods Nutritional status was prospectively evaluated using patient-generated subjective global assessment (PG-SGA) perioperatively between May and September 2011. Results A total of 435 patients were enrolled. Among them, 279 patients had been diagnosed with gastric cancer and 156 with colorectal cancer. Minimal invasive surgery was performed in 225 patients. PG-SGA score increased from 4.5 preoperatively to 10.6 postoperatively (p60, pnutritional support should be considered. PMID:24142640
Educators today need innovative teaching strategies to meet the learning needs of the multigenerational population of perioperative nurses. Emerging technologies, such as YouTube, the world's largest video-sharing web site, can be used as a component of an active learning strategy that can appeal to a broad group of nurses along the novice-to-expert proficiency continuum. Using video clips can be a useful method to engage learners and promote critical thinking, decision making, and creativity. YouTube videos can be used to teach skills or as a platform for discussion. Learners also can create and upload their own videos to educate others. Increased engagement and active learning can lead the perioperative nurse to a deeper understanding of the educational material. Copyright © 2012 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Ramos, Juan A; Brull, Sorin J
The number of patients with noncardiac implantable electronic devices is increasing, and the absence of perioperative management standards, guidelines, practice parameters, or expert consensus statements presents clinical challenges. A 69-year-old woman presented for latissimus dorsi breast reconstruction. The patient had previously undergone implantation of a spinal cord stimulator, a gastric pacemaker, a sacral nerve stimulator, and an intrathecal morphine pump. After consultation with device manufacturers, the devices with patient programmability were switched off. Bipolar cautery was used intraoperatively. Postoperatively, all devices were interrogated to ensure appropriate functioning before home discharge. Perioperative goals include complete preoperative radiologic documentation of device component location, minimizing electromagnetic interference, and avoiding mechanical damage to implanted device components.
Eric S. Schwenk
Full Text Available Interscalene nerve block impairs ipsilateral lung function and is relatively contraindicated for patients with lung impairment. We present a case of an 89-year-old female smoker with prior left lung lower lobectomy and mild to moderate lung disease who presented for right shoulder arthroplasty and insisted on regional anesthesia. The patient received a multimodal perioperative regimen that consisted of a continuous interscalene block, acetaminophen, ketorolac, and opioids. Surgery proceeded uneventfully and postoperative analgesia was excellent. Pulmonary physiology and management of these patients will be discussed. A risk/benefit discussion should occur with patients having impaired lung function before performance of interscalene blocks. In this particular patient with mild to moderate disease, analgesia was well managed through a multimodal approach including a continuous interscalene block, and close monitoring of respiratory status took place throughout the perioperative period, leading to a successful outcome.
Timm, Fanny P; Houle, Timothy T; Grabitz, Stephanie D
OBJECTIVE: To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate. DESIGN: Prospective hospital registry study. SETTING: Massachusetts General Hospital and two satellite campuses between...... January 2007 and August 2014. PARTICIPANTS: 124 558 surgical patients (mean age 52.6 years; 54.5% women). MAIN OUTCOME MEASURES: The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome...... was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location. RESULTS: 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0...
Chilkoti, Geetanjali; Wadhwa, Rachna; Saxena, Ashok Kumar
Minimal mandatory monitoring in the perioperative period recommended by Association of Anesthetists of Great Britain and Ireland and American Society of Anesthesiologists are universally acknowledged and has become an integral part of the anesthesia practice. The technologies in perioperative monitoring have advanced, and the availability and clinical applications have multiplied exponentially. Newer monitoring techniques include depth of anesthesia monitoring, goal-directed fluid therapy, transesophageal echocardiography, advanced neurological monitoring, improved alarm system and technological advancement in objective pain assessment. Various factors that need to be considered with the use of improved monitoring techniques are their validation data, patient outcome, safety profile, cost-effectiveness, awareness of the possible adverse events, knowledge of technical principle and ability of the convenient routine handling. In this review, we will discuss the new monitoring techniques in anesthesia, their advantages, deficiencies, limitations, their comparison to the conventional methods and their effect on patient outcome, if any.
Acar, H Volkan
Acupuncture has been used in the Far East for more than 2000 years. Since the early 1970s, this technique has been gaining popularity among Western medical community. A number of studies suggest that its mechanism of effect can be explained in biomedical terms. In this context, a number of transmitters and modulators including beta-endorphin, serotonin, substance P, interleukins, and calcitonin gene-related peptide are released. For that reason, acupuncture can be used in a wide variety of clinical conditions. Studies showed that acupuncture may have beneficial effect in perioperative period. It relieves preoperative anxiety, decreases postoperative analgesic requirements, and decreases the incidence of postoperative nausea and vomiting. In this review article, we examine perioperative use of acupuncture for a variety of conditions. Copyright Â© 2016 Elsevier Ltd. All rights reserved.
Full Text Available An osteo-odonto-keratoprosthesis (OOKP procedure is indicated in patients with failed corneal transplant but having intact retina for visual improvement. We studied perioperative concerns of patients who underwent the staged OOKP procedure. This was a retrospective analysis of patients who underwent OOKP. The information regarding symptoms, associated comorbidities, perioperative events including anaesthetic management were collected. Eight patients (five females and three males underwent the staged OOKP procedure. The median age was 18 years. The median weight was 45 kg. The median duration of loss of vision was 4 years. The aetiology of blindness included Stevens-Johnson′s syndrome (SJS (7 and chemical burn (1. Four patients had generalized skin problem due to SJS. All cases were managed under general anaesthesia, and airway management included nasotracheal intubation for stage I and orotracheal intubation for stage II. The median mallampati classification was I prior to OOKP stage I procedure while it changed to II at stage II procedure. Two patients required fibreoptic nasotracheal intubation. One patient had excessive oozing from the mucosal harvest site and was managed conservatively. In one patient, tooth harvesting was done twice as the first tooth was damaged during creating a hole in it. We conclude that OOKP requires multidisciplinary care. Anaesthesiologist should evaluate the airway carefully and disease-associated systemic involvements. The use of various drugs requires caution and steroid supplementation should be done. Airway difficulty should be anticipated, mandating thorough evaluation. Re-evaluation of airway is prudent as it may become difficult during the staged OOKP procedure.
Kehlet, M.; Heesemann, Sabine; Tonnesen, H.
Background: The effect of intensive smoking cessation programs on postoperative complications has never before been assessed in soft tissue surgery when smoking cessation is initiated on the day of surgery. Methods: A single-blinded randomized clinical trial conducted at two vascular surgery...... departments in Denmark. The intervention group was offered the Gold Standard Program (GSP) for smoking cessation intervention. The control group was offered the departments' standard care. Inclusion criteria were patients with planned open peripheral vascular surgery and who were daily smokers. According...... intervention and 21 as controls. There was no difference in 30-day complication rates or 6-week abstinence rates between the two groups. Conclusions: A trial assessing the effect of smoking cessation on postoperative complications on the day of soft tissue surgery is still needed. If another trial...
Perrino, A C; Luther, M A; Phillips, D B; Levin, F L
To develop a multimedia perioperative recordkeeper that provides: 1. synchronous, real-time acquisition of multimedia data, 2. on-line access to the patient's chart data, and 3. advanced data analysis capabilities through integrated, multimedia database and analysis applications. To minimize cost and development time, the system design utilized industry standard hardware components and graphical. software development tools. The system was configured to use a Pentium PC complemented with a variety of hardware interfaces to external data sources. These sources included physiologic monitors with data in digital, analog, video, and audio as well as paper-based formats. The development process was guided by trials in over 80 clinical cases and by the critiques from numerous users. As a result of this process, a suite of custom software applications were created to meet the design goals. The Perioperative Data Acquisition application manages data collection from a variety of physiological monitors. The Charter application provides for rapid creation of an electronic medical record from the patient's paper-based chart and investigator's notes. The Multimedia Medical Database application provides a relational database for the organization and management of multimedia data. The Triscreen application provides an integrated data analysis environment with simultaneous, full-motion data display. With recent technological advances in PC power, data acquisition hardware, and software development tools, the clinical researcher now has the ability to collect and examine a more complete perioperative record. It is hoped that the description of the MPR and its development process will assist and encourage others to advance these tools for perioperative research.
Roxburgh, Campbell S; Horgan, Paul G; McMillan, Donald C
Within the tumor microenvironment, non-specific innate immune responses can suppress adaptive cytotoxic immunity and hence promote tumor progression. Surgery and trauma provokes high-grade, non-specific inflammatory responses that suppress cell-mediated immunity. Here, the surgical resection of neoplastic lesions is considered in the context of antitumor immunity, providing the rationale for development of perioperative interventions to maintain the immunological competence of the host.
Uciteli, Alexandr; Neumann, Juliane; Tahar, Kais; Saleh, Kutaiba; Stucke, Stephan; Faulbrück-Röhr, Sebastian; Kaeding, André; Specht, Martin; Schmidt, Tobias; Neumuth, Thomas; Besting, Andreas; Stegemann, Dominik; Portheine, Frank; Herre, Heinrich
Medical personnel in hospitals often works under great physical and mental strain. In medical decision-making, errors can never be completely ruled out. Several studies have shown that between 50 and 60% of adverse events could have been avoided through better organization, more attention or more effective security procedures. Critical situations especially arise during interdisciplinary collaboration and the use of complex medical technology, for example during surgical interventions and in perioperative settings (the period of time before, during and after surgical intervention). In this paper, we present an ontology and an ontology-based software system, which can identify risks across medical processes and supports the avoidance of errors in particular in the perioperative setting. We developed a practicable definition of the risk notion, which is easily understandable by the medical staff and is usable for the software tools. Based on this definition, we developed a Risk Identification Ontology (RIO) and used it for the specification and the identification of perioperative risks. An agent system was developed, which gathers risk-relevant data during the whole perioperative treatment process from various sources and provides it for risk identification and analysis in a centralized fashion. The results of such an analysis are provided to the medical personnel in form of context-sensitive hints and alerts. For the identification of the ontologically specified risks, we developed an ontology-based software module, called Ontology-based Risk Detector (OntoRiDe). About 20 risks relating to cochlear implantation (CI) have already been implemented. Comprehensive testing has indicated the correctness of the data acquisition, risk identification and analysis components, as well as the web-based visualization of results.
Nayara de Castro Pereira; Ruth Natalia Teresa Turrini; Vanessa de Brito Poveda
Abstract OBJECTIVE To identify the length of perioperative fasting among patients submitted to gastrointestinal cancer surgeries. METHOD Retrospective cohort study, developed by consulting the medical records of 128 patients submitted to gastrointestinal cancer surgeries. RESULTS The mean of total length of fasting was 107.6 hours. The total length of fasting was significantly associated with the number of symptoms presented before (p=0.000) and after the surgery (p=0.007), the length of h...
Dr Fodor Gergely
Aspiration of the gastric contents, blood loss and fluid replacement are important factors of perioperative morbidity. Respiratory effects are among the most critical changes related to their morbidity. In the present thesis, an animal model was established for the separate investigation of the mechanical properties of the left and the right lung. The use of a double-lumen ET tube allowed the independent introduction of the forcing signal to each lung, allowing characterization of the cha...
Le, Catherine; Guppy, Kern H; Axelrod, Yekaterina V; Hawk, Mark W; Silverthorn, James; Inacio, Maria C; Akins, Paul T
The overall benefits of craniectomy must include procedural risks from cranioplasty. Cranioplasty carries a high risk of surgical site infections (SSI) particularly with antibiotic resistant bacteria. The goal of this study was to measure the effect of a cranioplasty bundle on peri-operative complications. The authors queried a prospective, inpatient neurosurgery database at Kaiser Sacramento Medical Center for craniectomy and cranioplasty over a 7 year period. 57 patients who underwent cranioplasties were identified. A retrospective chart review was completed for complications, including surgical complications such as SSI, wound dehiscence, and re-do cranioplasty. We measured cranioplasty complication rates before and after implementation of a peri-operative bundle, which consisted of peri-operative vancomycin (4 doses), a barrier dressing through post-operative day (POD) 3, and de-colonization of the surgical incision using topical chlorhexidine from POD 4 to 7. The rate of MRSA colonization in cranioplasty patients is three times higher than the average seen on ICU admission screening (19% vs. 6%). The cranioplasty surgical complication rate was 22.8% and SSI rate was 10.5%. The concurrent SSI rate for craniectomy was 1.9%. Organisms isolated were methicillin-resistant Staphylococcus aureus (4), methicillin-sensitive S. aureus (1), Propionibacterium acnes (1), and Escherichia coli (1). Factors associated with SSI were peri-operative vancomycin (68.6% vs. 16.7%, p=0.0217). Complication rates without (n=21) and with (n=36) the bundle were: SSI (23.8% vs. 2.8%, p=0.0217) and redo cranioplasty (19% vs. 0%, p=0.0152). Bundle use did not affect rates for superficial wound dehiscence, seizures, or hydrocephalus. The cranioplasty bundle was associated with reduced SSI rates and the need for re-do cranioplasties. Copyright © 2014 Elsevier B.V. All rights reserved.
Nicoleta Stoicea MD, PhD
Full Text Available Methylphenidate is frequently prescribed for attention deficit hyperactivity disorder, narcolepsy, and other sleep disorders requiring psychostimulants. Our report is based on 2 different clinical experiences of patients with chronic methylphenidate use, undergoing general anesthesia. These cases contrast different strategies of taking versus withholding the drug treatment on the day of surgery. From the standpoint of anesthetic management and patient safety, the concerns for perioperative methylphenidate use are mainly related to cardiovascular stability and possible counteraction of sedatives and anesthetics.
Patel, Priyesh N; Jayawardena, Asitha D L; Walden, Rachel L; Penn, Edward B; Francis, David O
Objective To identify and clarify current evidence supporting and disputing the effectiveness of perioperative antibiotic use for common otolaryngology procedures. Data Sources PubMed, Embase (OVID), and CINAHL (EBSCO). Review Methods English-language, original research (systematic reviews/meta-analyses, randomized control trials, prospective or retrospective cohort studies, case-control studies, or case series) studies that evaluated the role of perioperative antibiotic use in common otolaryngology surgeries were systematically extracted using standardized search criteria by 2 investigators independently. Conclusions Current evidence does not support routine antibiotic prophylaxis for tonsillectomy, simple septorhinoplasty, endoscopic sinus surgery, clean otologic surgery (tympanostomy with tube placement, tympanoplasty, stapedectomy, and mastoidectomy), and clean head and neck surgeries (eg, thyroidectomy, parathyroidectomy, salivary gland excisions). Antibiotic prophylaxis is recommended for complex septorhinoplasty, skull base surgery (anterior and lateral), clean-contaminated otologic surgery (cholesteatoma, purulent otorrhea), and clean-contaminated head and neck surgery (violation of aerodigestive tract, free flaps). In these cases, antibiotic use for 24 to 48 hours postoperatively has shown equal benefit to longer duration of prophylaxis. Despite lack of high-quality evidence, the US Food and Drug Administration suggests antibiotic prophylaxis for cochlear implantation due to the devastating consequence of infection. Data are inconclusive regarding postoperative prophylaxis for nasal packing/splints after sinonasal surgery. Implications for Practice Evidence does not support the use of perioperative antibiotics for most otolaryngologic procedures. Antibiotic overuse and variability among providers may be due to lack of formal practice guidelines. This review can help otolaryngologists understand current evidence so they can make informed decisions about
Full Text Available Robotic-assisted laparoscopic radical prostatectomy (RARP needs a steep Trendelenburg position and a relatively high CO2 insufflation pressure, and patients undergoing RARP are usually elderly. These factors make intraoperative ventilatory care difficult and increase the risk of perioperative pulmonary complications. The aim was to determine the efficacy of recruitment manoeuvre (RM on perioperative pulmonary complications in elderly patients undergoing RARP. A total of 60 elderly patients scheduled for elective RARP were randomly allocated to two groups after induction of anaesthesia; positive end expiratory pressure (PEEP was applied during the operation without RM in the control group (group C and after RM in the recruitment group (group R. The total number of patients who developed intraoperative desaturation or postoperative atelectasis was significantly higher in group C compared to group R (43.3% vs. 17.8%, P = 0.034. Intraoperative respiratory mechanics, perioperative blood gas analysis, and pulmonary function testing did not show differences between the groups. Adding RM to PEEP compared to PEEP alone significantly reduced perioperative pulmonary complications in elderly patients undergoing RARP.
Steenhagen, Elles; van Vulpen, Jonna K; van Hillegersberg, Richard; May, Anne M; Siersema, Peter D
Nutritional status and dietary intake are increasingly recognized as essential areas in esophageal cancer management. Nutritional management of esophageal cancer is a continuously evolving field and comprises an interesting area for scientific research. Areas covered: This review encompasses the current literature on nutrition in the pre-operative, peri-operative, and post-operative phases of esophageal cancer. Both established interventions and potential novel targets for nutritional management are discussed. Expert commentary: To ensure an optimal pre-operative status and to reduce peri-operative complications, it is key to assess nutritional status in all pre-operative esophageal cancer patients and to apply nutritional interventions accordingly. Since esophagectomy results in a permanent anatomical change, a special focus on nutritional strategies is needed in the post-operative phase, including early initiation of enteral feeding, nutritional interventions for post-operative complications, and attention to long-term nutritional intake and status. Nutritional aspects of pre-optimization and peri-operative management should be incorporated in novel Enhanced Recovery After Surgery programs for esophageal cancer.
Santoso, Joseph T; Barton, Ginny; Riedley-Malone, Shannon; Wan, Jim Y
Obesity is a significant risk factor in developing endometrial cancer. As obesity is becoming more endemic, we wish to evaluate the impact of obesity on perioperative outcomes in patients undergoing uterine cancer surgery. We analyzed our prospective database on patients with endometrial cancer who underwent abdominal hysterectomy and pelvic/aortic lymphadenectomy by one gynecologic oncologist. Information regarding race, age, body mass index (BMI), lymph node counts, staging, and estimated blood loss were analyzed against patient's weight category. Weight category was divided as follows: Normal weight (BMI obese (BMI 30 to obesity (BMI ≥ 35). Between April 2003 and December 2009, 233 patients were recruited prospectively. This study found no difference in the number of lymph nodes harvested patient (P = 0.0539) or length of hospital stay (P = 0.4234) in patients with a normal BMI versus that of an overweight, obese, or morbidly obese. However, estimated blood loss (P = 0.01) and operative time (P = 0.0015) were greater as BMI increased. African American patients were more morbidly obese than Caucasian patients. Furthermore, younger patients tend to be more obese across all races. Finally, obesity did not affect perioperative complications (P = 0.78). Obesity increases surgical blood loss and operative time. However, obesity does not affect length of hospital stay, number of lymph nodes harvested, or perioperative complications in uterine cancer staging surgery.
Hofer, Ira S; Gabel, Eilon; Pfeffer, Michael; Mahbouba, Mohammed; Mahajan, Aman
Extraction of data from the electronic medical record is becoming increasingly important for quality improvement initiatives such as the American Society of Anesthesiologists Perioperative Surgical Home. To meet this need, the authors have built a robust and scalable data mart based on their implementation of EPIC containing data from across the perioperative period. The data mart is structured in such a way so as to first simplify the overall EPIC reporting structure into a series of Base Tables and then create several Reporting Schemas each around a specific concept (operating room cases, obstetrics, hospital admission, etc.), which contain all of the data required for reporting on various metrics. This structure allows centralized definitions with simplified reporting by a large number of individuals who access only the Reporting Schemas. In creating the database, the authors were able to significantly reduce the number of required table identifiers from >10 to 3, as well as to correct errors in linkages affecting up to 18.4% of cases. In addition, the data mart greatly simplified the code required to extract data, making the data accessible to individuals who lacked a strong coding background. Overall, this infrastructure represents a scalable way to successfully report on perioperative EPIC data while standardizing the definitions and improving access for end users.
Davis, Yeta; Perham, Marjorie; Hurd, Alicia M; Jagersky, Ronald; Gorman, William J; Lynch-Carlson, Diane; Senseney, Deborah
The purpose of this study was to determine the needs and experiences of patients and family members throughout the entire perioperative experience. Using a descriptive study design, a convenience sample of patients and family members were surveyed about their needs and how well those needs were met during the perioperative period. Survey questions were adapted from valid and reliable patient and family needs surveys. Rank order of patient and family needs were determined based on average item scores. A total of 68 patients and 63 family members were surveyed over an 8-month period. Patient needs with the highest scores were related to pain and/or nausea management, having information about the condition after surgery, and treatment with respect and dignity. Family member needs with the highest scores were related to communication with the surgeon after the procedure, opportunities to ask questions and address concerns with hospital staff, and receiving information about the surgical procedure itself before coming to the hospital. Patients and family members perceived that their needs were met most of the time. Results of this survey identify the needs of patients and family members throughout the perioperative time period. Copyright © 2014 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
Full Text Available Alice L Yu,1 Michaela Kaiser,1 Markus Schaumberger,1 Elisabeth Messmer,1 Daniel Kook,1 Ulrich Welge-Lussen2 1Department of Ophthalmology, Ludwig-Maximilians-University, Munich, 2Department of Ophthalmology, Friedrich-Alexander-University, Erlangen, Germany Purpose: In this study, we assessed the outcome of penetrating keratoplasties using organ-cultured corneal tissues at the University Eye Hospital, Ludwig-Maximilians-University, Munich, Germany. The goal was to identify perioperative and postoperative risk factors that may affect graft survival.Patients and methods: The medical records of 377 patients who underwent a penetrating keratoplasty between 2001 and 2011 were reviewed. Organ-cultured corneal tissue was obtained from the eye bank of Ludwig-Maximilians-University. Perioperative and postoperative risk factors for graft failure were evaluated by univariate and multivariate analyses.Results: The 5-year overall survival rate of penetrating keratoplasties was 68%. Graft failure occurred in 26% of patients. High-risk keratoplasties, such as repeat penetrating keratoplasties and emergency penetrating keratoplasties, as well as postoperative conditions, such as glaucoma, retinal surgery, suture problems, persistent epithelial defect, infectious keratitis, and graft rejection, were significantly associated with graft failure in the multivariate analyses.Conclusion: This study showed a similar graft-survival rate as demonstrated in previous studies. In addition, a number of perioperative and postoperative risk factors were identified in this specific patient population. Keywords: penetrating keratoplasty, graft failure, risk factor, cornea bank
McKendy, Katherine M; Watanabe, Yusuke; Lee, Lawrence; Bilgic, Elif; Enani, Ghada; Feldman, Liane S; Fried, Gerald M; Vassiliou, Melina C
Changes in surgical training have raised concerns about residents' operative exposure and preparedness for independent practice. One way of addressing this concern is by optimizing teaching and feedback in the operating room (OR). The objective of this study was to perform a systematic review on perioperative teaching and feedback. A systematic literature search identified articles from 1994 to 2014 that addressed teaching, feedback, guidance, or debriefing in the perioperative period. Data was extracted according to ENTREQ guidelines, and a qualitative analysis was performed. Thematic analysis of the 26 included studies identified four major topics. Observation of teaching behaviors in the OR described current teaching practices. Identification of effective teaching strategies analyzed teaching behaviors, differentiating positive and negative teaching strategies. Perceptions of teaching behaviors described resident and attending satisfaction with teaching in the OR. Finally models for delivering structured feedback cited examples of feedback strategies and measured their effectiveness. This study provides an overview of perioperative teaching and feedback for surgical trainees and identifies a need for improved quality and quantity of structured feedback. Copyright © 2016 Elsevier Inc. All rights reserved.
Maeno, M; Sakuyama, M; Motoyama, S; Matsuo, H
The objectives of this research were to examine the current status of perioperative treatment among foreigners, to elucidate the health status/outcome disparities that contribute to ethnic differences, and to recommend counter-measures to rectify these ethnic disparities. The authors identified 36 non-Japanese and 111 Japanese females who underwent gynecological surgery from 2004 to 2009 at a single institution. Electronic medical records were reviewed and telephone survey was conducted in order to obtain patient background, preoperative, operative, and postoperative data. The non-Japanese group showed significantly larger number of uninsured, shorter length of stay (LOS), higher rate of emergency surgery, and higher cases of spinal anesthesia. There were significant differences in length of residency in Japan and LOS among four foreign countries. Seventy-nine percent of patients contacted by phone understood informed consent from doctors, 73.7% understood explanation in operating room (OR), and 84.2% understood explanation from anesthesiologists. This research was the first survey of the ethnic disparities in perioperative management among foreign patients treated in Osaka. The authors have demonstrated differences in operative method, emergency surgery, anesthesia, and American Society of Anesthesiologists physical status (ASA-PS) due to the difference in disease structure, language, and culture. It is recommended that the barriers between non-Japanese patients and medical staff are rectified during the perioperative period when mutual understanding is needed the most.
Pavie, A; Lima, L; Bonnet, N; Regan, M; Aktar, R; Gandjbakhch, I
It is important to apply the same rules used for classical coronary revascularization to beating heart coronary surgery. The surgeons must have a strategy, and be prepared for adverse events, and complications. A careful analysis of the coronarography is essential to predict eventual contraindications or causes of possible operative difficulties. All the team must be involved in the surgical protocol. Three main problems need to be solved: the prevention of ischemia during the procedure, good stabilization of the anastomotic site and arterial occlusion. The first goal is reached by using a pre-conditioning technique or an intracoronary shunt. Vessel stabilization may be obtained by several methods: pressure adhesion devices, patch technique or suction devices. The final problem is to have a blood free field, this requires arterial occlusion which may be achieved in several ways: silastic Snares or sutures, aclan clamps, coronary occluder. We have developed at la Pitié a protocol to apply all these principles. From February 1997 to November 1998, multiple revascularization was performed on 167 patients. A total of 344 coronary anastomosis were carried out (mean: 2.05 graft/patient). Some simple rules had to be applied to reduce the rate of complications to the minimum: a good clinical case selection, use of a routine protocol, and recognize the need to adapt the indications to the learning curve of the operator.
Full Text Available Nalini Vadivelu,1 Alice M Kai,2 Daniel Tran,1 Gopal Kodumudi,3 Aron Legler,1 Eugenia Ayrian,4 1Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, 2Stony Brook University School of Medicine, Stony Brook, NY, 3California Northstate University College of Medicine, Elk Grove, 4Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA Abstract: Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects. Keywords: acute pain, post surgical pain, post craniotomy analgesia
Temperature Management After Cardiac Arrest: An Advisory Statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation.
Donnino, Michael W; Andersen, Lars W; Berg, Katherine M; Reynolds, Joshua C; Nolan, Jerry P; Morley, Peter T; Lang, Eddy; Cocchi, Michael N; Xanthos, Theodoros; Callaway, Clifton W; Soar, Jasmeet
For more than a decade, mild induced hypothermia (32 °C-34 °C) has been standard of care for patients remaining comatose after resuscitation from out-of-hospital cardiac arrest with an initial shockable rhythm, and this has been extrapolated to survivors of cardiac arrest with initially nonshockable rhythms and to patients with in-hospital cardiac arrest. Two randomized trials published in 2002 reported a survival and neurological benefit with mild induced hypothermia. One recent randomized trial reported similar outcomes in patients treated with targeted temperature management at either 33 °C or 36 °C. In response to these new data, the International Liaison Committee on Resuscitation Advanced Life Support Task Force performed a systematic review to evaluate 3 key questions: (1) Should mild induced hypothermia (or some form of targeted temperature management) be used in comatose post-cardiac arrest patients? (2) If used, what is the ideal timing of the intervention? (3) If used, what is the ideal duration of the intervention? The task force used Grading of Recommendations Assessment, Development and Evaluation methodology to assess and summarize the evidence and to provide a consensus on science statement and treatment recommendations. The task force recommends targeted temperature management for adults with out-of-hospital cardiac arrest with an initial shockable rhythm at a constant temperature between 32 °C and 36 °C for at least 24 hours. Similar suggestions are made for out-of-hospital cardiac arrest with a nonshockable rhythm and in-hospital cardiac arrest. The task force recommends against prehospital cooling with rapid infusion of large volumes of cold intravenous fluid. Additional and specific recommendations are provided in the document. Copyright © 2015. Published by Elsevier Ireland Ltd.
Anjolie Chhabra; Mahesh Kumar Arora; Dalim Kumar Baidya; Praveen Talawar; Preet Mohinder Singh; Arvind Jayswal
Background: Advances in scoliosis surgery have now made it possible for younger patients to be taken up for scoliosis correction. Objectives: To ascertain the patient profile, perioperative complications and need for intensive care management in children undergoing posterior fusion and instrumentation (PF), anterior release (AR), and growth rod (GR) insertion surgery. Patients and Methods: After taking parental consent, data were collected retrospectively for 33 patients who underwent ...
Full Text Available Postoperative acute kidney injury (AKI is common following cardiac surgery (CS. Body weight (BW may be an amenable variable by representing the summation of the nutritional and the fluid status. However, the predictive role of perioperative BW changes in CS patients with severe postoperative AKI is never explored. This study aimed to evaluate this association.This study was conducted using a prospectively collected multicenter cohort, NSARF (National Taiwan University Hospital Study Group on Acute Renal Failure database. The adult CS patients with postoperative AKI requiring renal replacement therapy (RRT, who had clear initial consciousness, received CS within 14 days of hospitalization, and underwent RRT within seven days after CS in intensive care units from January 2001 to January 2014 were enrolled. With the endpoint of 30-day postoperative mortality, we evaluated the association between the clinical factors denoting fluid status and patients outcomes.A total of 188 patients (70 female, mean age 63.7 ± 15.2 years were enrolled. Comparing with the survivors (n = 124, the non-survivors (n = 64 had a significantly higher perioperative BW change [3.6 ± 6.1% versus 0.1 ± 8.3%, p = 0.003] but not the postoperative and pre-RRT BW changes. By using multivariate Cox proportional hazards model, the independent indicators of 30-day postoperative mortality included perioperative BW change (p = 0.026 and packed red blood cells transfusion (p = 0.007, postoperative intra-aortic balloon pump (p = 0.001 and central venous pressure level (p = 0.005, as well as heart rate (p = 0.022, sequential organ failure assessment score (p < 0.001, logistic organ dysfunction score (p = 0.001, and blood total bilirubin level (p = 0.044 at RRT initiation. The generalized additive models further demonstrated, in a multivariate manner, that the mortality risk rose significantly during a perioperative BW change of 2% to 15%.Perioperative BW change was independently
Full Text Available Patients who present in young age with accelerated hypertension (HTN should always be evaluated for secondary causes of hypertension. Renal parenchyma and vascular diseases constitute the majority of the etiology. Other causes include endocrine diseases such as pheochromocytoma, pregnancy-related HTN, and sleep apnea. We report a 23-year-old female who presented with palpitations and headache under treatment for anxiety from a tertiary care hospital. She was found to have accelerated HTN and was thoroughly worked up for etiology and treatment.
Wallace, Arthur W; Au, Selwyn; Cason, Brian A
The 1996 atenolol study provided evidence that perioperative β-adrenergic receptor blockade (β-blockade) reduced postsurgical mortality. In 1998, the indications for perioperative β-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Administration Medical Center, San Francisco, California. The present study analyzed the association of the pattern of use of perioperative β-blockade with perioperative mortality since introduction of the Perioperative Cardiac Risk Reduction protocol. Epidemiologic analysis of the operations undertaken since 1996 at the San Francisco Veterans Administration Medical Center was performed. The pattern of use of perioperative β-blockade was divided into four groups: None, Addition, Withdrawal, and Continuous. Logistic regression, survival analysis, and propensity analysis were performed. A total of 38,779 operations were performed between 1996 and 2008. In patients meeting Perioperative Cardiac Risk Reduction indications for perioperative β-blockade, Addition is associated with a reduction in 30-day (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33 to 0.83; P = 0.006) and 1-yr mortality (OR, 0.64; 95%, CI 0.51 to 0.79; P < 0.0001). Continuous is associated with a reduction in 30-day (OR, 0.68; 95% CI, 0.47 to 0.98; P = 0.04) and 1-yr mortality (OR, 0.82; 95% CI, 0.67 to 1.0; P = 0.05). Withdrawal is associated with an increase in 30-day (OR 3.93, 95% CI, 2.57 to 6.01; P less than 0.0001) and 1-yr mortality (OR, 1.96; 95% CI, 1.49 to 2.58; P < 0.0001). Perioperative β-blockade administered according to the Perioperative Cardiac Risk Reduction protocol is associated with a reduction in 30-day and 1-yr mortality. Perioperative withdrawal of β-blockers is associated with increased mortality.
Lotfi Fatemi Seyed Naser
Full Text Available Inadvertent perioperative hypothermia is a common anesthesia-related complication in patients undergoing surgery. This could possibly lead to several clinical consequences, which adversely affect the surgery outcome, particularly in high risk patient. The combination of anesthetic drugs and cold operating room environment are among the most common predisposing factors of perioperative hypothermia. The aim of this comprehensive literature review is to describe the importance, monitoring techniques, potential complications, appropriate pharmacologic interventions and modalities to manage perioperative hypothermia.
Simsek, Esen; Karaman, Yucel; Gonullu, Mustafa; Tekgul, Zeki; Cakmak, Meltem
The incidence of perioperative respiratory complications and postoperative care unit recovery time investigated in patients with passive tobacco smoke exposure according to the degree of exposure. Total 270 patients ranging in age from 18 to 60 years with the ASA physical status I or II exposed and not exposed to passive tobacco smoke received general anesthesia for various elective surgical operations evaluated for the study. Patients divided into two groups as exposed and non-exposed to passive tobacco smoke, those exposed to passive smoke are also divided into two groups according to the degree of exposure. Patients taken to the postoperative care unit (PACU) at the end of the operation and monitorized until Modified Aldrete's Scores became 9 and more. Respiratory complications evaluated and recorded in intraoperative and postoperative period. A total of 251 patients were enrolled; 63 (25.1%) patients had airway complications, 11 (4.4%) had complications intraoperatively and 52 (20.7%) patients had complications postoperatively. There has been found significant relation with passive tobacco smoke exposure and high incidences of perioperative and postoperative respiratory complications. The risk of cough, desaturation and hypersecretion complications were found to be increased depending on the degree of exposure. There was significant relation between the degree of passive smoke exposure and the duration of PACU stay. Passive tobacco smoke exposed general anesthesia receiving patients also regarding to the degree of exposure having high rates of perioperative respiratory complications and prolongation of PACU stays when compared with unexposed patients. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.
Simsek, Esen; Karaman, Yucel; Gonullu, Mustafa; Tekgul, Zeki; Cakmak, Meltem
The incidence of perioperative respiratory complications and postoperative care unit recovery time investigated in patients with passive tobacco smoke exposure according to the degree of exposure. Total 270 patients ranging in age from 18 to 60 years with the ASA physical status I or II exposed and not exposed to passive tobacco smoke received general anesthesia for various elective surgical operations evaluated for the study. Patients divided into two groups as exposed and non-exposed to passive tobacco smoke, those exposed to passive smoke are also divided into two groups according to the degree of exposure. Patients taken to the postoperative care unit (PACU) at the end of the operation and monitorized until Modified Aldrete's Scores became 9 and more. Respiratory complications evaluated and recorded in intraoperative and postoperative period. A total of 251 patients were enrolled; 63 (25.1%) patients had airway complications, 11 (4.4%) had complications intraoperatively and 52 (20.7%) patients had complications postoperatively. There has been found significant relation with passive tobacco smoke exposure and high incidences of perioperative and postoperative respiratory complications. The risk of cough, desaturation and hypersecretion complications were found to be increased depending on the degree of exposure. There was significant relation between the degree of passive smoke exposure and the duration of PACU stay. Passive tobacco smoke exposed general anesthesia receiving patients also regarding to the degree of exposure having high rates of perioperative respiratory complications and prolongation of PACU stays when compared with unexposed patients. Copyright © 2015 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.
Full Text Available Health care, in common with many other industries, is generating large amounts of routine data, data that are challenging to process, analyse or curate, so-called ‘big data’. A challenge for health informatics is to make sense of these data. Part of the answer will come from the development of ontologies that support the use of heterogeneous data sources and the development of intermediate processors of health information (IPHI. IPHI will sit between the generators of health data and information, often the providers of health care, and the managers, commissioners, policy makers, researchers, and the pharmaceutical and other healthcare industries. They will create a health ecosystem by processing data in a way that stimulates improved data quality and potentially health care delivery by providers of health care, and by providing greater insights to legitimate users of data. Exemplars are provided of how a health ecosystem might be encouraged and developed to promote patient safety and more efficient health care. These are in the areas of how to integrate data around the unsafe use of alcohol and to explore vaccine safety. A challenge for IPHI is how to ensure that their processing of data is valid, safe and maintains privacy. Development of the healthcare ecosystem and IPHI should be actively encouraged internationally. Governments, regulators and providers of health care should facilitate access to health data and the use of national and international comparisons to monitor standards. However, most importantly, they should pilot new methods of improving quality and safety through the intermediate processing of health data.
Martin-McDonald, K; McIntyre, P; Hegney, D
Within an 8-month period, an unprecedented and historical first in Queensland, Australia, the perioperative nurses were members of teams involved in the surgical separation of two sets of conjoined twins. Little is known about the (dis)stress that some of these perioperative nurses experienced nor how best to support them during such experiences. The aim of this paper is to report on the qualitative study that explored the experiences of those perioperative nurses involved in the surgical separation of cojoined twins and from their stories propose recommendations to support perioperative nurses who are confronted with such workplace experiences. Using a narrative methodology, nine perioperative nurses shared their stories of being involved in the surgical separation of conjoined twins in Australia. Narrative and thematic analyses were conducted and recommendations to support perioperative nurses through workplace (dis)stress were identified. Participants validated the findings and recommendations. The analyses revealed the themes of professionalism, teamwork, 'them vs. us' and emotional loads. The sensationalism around the rarity of conjoined twins brought an intensive intrusiveness from the world media. As a result, secrecy within the hospital about the conjoined twin cases created divisions between those perioperative nurses on the teams and those not. The processes and outcomes of the two surgical cases were in contrast to each other. For some perioperative nurses this caused distress. It is essential that professional support is offered in a way in which the perioperative nurse can take it up without fear of negative judgement.
Luciana Regina Ferreira da Mata
Full Text Available Objective. To identify nursing actions in the perioperative period and in preparing prostatectomy patients for discharge. Methodology. Cross-sectional, retrospective study. Data were collected from medical record of patients who underwent partial or total prostatectomy between August 2009 and August 2010 at hospitals in Divinopolis, Minas Gerais, Brazil. Results. A total of 121 patients were identified; the mean age was 67 years. The most frequent diagnosis was prostate cancer (70%. Main preoperative activities were measuring vital signs (55%, administering drugs (52%, educating patients about fasting (50%, and managing edema (45%. After surgery, the most frequent tasks were measuring vital signs (100%, measuring urine and emptying the urinary bag (100% for each, facilitating the healing of surgical wounds (77%, and evaluating Penrose drain discharge (48%. Among the 25 types of care observed, the activity that nurses performed most often for patients about to be discharged was providing education about urinary catheter manipulation (16%. Conclusion. This study identified weaknesses in care delivery for prostatectomy patients, particularly regarding home care education.
Kamei, Takashi; Miyazaki, S
Salvage esophagectomy has been increasing as a second-line treatment after failure of definitive chemoradiotherapy (CRT) for esophageal cancer. A number of patients who have received CRT, especially those who have residual tumors and shorter waiting times until operation, have developed malnutrition and problems in their immunologic condition because of decreasing oral intake and bone marrow suppression. Because high-dose radiation causes inflammation, fibrosis and peripheral circulatory disturbance of various tissues in the treatment fields, salvage surgery can be a technically difficult operation. In our previous experience, postoperative complications of salvage esophagectomy are more frequent and more serious than that of planned esophagectomy. For example, we have experienced necrosis of the reconstructed gastric tube, esophago-tracheal fistula, mediastinal abscess, hard-to-treat acute respiratory distress syndrome (ARDS) and so on. In particular, respiratory tract necrosis or perforation is the most critical complication and frequently becomes lethal. Patients who undergo a salvage esophagectomy have a significantly higher risk of pulmonary and cardiac complication, and have high rates of repeated surgery. Rapid diagnosis and appropriate treatment of complications are necessary to reduce postoperative mortality. To improve the overall outcome, it is very important to better understand the condition of patients after CRT, so appropriate surgery can be carefully planned. Furthermore, it is absolutely essential to perform the operation with great care and to meticulously manage the perioperative care for salvage esophagectomy.
Full Text Available Visith Siriphuwanun,1 Yodying Punjasawadwong,1 Worawut Lapisatepun,1 Somrat Charuluxananan,2 Ketchada Uerpairojkit2 1Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Mueang District, Chiang Mai, Thailand; 2Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Purpose: To determine the incidence of and factors associated with perioperative cardiac arrest within 24 hours of receiving anesthesia for emergency surgery. Patients and methods: This retrospective cohort study was approved by the ethical committee of Maharaj Nakorn Chiang Mai Hospital, Thailand. We reviewed the data of 44,339 patients receiving anesthesia for emergency surgery during the period from January 1, 2003 to March 31, 2011. The data included patient characteristics, surgical procedures, American Society of Anesthesiologists (ASA physical status classification, anesthesia information, location of anesthesia performed, and outcomes. Data of patients who had received topical anesthesia or monitoring anesthesia care were excluded. Factors associated with cardiac arrest were identified by univariate analyses. Multiple regressions for the risk ratio (RR and 95% confidence intervals (CI were used to determine the strength of factors associated with cardiac arrest. A forward stepwise algorithm was chosen at a P-value <0.05. Results: The incidence (within 24 hours of perioperative cardiac arrest in patients receiving anesthesia for emergency surgery was 163 per 10,000. Factors associated with 24-hour perioperative cardiac arrest in emergency surgery were age of 2 years or younger (RR =1.46, CI =1.03–2.08, P=0.036, ASA physical status classification of 3–4 (RR =5.84, CI =4.20–8.12, P<0.001 and 5–6 (RR =33.98, CI =23.09–49.98, P<0.001, the anatomic site of surgery (upper intra-abdominal, RR =2.67, CI =2.14–3.33, P<0.001; intracranial, RR =1.74, CI =1.35–2.25, P<0.001; intrathoracic, RR =2.35, CI =1.70–3
Bryan G. Maxwell
Full Text Available Background. Do-not-resuscitate (DNR orders are often active in patients with multiple comorbidities and a short natural life expectancy, but limited information exists as to how often these patients undergo high-risk operations and of the perioperative outcomes in this population.Methods. Using comprehensive inpatient administrative data from the Public Discharge Data file (years 2005 through 2010 of the California Office of Statewide Health Planning and Development, which includes a dedicated variable recording DNR status, we identified cohorts of DNR patients who underwent major cardiac or thoracic operations and compared themto age- and procedure-matched comparison cohorts. The primary study outcome was in-hospital mortality.Results. DNR status was not uncommon in cardiac (n = 2,678, 1.1% of all admissions for cardiac surgery, age 71.6 ± 15.9 years and thoracic (n = 3,129, 3.7% of all admissions for thoracic surgery, age 73.8 ± 13.6 years surgical patient populations. Relative to controls, patients who were DNR experienced significantly greater inhospital mortality after cardiac (37.5% vs. 11.2%, p < 0.0001 and thoracic (25.4% vs. 6.4% operations. DNR status remained an independent predictor of in-hospital mortality onmultivariate analysis after adjustment for baseline and comorbid conditions in both the cardiac (OR 4.78, 95% confidence interval 4.21–5.41, p < 0.0001 and thoracic (OR 6.11, 95% confidence interval 5.37–6.94, p < 0.0001 cohorts.Conclusions. DNR status is associated with worse outcomes of cardiothoracic surgery even when controlling for age, race, insurance status, and serious comorbid disease. DNR status appears to be a marker of substantial perioperative risk, and may warrant substantial consideration when framing discussions of surgical risk and benefit, resource utilization, and biomedical ethics surrounding end-of-life care.
Lin, Shun-Yuan; Huang, Hung-An; Lin, Sung-Chun; Huang, Yuan-Ting; Wang, Kuo-Yang; Shi, Hon-Yi
Despite growing evidence that an educational anaesthesia video can effectively reduce perioperative anxiety, the ideal medium for addressing perioperative anxiety is unclear. The purpose of this study was to investigate the effect of viewing an anaesthetic patient information video on anxiety levels in patients scheduled to undergo surgery. A randomised controlled trial. Pingtung Christian Hospital (PTCH), Taiwan. One hundred patients were randomised to either an experimental group (n = 50) or a control group (n = 50). At the preoperative clinic, the experimental group watched the an 8 minute educational anaesthetic video, whereas the control group received a standard 8-min verbal briefing on anaesthesia after preoperative assessment. The Chinese version of the Spielberger state trait anxiety inventory, which included a state scale (STAI-S) and a trait scale (STAI-T), was performed in the preoperative clinic (T1) before anaesthetic preassessment, at the preoperative holding area just before surgery (T2) and again on the third day after surgery (T3). Scores for overall satisfaction with medical care were obtained on the third day after surgery. For two time interval comparisons, effect size was used to standardise the extent of change as measured by STAI-S. After the educational intervention, state anxiety was lower in the experimental group than in the control group at both T2 (42.9 ± 6.5 vs. 45.0 ± 12.7) and T3 (40.2 ± 5.3 vs. 48.8 ± 8.5). Compared with control group, the experimental group had a larger effect size at T2 and T3 (-0.65 and -0.36, respectively). Overall satisfaction was significantly higher in the experimental group than in the control group (P anxiety was significantly reduced and overall patient satisfaction increased after viewing a preoperative educational anaesthesia video compared with a standard verbal briefing on anaesthesia.
Lan, Roy H; Kamath, Atul F
Medical evaluation pre-operatively is an important component of risk stratification and potential risk optimization. However, the effect of timing prior to surgical intervention is not well-understood. We hypothesized that total hip arthroplasty (THA) patients seen in pre-operative evaluation closer to the date of surgery would experience better perioperative outcomes. We retrospectively reviewed 167 elective THA patients to study the relationship between the number of days between pre-operative evaluation (range, 0-80 days) and surgical intervention. Patients' demographics, length of stay (LOS), ICU admission frequency, and rate of major complications were recorded. When pre-operative evaluation carried out 4 days or less before the procedure date, there was a significant reduction in LOS (3.91 vs. 4.49; p=0.03). When pre-operative evaluation carried out 11 days or less prior to the procedure date, there was a four-fold decrease in rate of intensive care admission (p=0.04). Furthermore, the major complication rate also significantly reduced (ppre-operative evaluation took place 30 days or less before the procedure date compared to more than 30 days prior, there were no significant changes in the outcomes. From this study, pre-operative medical evaluation closer to the procedure date was correlated with improved selected peri-operative outcomes. However, further study on larger patient groups must be done to confirm this finding. More study is needed to define the effect on rare events like infection, and to analyze the subsets of THA patients with modifiable risk factors that may be time-dependent and need further time to optimization.
Contemporary comparisons of reusable and single-use perioperative textiles (surgical gowns and drapes) reflect major changes in the technologies to produce and reuse these products. Reusable and disposable gowns and drapes meet new standards for medical workers and patient protection, use synthetic lightweight fabrics, and are competitively priced. In multiple science-based life cycle environmental studies, reusable surgical gowns and drapes demonstrate substantial sustainability benefits over the same disposable product in natural resource energy (200%-300%), water (250%-330%), carbon footprint (200%-300%), volatile organics, solid wastes (750%), and instrument recovery. Because all other factors (cost, protection, and comfort) are reasonably similar, the environmental benefits of reusable surgical gowns and drapes to health care sustainability programs are important for this industry. Thus, it is no longer valid to indicate that reusables are better in some environmental impacts and disposables are better in other environmental impacts. It is also important to recognize that large-scale studies of comfort, protection, or economics have not been actively pursued in the last 5 to 10 years, and thus the factors to improve both reusables and disposable systems are difficult to assess. In addition, the comparison related to jobs is not well studied, but may further support reusables. In summary, currently available perioperative textiles are similar in comfort, safety, and cost, but reusable textiles offer substantial opportunities for nurses, physicians, and hospitals to reduce environmental footprints when selected over disposable alternatives. Evidenced-based comparison of environmental factors supports the conclusion that reusable gowns and drapes offer important sustainability improvements. The benefit of reusable systems may be similar for other reusables in anesthesia, such as laryngeal mask airways or suction canisters, but life cycle studies are needed to
Kozek-Langenecker, Sibylle A; Afshari, Arash; Albaladejo, Pierre; Santullano, Cesar Aldecoa Alvarez; De Robertis, Edoardo; Filipescu, Daniela C; Fries, Dietmar; Görlinger, Klaus; Haas, Thorsten; Imberger, Georgina; Jacob, Matthias; Lancé, Marcus; Llau, Juan; Mallett, Sue; Meier, Jens; Rahe-Meyer, Niels; Samama, Charles Marc; Smith, Andrew; Solomon, Cristina; Van der Linden, Philippe; Wikkelsø, Anne Juul; Wouters, Patrick; Wyffels, Piet
The aims of severe perioperative bleeding management are three-fold. First, preoperative identification by anamesis and laboratory testing of those patients for whom the perioperative bleeding risk may be increased. Second, implementation of strategies for correcting preoperative anaemia and stabilisation of the macro- and microcirculations in order to optimise the patient's tolerance to bleeding. Third, targeted procoagulant interventions to reduce the amount of bleeding, morbidity, mortality and costs. The purpose of these guidelines is to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists throughout Europe to integrate this knowledge into daily patient care wherever possible. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of scientific subcommittees and individual expert members of the ESA. Electronic databases were searched without language restrictions from the year 2000 until 2012. These searches produced 20 664 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case-control studies and cross-sectional surveys were selected. At the suggestion of the ESA Guideline Committee, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was initially used to assess the level of evidence and to grade recommendations. During the process of guideline development, the official position of the ESA changed to favour the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. This report includes general recommendations as well as specific recommendations in various fields of surgical interventions. The final draft guideline was posted on the ESA website for four weeks and the link was sent to all ESA members. Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and
Kemp, Mark A.; Jongewaard, Erik N.; Haase, Andrew A.; Franzi, Matthew
A particle accelerator is provided that includes a piezoelectric accelerator element, where the piezoelectric accelerator element includes a hollow cylindrical shape, and an input transducer, where the input transducer is disposed to provide an input signal to the piezoelectric accelerator element, where the input signal induces a mechanical excitation of the piezoelectric accelerator element, where the mechanical excitation is capable of generating a piezoelectric electric field proximal to an axis of the cylindrical shape, where the piezoelectric accelerator is configured to accelerate a charged particle longitudinally along the axis of the cylindrical shape according to the piezoelectric electric field.
Rodriguez-Larrad, Ana; Lascurain-Aguirrebena, Ion; Abecia-Inchaurregui, Luis Carlos; Seco, Jesús
Physiotherapy is considered an important component of the perioperative period of lung resection surgery. A systematic review was conducted to assess evidence for the effectiveness of different physiotherapy interventions in patients undergoing lung cancer resection surgery. Online literature databases [Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, SCOPUS, PEDro and CINAHL] were searched up until June 2013. Studies were included if they were randomized controlled trials, compared 2 or more perioperative physiotherapy interventions or compared one intervention with no intervention, included only patients undergoing pulmonary resection for lung cancer and assessed at least 2 or more of the following variables: functional capacity parameters, postoperative pulmonary complications or length of hospital stay. Reviews and meta-analyses were excluded. Eight studies were selected for inclusion in this review. They included a total of 599 patients. Seven of the studies were identified as having a low risk of bias. Two studies assessed preoperative interventions, 4 postoperative interventions and the remaining 2 investigated the efficacy of interventions that were started preoperatively and then continued after surgery. The substantial heterogeneity in the interventions across the studies meant that it was not possible to conduct a meta-analysis. The most important finding of this systematic review is that presurgical interventions based on moderate-intense aerobic exercise in patients undergoing lung resection for lung cancer improve functional capacity and reduce postoperative morbidity, whereas interventions performed only during the postoperative period do not seem to reduce postoperative pulmonary complications or length of hospital stay. Nevertheless, no firm conclusions can be drawn because of the heterogeneity of the studies included. Further research into the efficacy and effectiveness of perioperative respiratory physiotherapy in
Agarwal, Shvetank; Bean, Matthew G; Hata, J Steven; Castresana, Manuel R
Takotsubo cardiomyopathy (TCM) is a condition that is characterized as a transient ventricular dysfunction in the absence of obstructive coronary artery disease (CAD) and is usually triggered by an acute medical illness or intense physical or emotional stress. Multiple cases of perioperative TCM (pTCM) have been reported from around the world, but a qualitative analysis of these cases has not yet been done. For this systematic review, we searched PubMed for case reports and case series of pTCM published from 1966 to April 2015 with the objective being to evaluate whether differences in demographics, clinical features and outcomes exist between pTCM and nonperioperative (npTCM), as well as to attempt to identify any predictors of the severe form of pTCM, which requires mechanical circulatory support (MCS) devices or leads to death. A total of 93 articles describing 102 cases were retrieved and reviewed. The findings were compared with the analysis of the International Takotsubo Registry by Templin et al and a systematic review of mainly non-perioperative TCM (npTCM) by Gianni et al. Although we were unable to identify definitive risk factors for pTCM, our review suggests that pTCM appears to occur in younger patients and with a lower likelihood of ST segment elevations and T-wave abnormalities than in npTCM. No demographic or clinical factors were identified that were predictive of more severe outcomes. As TCM in general can be a life-threatening event, it would therefore be prudent to consider pTCM within a differential diagnosis in any patient who decompensates in the perioperative period.
Schulman, Sam; Carrier, Marc; Lee, Agnes Y Y; Shivakumar, Sudeep; Blostein, Mark; Spencer, Frederick A; Solymoss, Susan; Barty, Rebecca; Wang, Grace; Heddle, Nancy; Douketis, James D
The perioperative management of dabigatran in clinical practice is heterogeneous. We performed this study to evaluate the safety of perioperative management of dabigatran using a specified protocol. Patients treated with dabigatran and planned for an invasive procedure were eligible for inclusion. The timing of the last dose of dabigatran before the procedure was based on the creatinine clearance and procedure-related bleeding risk. Resumption of dabigatran was prespecified according to the complexity of the surgery and consequences of a bleeding complication. Patients were followed up for 30 days for major bleeding (primary outcome), minor bleeding, arterial thromboembolism, and death. We included 541 cases: 324 procedures (60%) with standard risk of bleeding and 217 procedures (40%) with increased risk of bleeding. The last dose of dabigatran was at 24, 48, or 96 hours before surgery according to the protocol in 46%, 37%, and 6%, respectively, of the patients. Resumption was timed according to protocol in 77% with 75 mg as the first dose on the day of procedure in 40% of the patients. Ten patients (1.8%; 95% confidence interval, 0.7-3.0) had major bleeding, and 28 patients (5.2%; 95% confidence interval, 3.3-7.0) had minor bleeding events. The only thromboembolic complication was transient ischemic attack in 1 patient (0.2%; 95% confidence interval, 0-0.5), and there were 4 deaths unrelated to bleeding or thrombosis. Bridging was not used preoperatively but was administered in 9 patients (1.7%) postoperatively. Our protocol for perioperative management of dabigatran appears to be effective and feasible. © 2015 American Heart Association, Inc.
Lunn, T H; Kehlet, H
Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide......-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations....
Arnold, T; Shelbourne, K D
Rehabilitation programs have progressed alongside surgical advances in anterior cruciate ligament reconstruction. A perioperative program has been successfully used at our clinic for more than 10 years to reduce postoperative complications and return patients to activity safely and quickly. The four-phase program starts at the time of injury and preoperatively includes aggressive swelling reduction, hyperextension exercises, gait training, and mental preparation. Goals after surgery are to control swelling while regaining full knee range of motion. After quadriceps strengthening goals are reached, patients can shift to sport-specific exercises.
Chen, Zhihao; Hee, Hwan Ing; Ng, Soon Huat; Teo, Ju Teng; Yang, Xiufeng; Wang, Dier
We have demonstrated a highly sensitive microbend fiber optic sensor for perioperative pediatric vital signs monitoring that is free from direct contact with skin, cableless, electromagnetic interference free and low cost. The feasibility of our device was studied on infants undergoing surgery and 10 participants ranging from one month to 12 months were enrolled. The sensor was placed under a barrier sheet on the operating table. All patients received standard intraoperative monitoring. The results showed good agreement in heart rate and respiratory rate between our device and the standard physiological monitoring when signals are clean.
cocktail and I was out. Perioperative Experiences 42 Other than the guy not being able to get the IV started, everything went smooth. There was a student...apple sauce and drinking water and that’s not healthy and I was like, I can’t eat anything else. Yes, they were very kind, I have to admit, and my aunt...just getting my cocktail mix. Just hooking me up to the ... after he stuck my IV in there and put it in there, that was it. So, I just remember lying
Algera, Dirk A; Brownscombe, Jacob W; Gilmour, Kathleen M; Lawrence, Michael J; Zolderdo, Aaron J; Cooke, Steven J
Paternal care, where the male provides sole care for the developing brood, is a common form of reproductive investment among teleost fish and ubiquitous in the Centrarchidae family. Throughout the parental care period, nesting males expend energy in a variety of swimming behaviours, including routine and burst swimming, vigilantly monitoring the nest area and protecting the brood from predators. Parental care is an energetically demanding period, which is presumably made even more difficult if fish are exposed to additional challenges such as those arising from human disturbance, resulting in activation of the hypothalamic-pituitary-interrenal axis (i.e., elevation of cortisol). To study this situation, we examined the effects of experimental manipulation of the stress hormone cortisol on locomotor activity and behaviour of nest guarding male smallmouth bass (Micropterus dolomieu). We exogenously elevated circulating cortisol levels (via intracoelomic implants) and attached tri-axial accelerometers to wild smallmouth bass for three days. During the recovery period (i.e., ≤4h post-release), cortisol-treated fish exhibited significantly reduced locomotor activity and performed significantly less burst and routine swimming relative to control fish, indicating cortisol uptake was rapid, as were the associated behavioural responses. Post-recovery (i.e., >4h post-release), fish with high cortisol exhibited lower locomotor activity and reduced routine swimming relative to controls. Fish were less active and reduced routine and burst swimming at night compared to daylight hours, an effect independent of cortisol treatment. Collectively, our results suggest that cortisol treatment (as a proxy for anthropogenic disturbance and stress) contributed to altered behaviour, and consequently cortisol-treated males decreased parental investment in their brood, which could have potential fitness implications. Copyright © 2017 Elsevier Inc. All rights reserved.
Emond, Yvette E J J M; Calsbeek, Hiske; Teerenstra, Steven; Bloo, Gerrit J A; Westert, Gert P; Damen, Johan; Wolff, André P; Wollersheim, Hub C
This study is initiated to evaluate the effects, costs, and feasibility at the hospital and patient level of an evidence-based strategy to improve the use of Dutch perioperative safety guidelines. Based on current knowledge, expert opinions and expertise of the project team, a multifaceted implementation strategy has been developed. This is a stepped wedge cluster randomized trial including nine representative hospitals across The Netherlands. Hospitals are stratified into three groups according to hospital type and geographical location and randomized in terms of the period for receipt of the intervention. All adult surgical patients meeting the inclusion criteria are assessed for patient outcomes. The implementation strategy includes education, audit and feedback, organizational interventions (e.g., local embedding of the guidelines), team-directed interventions (e.g., multi-professional team training), reminders, as well as patient-mediated interventions (e.g., patient safety cards). To tailor the implementation activities, we developed a questionnaire to identify barriers for effective guideline adherence, based on (a) a theoretical framework for classifying barriers and facilitators, (b) an instrument for measuring determinants of innovations, and (c) 19 semi-structured interviews with perioperative key professionals. Primary outcome is guideline adherence measured at the hospital (i.e., cluster) and patient levels by a set of perioperative Patient Safety Indicators (PSIs), which was developed parallel to the perioperative guidelines. Secondary outcomes at the patient level are in-hospital complications, postoperative wound infections and mortality, length of hospital stay, and unscheduled transfer to the intensive care unit, non-elective readmission to the hospital and unplanned reoperation, all within 30 days after the initial surgery. Also, patient safety culture and team climate will be studied as potential determinants. Finally, a process evaluation is
Karuppiah, Sathappan; Mckee, Christopher; Hodge, Ashley; Galantowicz, Mark; Tobias, Joseph; Naguib, Aymen
Abstract: Over the years, there has been a growing recognition of the potential negative sequelae of allogeneic blood products on postoperative outcomes following cardiac surgery. In addition, followers of the Jehovah's Witness (JW) faith have a religious restriction against receiving blood or blood components. Advances in perioperative care, cardiopulmonary bypass (CPB), and surgical technique have minimized the need for allogeneic blood products. Specific blood conservation strategies include maximizing the preoperative hematocrit and coagulation function as well as intraoperative strategies, such as acute normovolemic hemodilution and adjustments of the technique of CPB. We report a 7-month-old patient whose parents were of the JW faith who underwent a comprehensive stage II procedure for hypoplastic left heart syndrome without exposure to blood or blood products during his hospital stay. Perioperative techniques for blood avoidance are discussed with emphasis on their application to infants undergoing surgery for congenital heart disease. PMID:27729708
O'Brien, Frank J
It is established that blood transfusions will promote sensitization to human leucocyte antigen (HLA) antigens, increase time spent waiting for transplantation and may lead to higher rates of rejection. Less is known about how perioperative blood transfusion influence patient and graft outcome. This study aims to establish if there is an association between perioperative blood transfusion and graft or patient survival.
We conducted a pharmaco-economic analysis of the prospective peri-operative studies of beta-blocker and statin administration for major elective non-cardiac surgery, using the Discovery Health claims costs for 2004. This analysis shows that acute peri-operative beta-blockade and statin therapy could result in a cost ...
Daradkeh, S; Shennak, M; Abu-Khalaf, M
Management of common bile duct stones in the era of laparoscopic surgery is still controversial. The purpose of this study is to investigate the safety, feasibility, success rate and short-term results of the selective use of endoscopic retrograde cholangiopancreatography in patients undergoing laparoscopic cholecystectomy. A prospective study comprising 300 consecutive patients with either symptomatic or complicated gallbladder stones was performed between January 1994 and November 1996. Depending on clinical, laboratory and ultrasonographic criteria, 73 patients (24.3%) underwent endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy. The procedure was successful in 71 patients (97%) either preoperatively in 62 patients (21%) or postoperatively in 9 patients (3%). Endoscopic retrograde cholangiopancreatography was positive in 37 cases (52%), endoscopic sphincterotomy and stone extraction was performed in 35 cases and endoscopic sphincterotomy alone was performed in 2 cases for benign papillary stenosis. The overall predictive value for the presence of common bile duct stone was 52%, the predictive value for patients with jaundice, dilated common bile duct together with elevated liver enzymes was 73.3%. Complications of perioperative endoscopic retrograde cholangiopancreatography were encountered in 4 patients (5.5%) with no mortality. We conclude that the combination of perioperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy is a useful approach for the management of choledochocholelithiasis.
Buchakjian, Marisa R; Davis, Andrew B; Sciegienka, Sebastian J; Pagedar, Nitin A; Sperry, Steven M
To evaluate perioperative pain in patients undergoing major head and neck cancer surgery and identify associations between preoperative and postoperative pain characteristics. Patients undergoing head and neck surgery with regional/free tissue transfer were enrolled. Preoperative pain and validated screens for symptoms (neuropathic pain, anxiety, depression, fibromyalgia) were assessed. Postoperatively, patients completed a pain diary for 4 weeks. Twenty-seven patients were enrolled. Seventy-eight percent had pain prior to surgery, and for 38%, the pain had neuropathic characteristics. Thirteen patients (48%) completed at least 2 weeks of the postoperative pain diary. Patients with moderate/severe preoperative pain report significantly greater pain scores postoperatively, though daily pain decreased at a similar linear rate for all patients. Patients with more severe preoperative pain consumed greater amounts of opioids postoperatively, and this correlated with daily postoperative pain scores. Patients who screened positive for neuropathic pain also reported worse postoperative pain. Longitudinal perioperative pain assessment in head and neck patients undergoing surgery suggests that patients with worse preoperative pain continue to endorse worse pain postoperatively and require more narcotics. Patients with preoperative neuropathic pain also report poor pain control postoperatively, suggesting an opportunity to identify these patients and intervene with empiric neuropathic pain treatment.
Full Text Available BACKGROUND: The appropriate use of antibiotics prophylaxis in the prevention and reduction in the incidence of surgical site infection is widespread. This study evaluates the appropriateness of the prescription of antibiotics prophylaxis prior to surgery amongst hospitalized patients in the geographic area of Avellino, Caserta, and Naples (Italy and the factors associated with a poor adherence. METHODS: A sample of 382 patients admitted to 23 surgical wards and undergoing surgery in five hospitals were randomly selected. RESULTS: Perioperative antibiotic prophylaxis was appropriate in 18.1% of cases. The multivariate logistic regression analysis showed that patients with hypoalbuminemia, with a clinical infection, with a wound clean were more likely to receive an appropriate antibiotic prophylaxis. Compared with patients with an American Society of Anesthesiologists (ASA score ≥4, those with a score of 2 were correlated with a 64% reduction in the odds of having an appropriate prophylaxis. The appropriateness of the timing of prophylactic antibiotic administration was observed in 53.4% of the procedures. Multivariate logistic regression model showed that such appropriateness was more frequent in older patients, in those admitted in general surgery wards, in those not having been underwent an endoscopic surgery, in those with a higher length of surgery, and in patients with ASA score 1 when a score ≥4 was chosen as the reference category. The most common antibiotics used inappropriately were ceftazidime, sultamicillin, levofloxacin, and teicoplanin. CONCLUSIONS: Educational interventions are needed to improve perioperative appropriate antibiotic prophylaxis.
John, M; Ford, J; Harper, M
Since the adverse consequences of accidental peri-operative hypothermia have been recognised, there has been a rapid expansion in the development of new warming equipment designed to prevent it. This is a review of peri-operative warming devices and a critique of the evidence assessing their performance. Forced-air warming is a common and extensively tested warming modality that outperforms passive insulation and water mattresses, and is at least as effective as resistive heating. More recently developed devices include circulating water garments, which have shown promising results due to their ability to cover large surface areas, and negative pressure devices aimed at improving subcutaneous perfusion for warming. We also discuss the challenge of fluid warming, looking particularly at how devices' performance varies according to flow rate. Our ultimate aim is to provide a guide through the bewildering array of devices on the market so that clinicians can make informed and accurate choices for their particular hospital environment. © 2014 The Association of Anaesthetists of Great Britain and Ireland.
Full Text Available Objective To observe the perioperative complications for metastatic cervical tumor, and explore their possible risk factors. Methods From January 2012 to January 2016, 57 patients undergoing surgery for cervical spine metastasis were retrospectively analyzed, who were followed-up for at least 12 months or until death. Data collected included pain (a 10-point visual analogue scale, VAS, Karnofsky performance status score, neurologic status according to Frankel scale, perioperative complications, postoperative mortality and so on. Results The VAS score decreased significantly postoperation (P300ml were significant risk factors for the complication. Multivariable analysis showed that iIntraoperative blood loss >300ml and preoperative Karnofsky score <60 were the independent predictors for the complication. Conclusions Surgical management for cervical spinal metastasis is effective in terms of neurological recovery, pain control, and performance status recovery. However, the surgery had a high risk of complications that special attention should be paid to. Furthermore, complications might be related to preoperative Karnofsky score and intraoperative blood loss. DOI: 10.11855/j.issn.0577-7402.2017.05.18
Cerantola, Yannick; Grass, Fabian; Cristaudi, Alessandra; Demartines, Nicolas; Schäfer, Markus; Hübner, Martin
Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.
Full Text Available Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.
Shim, Hongjin; Cheong, Jae Ho; Lee, Kang Young; Lee, Hosun; Lee, Jae Gil; Noh, Sung Hoon
The presence of gastrointestinal (GI) cancer and its treatment might aggravate patient nutritional status. Malnutrition is one of the major factors affecting the postoperative course. We evaluated changes in perioperative nutritional status and risk factors of postoperative severe malnutrition in the GI cancer patients. Nutritional status was prospectively evaluated using patient-generated subjective global assessment (PG-SGA) perioperatively between May and September 2011. A total of 435 patients were enrolled. Among them, 279 patients had been diagnosed with gastric cancer and 156 with colorectal cancer. Minimal invasive surgery was performed in 225 patients. PG-SGA score increased from 4.5 preoperatively to 10.6 postoperatively (pcancer patients, postoperative severe malnourishment increased significantly (p60, pcancer (pcancer, and open surgery remained significant as risk factors of severe malnutrition. The prevalence of severe malnutrition among GI cancer patients in this study increased from 2.3% preoperatively to 26.3% after an operation. Old age, preoperative weight loss, gastric cancer, and open surgery were shown to be risk factors of postoperative severe malnutrition. In patients at high risk of postoperative severe malnutrition, adequate nutritional support should be considered.
Carless, Paul A; Stokes, Barrie J; Moxey, Annette J; Henry, David A
Background Public concerns regarding the safety of blood have prompted reconsideration of the use of allogeneic blood (blood from an unrelated donor) transfusion and a range of techniques designed to minimise transfusion requirements. Objectives To examine the efficacy of desmopressin acetate (1-deamino-8-D-arginine-vasopressin) in reducing peri-operative blood loss and the need for red blood cell (RBC) transfusion in patients who do not have congenital bleeding disorders. Search methods We identified studies by searching CENTRAL (The Cochrane Library 2008, Issue 1), MEDLINE (1950 to 2008), EMBASE (1980 to 2008), the Internet (to May 2008), and bibliographies of published articles. Selection criteria Controlled parallel-group trials in which adult patients scheduled for non-urgent surgery were randomised to desmopressin (DDAVP) or to a control group that did not receive DDAVP treatment. Trials were eligible for inclusion if they reported data on the number of patients exposed to allogeneic red cell transfusion or the volume of blood transfused. Data collection and analysis Primary outcomes were: the number of patients exposed to allogeneic red blood cell (RBC) transfusion, and the amount of blood transfused. Other outcomes measured were: blood loss, re-operation for bleeding, post-operative complications (thrombosis, myocardial infarction, stroke), mortality, and length of hospital stay. Treatment effects were pooled using a random-effects model. Main results Nineteen trials that included a total of 1387 patients reported data on the number of patients exposed to allogeneic RBC transfusion. DDAVP did not significantly reduce the risk of exposure to allogeneic RBC transfusion (relative risk (RR) 0.96, 95% confidence interval (CI) 0.87 to 1.06). However, the use of DDAVP significantly reduced total blood loss (weighted mean difference (WMD) −241.78 ml, 95% CI −387.55 to −96.01 ml). Although DDAVP appeared to reduce the overall volume of allogeneic blood
Berlin, Ana; Kunac, Anastasia; Mosenthal, Anne C
Patients with postoperative complications are often subjected to prolonged life-sustaining treatment based on erroneous assumptions about their goals of care. Shared decision making (SDM) is an evidence-based approach that helps ensure patients' wishes and values are honored in their course of treatment. Perioperative palliative care can help create goal-concordant trajectories of care for high risk, seriously ill, or complicated patients, through sophisticated prognostication, higher-level communication, and recommendations based on the best available evidence and patients' stated goals and priorities. Here, we present a surgeon-to-surgeon consultative model that surmounts many barriers to perioperative palliative care consultation and, as illustrated in the cases presented herein, offers profound and unique benefits for patients, families, and surgeons alike. While the support of a surgical colleague with palliative care skills can be helpful postoperatively in the setting of unanticipated outcomes or prolonged recovery, it is particularly beneficial when accessed preoperatively for the purposes of goal-concordant decision making and advance care planning. We encourage both individuals and professional societies to develop and expand the niche for surgeons interested in assisting with goal setting and SDM for patients on a consultative basis, particularly in the preoperative period.
Dhatariya, K; Levy, N; Kilvert, A; Watson, B; Cousins, D; Flanagan, D; Hilton, L; Jairam, C; Leyden, K; Lipp, A; Lobo, D; Sinclair-Hammersley, M; Rayman, G
These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery. © 2012 Crown copyright. Diabetic Medicine © 2012 Diabetes UK.
Full Text Available Abstract Background We made a survey among Finnish anesthesiologists concerning the current perioperative anesthetic practice of hip fracture patients for further development in patient care. Methods All members of the Finnish Society of Anesthesiologists with a known e-mail address (786 were invited to participate in an internet-based survey. Results The overall response rate was 55% (423 responses; 298 respondents participated in the care of hip fracture patients. Preoperative analgesia was mostly managed with oxycodone and paracetamol; every fifth respondent applied an epidural infusion. Most respondents (98% employed a spinal block with or without an epidural catheter for intraoperative anesthesia. Midazolam, propofol and/or fentanyl were used for additional sedation. General anesthesia was used rarely. Postoperatively, paracetamol and non-steroidal anti-inflammatory drugs and occasionally peroral oxycodone, were prescribed in addition to epidural analgesia. Conclusions The survey suggests that the impact of more individualised analgesia regimens, both preoperatively and postoperatively, should be investigated in further studies.
Tew, Shannon; Taicher, Brad M
Service dogs are beneficial in providing assistance to people with multiple types of disabilities and medical disorders including visual impairment, physical disabilities, seizure disorders, diabetes, and mental illness. Some service animals have been trained as a screening tool for cancer. We review a case involving a 6-year-old female with a history of mast cell mediator release and immediate hypersensitivity due to the urticaria pigmentosa variant of cutaneous mastocytosis who underwent a cystourethroscopy. Her service dog, JJ, who would alert to mast cell mediator release, was used throughout the perioperative course as a means of anxiolysis and comfort and to monitor for mast cell mediator release. This case presents an example of a service dog used in a family-care model in the field of anesthesiology and provides a unique example of using a service dog as an additional monitor to alert the care team for impending mast cell mediator release.
Full Text Available Service dogs are beneficial in providing assistance to people with multiple types of disabilities and medical disorders including visual impairment, physical disabilities, seizure disorders, diabetes, and mental illness. Some service animals have been trained as a screening tool for cancer. We review a case involving a 6-year-old female with a history of mast cell mediator release and immediate hypersensitivity due to the urticaria pigmentosa variant of cutaneous mastocytosis who underwent a cystourethroscopy. Her service dog, JJ, who would alert to mast cell mediator release, was used throughout the perioperative course as a means of anxiolysis and comfort and to monitor for mast cell mediator release. This case presents an example of a service dog used in a family-care model in the field of anesthesiology and provides a unique example of using a service dog as an additional monitor to alert the care team for impending mast cell mediator release.
A specialised school on Plasma Wake Acceleration will be held at CERN, Switzerland from 23-29 November, 2014. This course will be of interest to staff and students in accelerator laboratories, university departments and companies working in or having an interest in the field of new acceleration techniques. Following introductory lectures on plasma and laser physics, the course will cover the different components of a plasma wake accelerator and plasma beam systems. An overview of the experimental studies, diagnostic tools and state of the art wake acceleration facilities, both present and planned, will complement the theoretical part. Topical seminars and a visit of CERN will complete the programme. Further information can be found at: http://cas.web.cern.ch/cas/PlasmaWake2014/CERN-advert.html http://indico.cern.ch/event/285444/
Collaborative Approaches and Policy Opportunities for Accelerated Progress toward Effective Disease Prevention, Care, and Control: Using the Case of Poverty Diseases to Explore Universal Access to Affordable Health Care.
There is a massive global momentum to progress toward the sustainable development and universal health coverage goals. However, effective policies to health-care coverage can only emerge through high-quality services delivered to empowered care users by means of strong local health systems and a translational standpoint. Health policies aimed at removing user fees for a defined health-care package may fail at reaching desired results if not applied with system thinking. Secondary data analysis of two country-based cost-of-illness studies was performed to gain knowledge in informed decision-making toward enhanced access to care in the context of resource-constraint settings. A scoping review was performed to map relevant experiences and evidence underpinning the defined research area, the economic burden of illness. Original studies reflected on catastrophic costs to patients because of care services use and related policy gaps. Poverty diseases such as tuberculosis (TB) may constitute prime examples to assess the extent of effective high-priority health-care coverage. Our findings suggest that a share of the economic burden of illness can be attributed to implementation failures of health programs and supply-side features, which may highly impair attainment of the global stated goals. We attempted to define and discuss a knowledge development framework for effective policy-making and foster system levers for integrated care. Bottlenecks to effective policy persist and rely on interrelated patterns of health-care coverage. Health system performance and policy responsiveness have to do with collaborative work among all health stakeholders. Public-private mix strategies may play a role in lowering the economic burden of disease and solving some policy gaps. We reviewed possible added value and pitfalls of collaborative approaches to enhance dynamic local knowledge development and realize integration with the various health-care silos. Despite a large political
Collaborative Approaches and Policy Opportunities for Accelerated Progress toward Effective Disease Prevention, Care, and Control: Using the Case of Poverty Diseases to Explore Universal Access to Affordable Health Care
Full Text Available BackgroundThere is a massive global momentum to progress toward the sustainable development and universal health coverage goals. However, effective policies to health-care coverage can only emerge through high-quality services delivered to empowered care users by means of strong local health systems and a translational standpoint. Health policies aimed at removing user fees for a defined health-care package may fail at reaching desired results if not applied with system thinking.MethodSecondary data analysis of two country-based cost-of-illness studies was performed to gain knowledge in informed decision-making toward enhanced access to care in the context of resource-constraint settings. A scoping review was performed to map relevant experiences and evidence underpinning the defined research area, the economic burden of illness.FindingsOriginal studies reflected on catastrophic costs to patients because of care services use and related policy gaps. Poverty diseases such as tuberculosis (TB may constitute prime examples to assess the extent of effective high-priority health-care coverage. Our findings suggest that a share of the economic burden of illness can be attributed to implementation failures of health programs and supply-side features, which may highly impair attainment of the global stated goals. We attempted to define and discuss a knowledge development framework for effective policy-making and foster system levers for integrated care.DiscussionBottlenecks to effective policy persist and rely on interrelated patterns of health-care coverage. Health system performance and policy responsiveness have to do with collaborative work among all health stakeholders. Public–private mix strategies may play a role in lowering the economic burden of disease and solving some policy gaps. We reviewed possible added value and pitfalls of collaborative approaches to enhance dynamic local knowledge development and realize integration with the various
Guo, Yong; Sun, Lulu; Li, Li; Jia, Peiyu; Zhang, Junfeng; Jiang, Hong; Jiang, Wei
To investigate the impact of multicomponent, nonpharmacologic interventions (MNI) on perioperative cortisol and melatonin levels, as well as postoperative delirium (PD), in elderly oral cancer patients. A total of 160 elderly oral cancer patients who underwent tumor resection surgery and completed our investigation were included in this study. The cancer patients were randomly divided into 2 groups: Group U or Group I. During the perioperative period, Group U received usual care, while Group I received MNI, which is based on usual care and aims to decrease the risk of PD. MNI focused on general geriatric approaches and supportive nursing care. On the day before surgery and the first three postoperative days, nocturnal (20:00-8:00) urine samples were collected. The melatonin sulfate and cortisol levels in the urine samples were determined. Moreover, the RASS (Richmond Agitation Sedation Scale), CAM-ICU (Confusion Assessment Method for the Intensive Care Unit) and QoR40 (40-item quality of recovery score) scores were dynamically monitored. There were no significant differences in the general characteristics between the 2 groups. After surgery, the melatonin sulfate levels in the nocturnal urine of Group I were higher than those in Group U. The cortisol concentrations were lower in Group I compared to those in Group U. Group I achieved better postoperative RASS and QoR40 scores than Group U. Compared to Group U, Group I also experienced less PD (incidence and duration). MNI ameliorated some postoperative disturbances regarding sleep and stress, decreased the incidence of PD and improved recovery quality. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Albaladejo, Pierre; Aubrun, Frédéric; Samama, Charles-Marc; Jouffroy, Laurent; Beaussier, Marc; Benhamou, Dan; Romegoux, Pauline; Skaare, Kristina; Bosson, Jean-Luc; Ecoffey, Claude
The organization of health care establishments and perioperative care are essential for ensuring the quality of care and safety of patients undergoing outpatient surgery. In order to correctly inventory these organizations and practices, in 2013-2014, the French society of anaesthesia and intensive care organized an extensive practical survey in French ambulatory surgery units entitled the "OPERA" study (Organisation periopératoire de l'anesthésie en chirurgie ambulatoire). From among all of the ambulatory surgery centres listed by the Agences régionales de santé (Regional health agencies, France), 206 public and private centres were randomly selected. A structural (typology, organization) survey and a medical-practice survey (focusing on the management of postoperative pain, nausea and vomiting as well as the prevention of venous thromboembolism) were collected and managed by a prospective audit of practices occurring on two randomly selected days. The latter was further accompanied by an additional audit specifically focussing on ten representative procedures: (1) stomatology surgery (third molar removal); (2) knee arthroscopy; (3) surgery of the abdominal wall (including inguinal hernia); (4) perianal surgery; (5) varicose vein surgery; (6) digestive laparoscopy-cholecystectomy; (7) breast surgery (tumourectomy); (8) uterine surgery; (9) hallux valgus and (10) hand surgery (excluding carpal tunnel). Over the 2 days of observation, 7382 patients were included comprising 2174 patients who underwent one of the procedures from the above list. The analysis of these data will provide an overview of the organization of health establishments, the modalities thus supported and compliance with standards. Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
Var, Chivorn; Bazzano, Alessandra N; Srivastav, Sudesh K; Welty, James C; Ek, Navapol Iv; Oberhelman, Richard A
Newborn health is a key issue in addressing the survival of children under five years old, particularly in low and middle income countries, and the evidence base for newborn health interventions continues to evolve. Over the last decade, maternal and under five-year-old mortality and morbidity rates have been successfully reduced in Cambodia, but newborn health has lagged behind. Evidence suggests that an important proportion of newborn mortality both globally and in Cambodia is attributable to infections and sepsis. While initiatives are being implemented to address some causes of newborn illness (related to pre-term birth and asphyxia), a country-level approach to reducing infections has not been formulated. The Newborn Infection Control and Care Initiative (NICCI) is a community and health facility linked intervention to improve health outcomes for newborns. The present study applies a cluster randomized trial, using a stepped wedge design, to assess the impact of a package intervention on newborn health. The intervention components include addressing infection control in the perinatal period in health facilities, promoting infection prevention and control practices in health center and home environments, and improving the timeliness of referrals for newborns with suspected infections to appropriate health facilities, by linking families to the medical system through a network of community based volunteers who will make home visits to families in the first week of a newborn's life. The NICCI trial is designed to complement and enhance the Cambodian Ministry of Health strategies and objectives for maternal and newborn care. Results of the study will help to inform policy and the possible scale-up of newborn health interventions in the country. This trial was registered with Clinicaltrials.gov (identifier: NCT02271737) on 5 October 2014.
Audio Productions, Inc, New York
Film about the different particle accelerators in the US. Nuclear research in the US has developed into a broad and well-balanced program.Tour of accelerator installations, accelerator development work now in progress and a number of typical experiments with high energy particles. Brookhaven, Cosmotron. Univ. Calif. Berkeley, Bevatron. Anti-proton experiment. Negative k meson experiment. Bubble chambers. A section on an electron accelerator. Projection of new accelerators. Princeton/Penn. build proton synchrotron. Argonne National Lab. Brookhaven, PS construction. Cambridge Electron Accelerator; Harvard/MIT. SLAC studying a linear accelerator. Other research at Madison, Wisconsin, Fixed Field Alternate Gradient Focusing. (FFAG) Oakridge, Tenn., cyclotron. Two-beam machine. Comments : Interesting overview of high energy particle accelerators installations in the US in these early years. .
Cheng, D. Y.
Converging, coaxial accelerator electrode configuration operates in vacuum as plasma gun. Plasma forms by periodic injections of high pressure gas that is ionized by electrical discharges. Deflagration mode of discharge provides acceleration, and converging contours of plasma gun provide focusing.
Epstein, Richard H; Dexter, Franklin; Hofer, Ira S; Rodriguez, Luis I; Schwenk, Eric S; Maga, Joni M; Hindman, Bradley J
Perioperative hypothermia may increase the incidences of wound infection, blood loss, transfusion, and cardiac morbidity. U.S. national quality programs for perioperative normothermia specify the presence of at least 1 "body temperature" ≥35.5°C during the interval from 30 minutes before to 15 minutes after the anesthesia end time. Using data from 4 academic hospitals, we evaluated timing and measurement considerations relevant to the current requirements to guide hospitals wishing to report perioperative temperature measures using electronic data sources. Anesthesia information management system databases from 4 hospitals were queried to obtain intraoperative temperatures and intervals to the anesthesia end time from discontinuation of temperature monitoring, end of surgery, and extubation. Inclusion criteria included age >16 years, use of a tracheal tube or supraglottic airway, and case duration ≥60 minutes. The end-of-case temperature was determined as the maximum intraoperative temperature recorded within 30 minutes before the anesthesia end time (ie, the temperature that would be used for reporting purposes). The fractions of cases with intervals >30 minutes between the last intraoperative temperature and the anesthesia end time were determined. Among the hospitals, averages (binned by quarters) of 34.5% to 59.5% of cases had intraoperative temperature monitoring discontinued >30 minutes before the anesthesia end time. Even if temperature measurement had been continued until extubation, averages of 5.9% to 20.8% of cases would have exceeded the allowed 30-minute window. Averages of 8.9% to 21.3% of cases had end-of-case intraoperative temperatures <35.5°C (ie, a quality measure failure). Because of timing considerations, a substantial fraction of cases would have been ineligible to use the end-of-case intraoperative temperature for national quality program reporting. Thus, retrieval of postanesthesia care unit temperatures would have been necessary. A
Full Text Available Purpose : To evaluate peri-operative multicatheter interstitial pulsed-dose-rate brachytherapy (PDR-BT with an intra-operative catheter placement to boost the tumor excision site in breast cancer patients treated conservatively. Material and methods: Between May 2002 and October 2008, 96 consecutive T1-3N0-2M0 breast cancer patients underwent breast-conserving therapy (BCT including peri-operative PDR-BT boost, followed by whole breast external beam radiotherapy (WBRT. The BT dose of 15 Gy (1 Gy/pulse/h was given on the following day after surgery. Results: No increased bleeding or delayed wound healing related to the implants were observed. The only side effects included one case of temporary peri-operative breast infection and 3 cases of fat necrosis, both early and late. In 11 patients (11.4%, subsequent WBRT was omitted owing to the final pathology findings. These included eight patients who underwent mastectomy due to multiple adverse prognostic pathological features, one case of lobular carcinoma in situ, and two cases with no malignant tumor. With a median follow-up of 12 years (range: 7-14 years, among 85 patients who completed BCT, there was one ipsilateral breast tumor and one locoregional nodal recurrence. Six patients developed distant metastases and one was diagnosed with angiosarcoma within irradiated breast. The actuarial 5- and 10-year disease free survival was 90% (95% CI: 84-96% and 87% (95% CI: 80-94%, respectively, for the patients with invasive breast cancer, and 91% (95% CI: 84-97% and 89% (95% CI: 82-96%, respectively, for patients who completed BCT. Good cosmetic outcome by self-assessment was achieved in 58 out of 64 (91% evaluable patients. Conclusions : Peri-operative PDR-BT boost with intra-operative tube placement followed by EBRT is feasible and devoid of considerable toxicity, and provides excellent long-term local control. However, this strategy necessitates careful patient selection and histological confirmation
Alfonsi, P; Schaack, E
Accelerated recovery programs are clinical pathways which outline the stages, and streamline the means, and techniques aiming toward the desired end a rapid return of the patient to his pre-operative physical and psychological status. Recovery from colo-rectal surgery may be slowed by the patient's general health, surgical stress, post-surgical pain, and post-operative ileus. Both surgeons and anesthesiologists participate throughout the peri-operative period in a clinical pathway aimed at minimizing these delaying factors. Key elements of this pathway include avoidance of pre-operative colonic cleansing, early enteral feeding, and effective post-operative pain management permitting early ambulation (usually via thoracic epidural anesthesia). Pre-operative information and motivation of the patient is also a key to the success of this accelerated recovery program. Studies of such programs have shown decreased duration of post-operative ileus and hospital stay without an increase in complications or re-admissions. The elements of the clinical pathway must be regularly re-evaluated and updated according to local experience and published data.
Introduction to accelerator physics The CERN Accelerator School: Introduction to Accelerator Physics, which should have taken place in Istanbul, Turkey, later this year has now been relocated to Budapest, Hungary. Further details regarding the new hotel and dates will be made available as soon as possible on a new Indico site at the end of May.
Turner, Michael Stanley
Using naturally occuring particles on which to research might have made accelerators become extinct. But in fact, results from astrophysics have made accelerator physics even more important. Not only are accelerators used in hospitals but they are also being used to understand nature's inner workings by searching for Higgs bosons, CP violation, neutrino mass and dark matter (2 pages)
He, Hong-Gu; Zhu, Lixia; Chan, Sally Wai-Chi; Liam, Joanne Li Wee; Li, Ho Cheung William; Ko, Saw Sandar; Klainin-Yobas, Piyanee; Wang, Wenru
To examine if therapeutic play intervention could reduce perioperative anxiety, negative emotional manifestation and postoperative pain in children undergoing inpatient elective surgery. Children undergoing surgery commonly experience anxiety and postoperative pain and exhibit negative emotional manifestations. Previous studies have shown inconsistent conclusions about the influence of therapeutic play on children's perioperative anxiety, negative emotional manifestation and postoperative pain. A randomized controlled trial was used. Suitable children were recruited from November 2011-August 2013. They were randomized to receive either routine care (control group, n = 47) or a 1-hour therapeutic play intervention (experimental group, n = 48). Children's state anxiety, negative emotional manifestations and postoperative pain were measured at baseline, on the day of surgery and around 24 hours after surgery. Repeated measures analysis of covariance (ancova) and univariate ancova adjusting for all possible confounding factors were used in the data analysis. The time effect of state anxiety was significant, but no group and interaction (group x time) effects between the control and experimental groups were found. Compared with the control group, children in the experimental group demonstrated significantly lower scores of negative emotional manifestations prior to anaesthesia induction and postoperative pain. Therapeutic play intervention is effective in reducing negative emotional manifestations before anaesthesia induction and in reducing postoperative pain in children undergoing inpatient elective surgery. These results suggest that it is useful to give children with therapeutic play intervention prior to inpatient elective surgery. © 2015 John Wiley & Sons Ltd.
Dafne Eva Corrêa Brandão
Full Text Available This integrative review aimed at analyzing evidences available in literature regarding stress levels in nursing teams during the perioperative period. Primary studies were searched in the following databases: PubMed, CINAHL and LILACS. Included studies were grouped into the following thematic categories: stress level in the workplace and stress factors (n=8 and stress coping strategies used by the nursing staff (n=6. Evidence suggests that stress in the workplace worsens the health of the nursing team, provoking undesirable effects both in the professional and personal lives of these professionals. The assessment of working conditions to identify the main stressing factors and the implementation of individual and organizational measures to reduce nursing teams stress may increase productivity and workers’ satisfaction, improving the assistance quality offered to surgical patients.
Poveda-Jaramillo, R; Castro-Arias, H D; Vallejo-Zarate, C; Ramos-Hurtado, L F
The use of implantable cardiac devices in people of all ages is increasing, especially in the elderly population: patients with pacemakers, cardioverter-defibrillators or cardiac resynchronization therapy devices regularly present for surgery for non-cardiac causes. This review was made in order to collect and analyze the latest evidence for the proper management of implantable cardiac devices in the perioperative period. Through a detailed exploration of PubMed, Academic Search Complete (EBSCO), ClinicalKey, Cochrane (Ovid), the search software UpToDate, textbooks and patents freely available to the public on Google, we selected 33 monographs, which matched the objectives of this publication. Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.
Clouse, W Darrin; Ergul, Emel A; Patel, Virendra I; Lancaster, R Todd; LaMuraglia, Glenn M; Cambria, Richard P; Conrad, Mark F
Contralateral stroke is an infrequent cause of perioperative stroke after carotid endarterectomy (CEA). Whereas the risks of ipsilateral stroke complicating CEA have been discriminated, factors that lead to contralateral stroke are poorly defined. The purpose of this study was to identify the risk of perioperative (30-day) contralateral stroke after CEA as well as predisposing preoperative and operative factors. Its specific effect on long-term survival was interrogated. The Vascular Study Group of New England (VSGNE) was queried from April 1, 2003, to February 29, 2016, for all CEAs. Duplicated patients and those without complete data were excluded. Patients sustaining contralateral stroke after CEA in the 30-day postoperative period were identified. Demographic, preoperative, and operative factors were analyzed to identify discriminators between those with and those without contralateral stroke. Logistic regression modeling was performed to identify factors independently associated with contralateral stroke. The effect of contralateral stroke on 5-year survival was compared with patients with ipsilateral stroke and no stroke using the Kaplan-Meier method. Log-rank testing compared survival curves. There were 10,837 CEAs performed during the study. Average age was 70.4 ± 9.3 years; 6605 (61%) patients were male, and 40% (n = 4324) were performed for symptoms. Most were current or former smokers (n = 8619 [80%]). Coronary artery disease and congestive heart failure were identified in 31% and 8.6%, respectively. Overall, there were 190 strokes within 30 days of CEA (1.8%); 131 were ipsilateral (1.3%), and 59 (0.5%) patients were identified as having contralateral perioperative stroke. Thirteen patients sustained bilateral stroke (0.1%). Significant univariate associations included urgency (P = .0001), ipsilateral stenosis severity (P = .004), length of operation (P = .0001), CEA with coronary artery bypass graft (P = .0001), CEA with other arterial surgery
Preoperative evaluation of infectious diseases in patients for elective and non-elective surgery is important for the anesthesiologists not only to rule out the patient's state of illness, but also to prevent transmission of infectious diseases in healthcare settings. To prevent transmission of infectious diseases in healthcare settings, Center for Disease Control published guidelines that consist of standard precaution and transmission-based precautions. In the face of exposure to known infectious diseases, certain post exposure prophylaxis has been established, especially against exposure to human immunodeficiency virus and hepatitis B virus. There are also growing interests in perioperative prevention of surgical site infection, since World Health Organization has published surgical safety checklist with the slogan "Safe surgery saves life". Anesthesiologists need to have knowledge on the prevention of surgical site infection especially on antibiotic prophylaxis, because it starts in the operating room.
Batista, Thales Paulo; de Mendonça, Lucas Marques; Fassizoli-Fonte, Ana Luiza
Gastric cancer is one of the most common neoplasms and a main cause of cancer-related mortality worldwide. Surgery remains the mainstay for cure and is considered for all patients with potentially curable disease. However, despite the fact that surgery alone usually leads to favorable outcomes in early stage disease, late diagnosis usually means a poor prognosis. In these settings, multimodal therapy has become the established treatment for locally advanced tumors, while the high risk of locoregional relapse has favored the inclusion of radiotherapy in the comprehensive therapeutic strategy. We provide a critical, non-systematic review of gastric cancer and discuss the role of perioperative radiation therapy in its treatment. PMID:25992221
Platt, R; Zucker, J R; Zaleznik, D F; Hopkins, C C; Dellinger, E P; Karchmer, A W; Bryan, C S; Burke, J F; Wikler, M A; Marino, S K
The effectiveness of perioperative antibiotic prophylaxis against wound infections following breast surgery was investigated by meta-analysis of published data from a randomized clinical trial and an observational data set, which included a total of 2587 surgical procedures, including excisional biopsy, lumpectomy, mastectomy, reduction mammoplasty and axillary node dissection. There were 98 wound infections (3.8%). Prophylaxis was used for 44% (1141) of these procedures, cephalosporins accounted for 986 (86%) of these courses of antibiotics. Prophylaxis prevented 38% of infections, after controlling for operation type, duration of surgery and participation in the randomized trial (Mantel-Haenszel Odds Ratio = 0.62, 95% confidence interval = 0.40-0.95, P = 0.03). There was no significant variation in efficacy according to operation type or duration. We conclude that antibiotic prophylaxis significantly reduces the risk of postoperative wound infection following these commonly performed breast procedures.
Søballe, Kjeld; Troelsen, Anders
are detached, and the femoral nerve and vessels are protected by the iliopsoas and sartorius muscles. This approach is safe, minimizes blood loss and transfusion requirements, is associated with a short duration of surgery, and allows for optimal correction of the acetabular fragment. Follow-ups (range, 3......, or any surgical procedure, should be characterized by few complications, minimized surgical trauma, and no compromise of long-term surgical results. A minimally invasive transsartorial approach using fluoroscopy and an approximately 7-cm skin incision has been developed for performing PAO. No muscles...... (local infiltration analgesia), and a progressive mobilization and exercise program. The transsartorial approach coupled with a specific perioperative management program has proved successful for PAO surgery....
Jessen Lundorf, Luise; Korvenius Nedergaard, Helene; Møller, Ann Merete
Background: Acute postoperative pain is still an issue in patients undergoing abdominal surgery. Postoperative pain and side effects of analgesic treatment, in particular those of opioids, need to be minimized. Opioid-sparing analgesics, possibly including dexmedetomidine, seem a promising avenue...... by which to improve postoperative outcomes. Objectives: Our primary aim was to determine the analgesic efficacy and opioid-sparing effect of perioperative dexmedetomidine for acute pain after abdominal surgery in adults. Secondary aims were to establish effects of dexmedetomidine on postoperative nausea...... surgery in adults. Trials included one of the following outcomes: amount of 'rescue' opioid, postoperative pain, time to 'rescue' analgesia, participants requiring 'rescue' analgesia, postoperative sedation, PONV, time to first passage of flatus and stool or time to first out-of-bed mobilization. Data...
Himmelfarb, Jonathan; Chertow, Glenn M; McCullough, Peter A; Mesana, Thierry; Shaw, Andrew D; Sundt, Thoralf M; Brown, Craig; Cortville, David; Dagenais, François; de Varennes, Benoit; Fontes, Manuel; Rossert, Jerome; Tardif, Jean-Claude
AKI after cardiac surgery is associated with mortality, prolonged hospital length of stay, use of dialysis, and subsequent CKD. We evaluated the effects of THR-184, a bone morphogenetic protein-7 agonist, in patients at high risk for AKI after cardiac surgery. We conducted a randomized, double-blind, placebo-controlled, multidose comparison of the safety and efficacy of perioperative THR-184 using a two-stage seamless adaptive design in 452 patients between 18 and 85 years of age who were scheduled for nonemergent cardiac surgery requiring cardiopulmonary bypass and had recognized risk factors for AKI. The primary efficacy end point was the proportion of patients who developed AKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The proportion of patients who developed AKI within 7 days of surgery was similar in THR-184 treatment groups and placebo groups (range, 74%-79%; P =0.43). Prespecified secondary end point analysis did not show significant differences in the severity of AKI stage ( P =0.53) or the total duration of AKI ( P =0.44). A composite of death, dialysis, or sustained impaired renal function by day 30 after surgery did not differ between groups (range, 11%-20%; P =0.46). Safety-related outcomes were similar across all treatment groups. In conclusion, compared with placebo, administration of perioperative THR-184 through a range of dose exposures failed to reduce the incidence, severity, or duration of AKI after cardiac surgery in high-risk patients. Copyright © 2018 by the American Society of Nephrology.
Platt, R; Zaleznik, D F; Hopkins, C C; Dellinger, E P; Karchmer, A W; Bryan, C S; Burke, J F; Wikler, M A; Marino, S K; Holbrook, K F
We assessed the efficacy of perioperative antibiotic prophylaxis for surgery in a randomized, double-blind trial of 1218 patients undergoing herniorrhaphy or surgery involving the breast, including excision of a breast mass, mastectomy, reduction mammoplasty, and axillary-node dissection. The prophylactic regimen was a single dose of cefonicid (1 g intravenously) administered approximately half an hour before surgery. The patients were followed up for four to six weeks after surgery. Blinding was maintained until the last patient completed the follow-up and all diagnoses of infection had been made. The patients who received prophylaxis had 48 percent fewer probable or definite infections than those who did not (Mantel-Haenszel risk ratio, 0.52; 95 percent confidence interval, 0.32 to 0.84; P = 0.01). For patients undergoing a procedure involving the breast, infection occurred in 6.6 percent of the cefonicid recipients (20 of 303) and 12.2 percent of the placebo recipients (37 of 303); for those undergoing herniorrhaphy, infection occurred in 2.3 percent of the cefonicid recipients (7 of 301) and 4.2 percent of the placebo recipients (13 of 311). There were comparable reductions in the numbers of definite wound infections (Mantel-Haenszel risk ratio, 0.49), wounds that drained pus (risk ratio, 0.43), Staphylococcus aureus wound isolates (risk ratio, 0.49), and urinary tract infections (risk ratio, 0.40). There were also comparable reductions in the need for postoperative antibiotic therapy, non-routine visits to a physician for problems involving wound healing, incision and drainage procedures, and readmission because of problems with wound healing. We conclude that perioperative antibiotic prophylaxis with cefonicid is useful for herniorrhaphy and certain types of breast surgery.
Langerman, Alexander; Ham, Sandra A; Pisano, Jennifer; Pariser, Joseph; Hohmann, Samuel F; Meltzer, David O
To assess hospital- and physician-level variation in pattern of perioperative antibiotic use for laryngectomy and the relationship between pattern of antibiotic use and surgical site infection (SSI), wound dehiscence, and antibiotic-induced complications. Retrospective analysis of University HealthSystem Consortium data. Academic medical centers and affiliated hospitals. Elective admissions for laryngectomy from 2008 to 2011 and associated 30-day readmissions were analyzed with multivariate logistic regression models. There were 439 unique antibiotic regimens (agents and duration) identified over the first 4 days of the 1865 admissions included in this study. Ampicillin/sulbactam, cefazolin + metronidazole, and clindamycin were the most common agents given on the day of surgery. Clindamycin was independently associated with higher odds of SSI (odds ratio [OR] = 3.87, 95% confidence interval [CI] = 2.31-6.49]), wound dehiscence (OR = 3.42, 95% CI = 2.07-5.64), and antibiotic-induced complications (OR = 3.01, 95% CI = 1.59-5.67) when given alone; it was also associated with higher odds of SSI (OR = 2.69, 95% CI = 1.43-5.05) and antibiotic-induced complications (OR = 2.20, 95% CI = 1.04-4.64) when given with other agents. These effects were stronger in a subsample of high-volume physicians and hospitals. There is substantial variability in perioperative antibiotic strategies for laryngectomy. Clindamycin was associated with much higher odds of short-term complications as compared to other common regimens. Based on these data, clinical trials should be planned to firmly establish the most effective and cost-effective antibiotic management for laryngectomy and determine potential alternatives to clindamycin for penicillin-allergic patients. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.
Lüdeke, Andreas; Giachino, R
A high reliability is a very important goal for most particle accelerators. The biennial Accelerator Reliability Workshop covers topics related to the design and operation of particle accelerators with a high reliability. In order to optimize the over-all reliability of an accelerator one needs to gather information on the reliability of many different subsystems. While a biennial workshop can serve as a platform for the exchange of such information, the authors aimed to provide a further channel to allow for a more timely communication: the Particle Accelerator Reliability Forum . This contribution will describe the forum and advertise it’s usage in the community.
Eva van der Meij
Full Text Available E-health interventions have become increasingly popular, including in perioperative care. The objective of this study was to evaluate the effect of perioperative e-health interventions on the postoperative course.We conducted a systematic review and searched for relevant articles in the PUBMED, EMBASE, CINAHL and COCHRANE databases. Controlled trials written in English, with participants of 18 years and older who underwent any type of surgery and which evaluated any type of e-health intervention by reporting patient-related outcome measures focusing on the period after surgery, were included. Data of all included studies were extracted and study quality was assessed by using the Downs and Black scoring system.A total of 33 articles were included, reporting on 27 unique studies. Most studies were judged as having a medium risk of bias (n = 13, 11 as a low risk of bias, and three as high risk of bias studies. Most studies included patients undergoing cardiac (n = 9 or orthopedic surgery (n = 7. All studies focused on replacing (n = 11 or complementing (n = 15 perioperative usual care with some form of care via ICT; one study evaluated both type of interventions. Interventions consisted of an educational or supportive website, telemonitoring, telerehabilitation or teleconsultation. All studies measured patient-related outcomes focusing on the physical, the mental or the general component of recovery. 11 studies (40.7% reported outcome measures related to the effectiveness of the intervention in terms of health care usage and costs. 25 studies (92.6% reported at least an equal (n = 8 or positive (n = 17 effect of the e-health intervention compared to usual care. In two studies (7.4% a positive effect on any outcome was found in favour of the control group.Based on this systematic review we conclude that in the majority of the studies e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative
Bick, Julian S; Wanderer, Jonathan P; Myler, Conrad S; Shaw, Andrew D; McEvoy, Matthew D
Credible methods for assessing competency in basic perioperative transesophageal echocardiography examinations have not been reported. The authors' objective was to demonstrate the collection of real-world basic perioperative transesophageal examination performance data and establish passing scores for each component of the basic perioperative transesophageal examination, as well as a global passing score for clinical performance of the basic perioperative transesophageal examination using the Angoff method. National Board of Echocardiography (Raleigh, North Carolina) advanced perioperative transesophageal echocardiography-certified anesthesiologists (n = 7) served as subject matter experts for two Angoff standard-setting sessions. The first session was held before data analysis, and the second session for calibration of passing scores was held 9 months later. The performance of 12 anesthesiology residents was assessed via the new passing score grading system. The first standard-setting procedure resulted in a global passing score of 63 ± 13% on a basic perioperative transesophageal examination. The global passing score from the second standard-setting session was 73 ± 9%. Three hundred seventy-one basic perioperative transesophageal examinations from 12 anesthesiology residents were included in the analysis and used to guide the second standard-setting session. All residents scored higher than the global passing score from both standard-setting sessions. To the authors' knowledge, this is the first demonstration that the collection of real-world anesthesia resident basic perioperative transesophageal examination clinical performance data is possible and that automated grading for competency assessment is feasible. The authors' findings demonstrate at least minimal basic perioperative transesophageal examination clinical competency of the 12 residents.
Niesen, Adam D; Jacob, Adam K; Aho, Lucyna E; Botten, Emily J; Nase, Karen E; Nelson, Julia M; Kopp, Sandra L
The occurrence of perioperative seizures in patients with a preexisting seizure disorder is unclear. There are several factors unique to the perioperative period that may increase a patient's risk of perioperative seizures, including medications administered, timing of medication administration, missed doses of antiepileptic medications, and sleep deprivation. We designed this retrospective chart review to evaluate the frequency of perioperative seizures in patients with a preexisting seizure disorder. We retrospectively reviewed the medical records of all patients with a documented history of a seizure disorder who received an anesthetic between January 1, 2002 and December 31, 2007. Patients excluded from this study include those who had an outpatient procedure or intracranial procedure, ASA classification of V, pregnant women, and patients younger than 2 years of age. The first hospital admission of at least 24 hours during which an anesthetic was provided was identified for each patient. Patient demographics, character of the seizure disorder, details of the surgical procedure, and clinically apparent seizure activity in the perioperative period (within 3 days after the anesthetic) were recorded. During the 6-year study period, 641 patients with a documented seizure disorder were admitted for at least 24 hours after an anesthetic. Twenty-two patients experienced perioperative seizure activity for an overall frequency of 3.4%(95% confidence interval, 2.2%-5.2%). The frequency of preoperative seizures (P seizure (P seizure. As the number of antiepileptic medications increased, so did the frequency of perioperative seizures (P seizures in this patient population. We conclude that the majority of perioperative seizures in patients with a preexisting seizure disorder are likely related to the patient's underlying condition. The frequency of seizures is not influenced by the type of anesthesia or procedure. Because patients with frequent seizures at baseline are
Alcock, Richard F; Naoum, Chris; Aliprandi-Costa, Bernadette; Hillis, Graham S; Brieger, David B
Cardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. The aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. We evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. Included were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. Approximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
Loeffelbein, Denys J; Julinek, Annette; Wolff, Klaus-Dietrich; Kochs, Eberhard; Haller, Bernhard; Haseneder, Rainer
Postoperative pulmonary complications (PPCs) are common and result in prolonged hospital stays, higher costs and increased mortality. However, data on the incidence and predictors of PPCs after major oral and maxillofacial surgery with microvascular reconstruction are rare. This retrospective analysis identifies perioperative risk factors for postoperative pulmonary complications (PPCs) after major oral and maxillofacial surgery with microvascular reconstruction. Perioperative data and patient records of 648 subjects were analyzed in the period of June 2007 to May 2013. PPCs were defined as pneumonia, atelectasis, pleural effusions, pulmonary embolism, pulmonary oedema, pneumothorax or respiratory failure. 18.8% of all patients developed PPCs. Patient-related risk factors for PPCs were male sex, advanced age, smoking, alcohol abuse, a body mass index >30, American Society of Anaesthesiologists grade higher than 2, pre-existent pulmonary diseases and preoperative antihypertensive medication. Among the investigated procedure-related variables, the length of the operation, the amount of fluid administration and blood transfusion and an impaired oxygenation index during surgery were shown to be associated with the development of PPCs. Using a multivariable logistic regression model, we identified a body mass index >30, American Society of Anaesthesiologists grade higher than 2 and alcohol abuse as independent risk factors for PPCs. Several perioperative factors can be identified that are associated with the development of PPCs. Patients having one or more of these conditions should be subjected to intensified postoperative pulmonary care. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
At CERN, we are very familiar with large, high energy particle accelerators. However, in the world outside CERN, there are more than 35000 accelerators which are used for applications ranging from treating cancer, through making better electronics to removing harmful micro-organisms from food and water. These are responsible for around $0.5T of commerce each year. Almost all are less than 20 MeV and most use accelerator types that are somewhat different from what is at CERN. These lectures will describe some of the most common applications, some of the newer applications in development and the accelerator technology used for them. It will also show examples of where technology developed for particle physics is now being studied for these applications. Rob Edgecock is a Professor of Accelerator Science, with a particular interest in the medical applications of accelerators. He works jointly for the STFC Rutherford Appleton Laboratory and the International Institute for Accelerator Applications at the Univer...