Enhanced recovery after surgery

Enhanced Recovery or Fast Track Recovery after Surgery protocols (ERAS) have significantly changed perioperative care following colorectal surgery and are promoted as reducing the stress response to surgery. The present systematic review aimed to examine the impact on the magnitude of the systemic inflammatory response (SIR) for each ERAS component following colorectal surgery using objective markers such as C-reactive protein (CRP) and interleukin-6 (IL-6). A literature search was performed of the US National Library of Medicine (MEDLINE), EMBASE, PubMed, and the Cochrane Database of Systematic Reviews using appropriate keywords and subject headings to February 2015. Included studies had to assess the impact of the selected ERAS component on the SIR using either CRP or IL-6. Nineteen studies, including 1898 patients, were included. Fourteen studies (1246 patients) examined the impact of laparoscopic surgery on the postoperative markers of SIR. Ten of these studies (1040 patients) reported that laparoscopic surgery reduced postoperative CRP. One study (53 patients) reported reduced postoperative CRP using opioid-minimising analgesia. One study (142 patients) reported no change in postoperative CRP following preoperative carbohydrate loading. Two studies (108 patients) reported conflicting results with respect to the impact of goal-directed fluid therapy on postoperative IL-6. No studies examined the effect of other ERAS components, including mechanical bowel preparation, antibiotic prophylaxis, thromboprophylaxis, and avoidance of nasogastric tubes and peritoneal drains on markers of the postoperative SIR following colorectal surgery. The present systematic review shows that, with the exception of laparoscopic surgery, objective evidence of the effect of individual components of ERAS protocols in reducing the stress response following colorectal surgery is limited

Quality of Postoperative Pain Management after Midfacial Fracture Repair—An Outcome-oriented Study

Objectives There is a lack of literature regarding the procedure-specific quality of acute postoperative pain management after midfacial fracture repair. The purpose of the presented prospective clinical study was to evaluate postoperative pain management after surgical repair of midfacial fractures. Materials and methods Eighty-five adults were evaluated on the first postoperative day following midfacial repair using the questionnaire of the Quality Improvement in Postoperative Pain Management (QUIPS) project. The main outcome measures were patients’ characteristics and clinical- and patient-reported outcome parameters. Results Overall, pain on the first postoperative day was moderate. A significant correlation between process and outcome parameters could be shown. Duration of surgery above the calculated median was significantly associated with higher maximum pain intensity (p = 0.017). Patients requiring opioids in the recovery room presented significantly higher pain on activity (p = 0.029) and maximum pain (p = 0.035). Sleeping impairment (p = 0.001) and mood disturbance (p = 0.008) were significantly more prevalent in patients undergoing repair of a centrolateral midfacial fracture. Conclusions QUIPS is a simple and qualified tool to evaluate the procedure specific quality of acute postoperative pain management. Pain on the first postoperative day following midfacial fracture repair seems overall to be moderate. Nearly a third of the patients showed inadequate postoperative pain management. To prevent inadequate postoperative pain management, it is necessary to establish a continued procedure-specific outcome measurement

Recovery and the use of postoperative physical therapy after total hip or knee replacement

BACKGROUND: Total hip or knee arthroplasties (THA/TKA) show favorable long-term effects, yet the recovery process may take weeks to months. Physical therapy (PT) following discharge from hospital is an effective intervention to enhance this recovery process. To investigate the relation between recovery and postoperative PT usage, including the presence of comorbidities, 6 months after THA/TKA. METHODS: Multicenter, observational study in primary THA/TKA patients who completed preoperative and 6 months postoperative assessments. The assessments included questions on PT use (yes/no and duration; long term use defined as ≥ 12 weeks), comorbidities (musculoskeletal, non-musculoskeletal, sensory comorbidities and frequency of comorbidities). Recovery was assessed with the HOOS/KOOS on all 5 subdomains. Logistic regression with long term PT as outcome was performed adjusted for confounding including an interaction term (comorbidity*HOOS/KOOS-subdomain). RESULTS: In total, 1289 THA and 1333 TKA patients were included, of whom 95% received postoperative PT, 56% and 67% received postoperative PT ≥ 12 weeks respectively. In both THA and TKA group, less improvement on all HOOS/KOOS domain scores was associated with ≥ 12 weeks of postoperative PT (range Odds Ratios 0.97–0.99). In the THA group the impact of recovery was smaller in patient with comorbidities as non- musculoskeletal comorbidities modified all associations between recovery and postoperative PT duration (Odds Ratios range 1.01–1.05). Musculoskeletal comorbidities modified the associations between Function-in-Daily-Living-and Sport-and-recreation recovery and postoperative PT. Sensory comorbidities only had an effect on Sport-and-recreation recovery and postoperative PT. Also the frequency of comorbidities modified the relation between Function-in-Daily-Living, pain and symptoms recovery and postoperative PT. In the TKA group comorbidity did not modify the associations. CONCLUSION: Worse recovery was associated with longer duration of postoperative PT suggesting that PT provision is in line with patients’ needs. The impact of physical recovery on the use of long-term postoperative PT was smaller in THA patients with comorbidities. TRIAL REGISTRATION: Registered in the Dutch Trial Registry on March 13, 2012. TRIAL ID NTR3348; registration number: P12.047. https://www.trialregister.nl/trial/3197. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12891-022-05429-z

Benefits of thoracic epidural analgesia in patients undergoing an open posterior component separation for abdominal herniorrhaphy

INTRODUCTION: The implementation of open posterior component separation (PCS) surgery has led to improved outcomes for complex hernias. While the PCS technique has been shown to decrease recurrence rates, and provide a feasible option to repair hernias in nontraditional locations, there is still significant postoperative pain associated with the laparotomy and extensive abdominal wall manipulation. Systemic opioids and thoracic epidural analgesia (TEA) are both commonly utilized, either together or independently, as postoperative analgesic regimens. The benefits of TEA have been studied following a variety of surgeries, however to date no study has been performed to investigate its efficacy in this particular surgery. The aim of this study is to evaluate the benefits of TEA following open PCS. We hypothesized that the incorporation of TEA in a patients postoperative analgesic regimen would show an advantage in time to bowel recovery. METHODS: An electronic medical record query was done to identify patients who had undergone an open PCS. Once this list was compiled, a retrospective chart review was performed and patients receiving TEA (either alone or combined with systemic opioids) were compared to patients receiving only systemic opioids. The primary endpoint compared time to resumption of a full diet, given by the patients postoperative day (POD). Secondarily, time to resumption of a liquid diet, postoperative length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and rates of several postoperative complications were all recorded and compared. A post-hoc analysis was also performed using the same endpoints. This analysis compared cohorts of patients receiving TEA and avoiding all systemic opioids, to patients who received systemic opioids (whether alone or combined with TEA). RESULTS: Based on inclusion parameters, 101 patients met criteria for analysis. In the initial analysis, 62 patients received TEA with or without systemic opioids, and 39 patients received only systemic opioids. In comparing these groups, there was no statistically significant difference in time to full diet (TEA 2.6 ± 1.7 vs Systemic opioids 3.1 ± 2.1 [mean POD ± SD]; P=0.21). In addition, no differences were found in the secondary outcomes of time to liquid diet, ICU admission, ICU LOS, or postoperative complications. In the post-hoc analysis, the 37 patients that received only TEA, were compared against 64 patients that received systemic opioids (either with or without TEA). In this comparison, the group receiving only TEA was found to have a statically shorter time to bowel recovery compared to patients receiving systemic opioids (TEA alone 2.2 ± 1.0 vs Systemic opioids 3.2 ± 2.2, P=0.0033). This subgroup (TEA only) also showed statically shorter time to liquid diet and a decreased postoperative LOS. CONCLUSION: For patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not shorten return of bowel function. However, when TEA was utilized and systemic opioids were avoided, time to bowel recovery and hospital LOS were both significantly shortened

Intraperitoneal aerosolization of bupivacaine is a safe and effective method in controlling postoperative pain in laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Obesity is a worldwide problem and has grown in severity in the last few decades making bariatric surgery and, in particular, laparoscopic banding and Roux-en-Y gastric bypass efficacious and cost-effective procedures. The laparoscopic approach has been shown to offer significant healthcare benefits, of particular interests are reports of decreased postoperative pain resulting in a shorter hospital stay and an earlier return to normal activity. However, many patients still experience significant pain, including shoulder tip pain, that require strong analgesia including opiates during their early recovery period. The aims of this study were to establish the safe use of the aerosolization technique in bariatric surgery and to investigate the possible benefits in reducing postoperative pain. METHODS: In this study, fifty patients undergoing laparoscopic gastric bypass were recruited and divided into two groups; control (n = 25) and therapeutic (n = 25). The control group received intraperitoneal aerosolization of 10 mL of 0.9% normal saline while the therapeutic group received 10 mL of 0.5% bupivacaine. All the patients had standard preoperative, intraoperative, and postoperative care. Pain scores were carried out by the nursing staff in recovery and 6 h, 12 h and 24 h postoperatively using a standard 0-10 pain scoring scale. In addition, opiate consumption via patient-controlled analgesia (PCA) was recorded. RESULTS: Aerosolized bupivacaine reduced postoperative pain in comparison to normal saline (p < 0.05). However, PCA usage showed no statistically significant change from the control group. CONCLUSION: The aims of this study were achieved and we were able to establish the safe use of the aerosolization technique in bariatric surgery and its benefits in reducing postoperative pain

Uterine Perforation With Subtotal Small Bowel Prolapse – A Rare Complication of Dilatation and Curettage

Uterine perforation is the well known complication of induced abortion. We report a rare case of uterine perforation with subtotal prolapse of small bowel following first trimester abortion by an unqualified physician. Early surgical exploration with resection and anastomosis of bowel performed. Patient discharged uneventfully after postoperative recovery

A prospective analysis of sleep deprivation and disturbance in surgical patients

Introduction: Sleep deprivation has a potentially deleterious effect on postoperative recovery. The aim of our prospective study was to identify the factors contributing to postoperative sleep deprivation and disturbance in order to recommend improvements in postoperative care. Methods: 102 consecutive patients attending for elective general and orthopaedic surgery were interviewed preoperatively (baseline) and postoperatively on their duration of sleep, number of wakenings during the night, factors contributing to sleep loss and the use of analgesia and night sedation. Results: Patients woke up a median of 5 times in the first postoperative night compared to a median of 3 times preoperatively (p = 0.01). Pain was the predominant factor preventing sleep, affecting 39% of patients preoperatively and 48% of patients on the first postoperative day. Other factors included noise from other patients and nursing staff, and using the toilet. Analgesia was taken by more than 90% of patients in the first two days, this number gradually reducing over the postoperative period. On the other hand, in the first two postoperative days, only about 5% of patients had night sedation. Discussion and conclusions: Apart from highlighting the need for effective pain management postoperatively, we believe that our study supports the drive towards single bed bays, where steps can be taken to minimize the impact of environmental factors on sleep

Measuring and Monitoring Cognition in the Postoperative Period

It is common for patients of all ages to experience some degree of cognitive disturbance following surgery. In most cases, impairment appears mild and is restricted to the acute post-operative period, resolving steadily and speedily. In a small number of cases, however, deficits may be more pronounced and/or endure for longer periods, significantly delaying recovery and increasing the risk of serious clinical complications. The ability to accurately measure postoperative cognition, and track recovery of function, is an important clinical task. This review explores practical and methodological issues that may confound this process, examining how best to obtain reliable and meaningful measures of cognition before and after surgery. It considers neuropsychological test selection, administration, analysis and interpretation and offers evidence-based practice points for clinicians and researchers