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Annals of Surgery Feb 2022Develop unifying definitions and paradigms for data-driven methods to augment postoperative resource intensity decisions. (Review)
Review
OBJECTIVE
Develop unifying definitions and paradigms for data-driven methods to augment postoperative resource intensity decisions.
SUMMARY BACKGROUND DATA
Postoperative level-of-care assignments and frequency of vital sign and laboratory measurements (ie, resource intensity) should align with patient acuity. Effective, data-driven decision-support platforms could improve value of care for millions of patients annually, but their development is hindered by the lack of salient definitions and paradigms.
METHODS
Embase, PubMed, and Web of Science were searched for articles describing patient acuity and resource intensity after inpatient surgery. Study quality was assessed using validated tools. Thirty-five studies were included and assimilated according to PRISMA guidelines.
RESULTS
Perioperative patient acuity is accurately represented by combinations of demographic, physiologic, and hospital-system variables as input features in models that capture complex, non-linear relationships. Intraoperative physiologic data enriche these representations. Triaging high-acuity patients to low-intensity care is associated with increased risk for mortality; triaging low-acuity patients to intensive care units (ICUs) has low value and imparts harm when other, valid requests for ICU admission are denied due to resource limitations, increasing their risk for unrecognized decompensation and failure-to-rescue. Providing high-intensity care for low-acuity patients may also confer harm through unnecessary testing and subsequent treatment of incidental findings, but there is insufficient evidence to evaluate this hypothesis. Compared with data-driven models, clinicians exhibit volatile performance in predicting complications and making postoperative resource intensity decisions.
CONCLUSION
To optimize value, postoperative resource intensity decisions should align with precise, data-driven patient acuity assessments augmented by models that accurately represent complex, non-linear relationships among risk factors.
Topics: Health Resources; Humans; Patient Acuity; Postoperative Period; Surgical Procedures, Operative
PubMed: 34261886
DOI: 10.1097/SLA.0000000000005079 -
Journal of Cardiothoracic Surgery Mar 2022Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has... (Review)
Review
OBJECTIVES
Previous research reports numerous factors of post-operative mortality in patients undergoing isolated coronary artery bypass graft surgery. However, this evidence has not been mapped to the conceptual framework of care improvement. Without such mapping, interventions designed to improve care quality remain unfounded.
METHODS
We identified reported factors of in-hospital mortality post isolated coronary artery bypass graft surgery in adults over the age of 19, published in English between January 1, 2000 and December 31, 2019, indexed in PubMed, CINAHL, and EMBASE. We grouped factors and their underlying mechanism for association with in-hospital mortality according to the augmented Donabedian framework for quality of care.
RESULTS
We selected 52 factors reported in 83 articles and mapped them by case-mix, structure, process, and intermediary outcomes. The most reported factors were related to case-mix (characteristics of patients, their disease, and their preoperative health status) (37 articles, 27 factors). Factors related to care processes (27 articles, 12 factors) and structures (11 articles, 6 factors) were reported less frequently; most proposed mechanisms for their mortality effects.
CONCLUSIONS
Few papers reported on factors of in-hospital mortality related to structures and processes of care, where intervention for care quality improvement is possible. Therefore, there is limited evidence to support quality improvement efforts that will reduce variation in mortality after coronary artery bypass graft surgery.
Topics: Adult; Coronary Artery Bypass; Hospital Mortality; Humans; Postoperative Period; Quality Improvement
PubMed: 35313895
DOI: 10.1186/s13019-022-01784-z -
Effects of the breath stacking technique after upper abdominal surgery: a randomized clinical trial.Jornal Brasileiro de Pneumologia :... 2022To evaluate the effect of the association of the breath stacking (BS) technique associated with routine physiotherapy on pulmonary function, lung volumes, maximum... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To evaluate the effect of the association of the breath stacking (BS) technique associated with routine physiotherapy on pulmonary function, lung volumes, maximum respiratory pressures, vital signs, peripheral oxygenation, thoracoabdominal mobility, and pain in the surgical incision in patients submitted to upper abdominal surgery during the postoperative period, as well as to analyze BS safety.
METHODS
This was a randomized clinical trial involving 34 patients divided into a control group (CG; n = 16), who underwent conventional physiotherapy only, and the BS group (BSG; n = 18), who underwent conventional physiotherapy and BS. Both groups performed two daily sessions from postoperative day 2 until hospital discharge. The primary outcomes were FVC and Vt. The safety of BS was assessed by the incidence of gastrointestinal, hemodynamic, and respiratory repercussions.
RESULTS
Although FVC significantly increased at hospital discharge in both groups, the effect was greater on the BSG. Significant increases in FEV1, FEV1/FVC ratio, PEF, and FEF25-75% occurred only in the BSG. There were also significant increases in Ve and Vt in the BSG, but not when compared with the CG values at discharge. MIP and MEP significantly increased in both groups, with a greater effect on the BSG. There was a significant decrease in RR, as well as a significant increase in SpO2 only in the BSG. SpO2 acutely increased after BS; however, no changes were observed in the degree of dyspnea, vital signs, or signs of respiratory distress, and no gastrointestinal and hemodynamic repercussions were observed.
CONCLUSIONS
BS has proven to be safe and effective for recovering pulmonary function; improving lung volumes, maximum respiratory pressures, and peripheral oxygenation; and reducing respiratory work during the postoperative period after upper abdominal surgery.
Topics: Dyspnea; Humans; Lung; Lung Volume Measurements; Postoperative Complications; Postoperative Period
PubMed: 35293484
DOI: 10.36416/1806-3756/e20210280 -
Anaesthesia Jan 2020Enhanced postoperative recovery programmes (ERAS) were developed about 20 years ago based on improved understanding of the pathophysiology of postoperative recovery... (Review)
Review
Enhanced postoperative recovery programmes (ERAS) were developed about 20 years ago based on improved understanding of the pathophysiology of postoperative recovery within an integrated multidisciplinary approach. The results across surgical procedures have been extremely positive with a reduction in hospitalisation and medical complications, without increased re-admission rates. However, several challenges lie ahead including improved implementation of existing scientific evidence, increased focus on post-discharge recovery problems and a need for improved design of future ERAS studies. However, the most important challenges lie within a better understanding and control of undesirable peri-operative pathophysiological responses with subsequent risk of organ dysfunction. These efforts should focus on: the inflammatory and neurohumoral surgical stress responses; fluid management; pain management; blood management; mechanisms of orthostatic intolerance; postoperative cognitive dysfunction; risk factors for thrombo-embolic complications; and mechanisms and prevention of postoperative ileus. Finally, more focus should be made on the different barriers to post-discharge functional recovery and the choice of (pre- and postoperative) rehabilitation. These efforts should be made on a procedure-specific as well as on a patient-specific basis.
Topics: Humans; Postoperative Complications; Postoperative Period; Recovery of Function
PubMed: 31903577
DOI: 10.1111/anae.14860 -
Cleveland Clinic Journal of Medicine Apr 2021Several studies published in the last year have shed light on the preoperative assessment of perioperative cardiovascular risk and on the need for anticoagulation in... (Review)
Review
Several studies published in the last year have shed light on the preoperative assessment of perioperative cardiovascular risk and on the need for anticoagulation in patients with postoperative atrial fibrillation, which are reviewed here.
Topics: Atrial Fibrillation; Heart; Humans; Perioperative Care; Postoperative Complications; Postoperative Period
PubMed: 33795245
DOI: 10.3949/ccjm.88a.21014 -
Critical Care (London, England) Apr 2022The transcapillary leakage of albumin is increased by inflammation and major surgery, but whether exogenous albumin also disappears faster is unclear. (Review)
Review
BACKGROUND
The transcapillary leakage of albumin is increased by inflammation and major surgery, but whether exogenous albumin also disappears faster is unclear.
METHODS
An intravenous infusion of 3 mL/kg of 20% albumin was given over 30 min to 70 subjects consisting of 15 healthy volunteers, 15 post-burn patients, 15 patients who underwent surgery with minor bleeding, 10 who underwent surgery with major bleeding (mean, 1.1 L) and 15 postoperative patients. Blood Hb and plasma albumin were measured on 15 occasions over 5 h. The rate of albumin disappearance from the plasma was quantitated with population kinetic methodology and reported as the half-life (T).
RESULTS
No differences were observed for T between volunteers, post-burn patients, patients who underwent surgery with minor bleeding and postoperative patients. The T averaged 16.2 h, which corresponds to 3.8% of the amount infused per h. Two groups showed plasma concentrations of C-reactive protein of approximately 60 mg/L and still had a similarly long T for albumin. By contrast, patients undergoing surgery associated with major hemorrhage had a shorter T, corresponding to 15% of the infused albumin per h. In addition, our analyses show that the T differ greatly depending on whether the calculations consider plasma volume changes and blood losses.
CONCLUSION
The disappearance rate of the albumin in 20% preparations was low in volunteers, in patients with moderately severe inflammation, and in postoperative patients.
Topics: Humans; Inflammation; Infusions, Intravenous; Plasma Volume; Postoperative Period; Serum Albumin
PubMed: 35410365
DOI: 10.1186/s13054-022-03979-1 -
BMJ Open Jul 2022A gap between clinical practice and evidence is common. The present multicentre study was designed to explore the actual postoperative fasting practice, including the...
OBJECTIVE
A gap between clinical practice and evidence is common. The present multicentre study was designed to explore the actual postoperative fasting practice, including the instructed fasting time from the ward staff and the actual postoperative fasting time.
DESIGN
Multicentre survey.
SETTING
Four tertiary hospitals in Shenzhen City, China.
PARTICIPANTS
A total of 988 patients completed a survey on instructed and actual postoperative fasting.
OUTCOMES
All patients received postoperative instructed fasting time from the ward staff. The median instructed fasting time for fluids from ward staff was 6 hours (IQR, 4-6 hours), and the median instructed fasting time for solid food was also 6 hours (IQR 5-6 hours) after surgery. The actual postoperative fasting time, including fluid and solid food intake, was significantly longer than the time recommended by the ward staff (both p<0.001).
RESULTS
The median time to postoperative first flatus (FFL) was 16.5 hours (IQR 8-25.5 hours), and the median time to postoperative first faeces (FFE) was 41 hours (IQR 25-57 hours). The fasting time was significantly shorter than the time to FFL and the time to FFE, regardless of surgery type or anaesthesia type (all p<0.001). Postoperative nausea and vomiting (PONV) occurred in 23.6% of patients. After surgery, 58.70% of patients reported thirst, and 47.47% reported hunger. No ileus occurred.
CONCLUSION
Approximately half of the patients reported thirst and hunger postoperatively. Patients initiated oral intake earlier than the time to FFL or FFE without increasing serious complications. This study may support the rationale for interventions targeting postoperative oral intake time in future studies.
Topics: Fasting; Humans; Hunger; Postoperative Period; Thirst; Time Factors
PubMed: 35803620
DOI: 10.1136/bmjopen-2021-060716 -
Current Oncology (Toronto, Ont.) Jan 2022Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement program that started in colorectal surgery and has now expanded to numerous specialties,... (Review)
Review
Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement program that started in colorectal surgery and has now expanded to numerous specialties, including gynecologic oncology. ERAS guidelines comprise multidisciplinary, evidence-based recommendations in the preoperative, intraoperative, and postoperative period; these interventions broadly encompass patient education, anesthetic choice, multimodal pain control, avoidance of unnecessary drains, maintenance of nutrition, and prevention of emesis. Implementation of ERAS has been shown to be associated with improved clinical outcomes (length of hospital stay, complications, readmissions) and cost. Marx and colleagues first demonstrated the feasibility of ERAS in gynecologic oncology in 2003; since then, over 30 comparative studies and 4 guidelines have been published encompassing major gynecologic surgery, cytoreductive surgery, and vulvar/vaginal surgery. Implementation of ERAS in gynecologic oncology has been demonstrated to provide improvements in length of stay, complications, cost, opioid use, and patient satisfaction. Increased compliance with ERAS guidelines has been associated with greater improvement in outcomes.
Topics: Enhanced Recovery After Surgery; Female; Genital Neoplasms, Female; Gynecologic Surgical Procedures; Humans; Length of Stay; Postoperative Period
PubMed: 35200556
DOI: 10.3390/curroncol29020056 -
European Urology Focus Jan 2024Surgeons must adopt multidisciplinary, evidence-based approaches to preoperative care for radical cystectomy to optimize outcomes. Implementation of early recovery after...
Surgeons must adopt multidisciplinary, evidence-based approaches to preoperative care for radical cystectomy to optimize outcomes. Implementation of early recovery after surgery protocols and individualized prehabilitation plans is crucial for reducing perioperative risks and enhancing postoperative quality of life.
Topics: Humans; Quality of Life; Preoperative Exercise; Preoperative Care; Cystectomy; Postoperative Period
PubMed: 37872082
DOI: 10.1016/j.euf.2023.10.013 -
Blood Advances Feb 2020Identifying the cause(s) of postoperative thrombocytopenia is challenging. The postoperative period includes numerous interventions, including fluid administration and...
Identifying the cause(s) of postoperative thrombocytopenia is challenging. The postoperative period includes numerous interventions, including fluid administration and transfusion of blood products, medication use (including heparin), and increased risk of organ dysfunction and infection. Understanding normal thrombopoietin physiology and the associated expected postoperative platelet count changes is the crucial first step in evaluation. Timing of thrombocytopenia is the most important feature when differentiating causes of postoperative thrombocytopenia. Thrombocytopenia within 4 days of surgery is commonly caused by hemodilution and increased perioperative platelet consumption prior to thrombopoietin-induced platelet count recovery and transient platelet count overshoot. A much broader list of possible conditions that can cause late-onset thrombocytopenia (postoperative day 5 [POD5] or later) is generally divided into consumptive and destructive causes. The former includes common (eg, infection-associated disseminated intravascular coagulation) and rare (eg, postoperative thrombotic thrombocytopenic purpura) conditions, whereas the latter includes such entities as drug-induced immune thrombocytopenia or posttransfusion purpura. Heparin-induced thrombocytopenia is a unique entity associated with thrombosis that is typically related to intraoperative/perioperative heparin exposure, although it can develop following knee replacement surgery even in the absence of heparin exposure. Very late onset (POD10 or later) of thrombocytopenia can indicate bacterial or fungal infection. Lastly, thrombocytopenia after mechanical device implantation requires unique considerations. Understanding the timing and severity of postoperative thrombocytopenia provides a practical approach to a common and challenging consultation.
Topics: Anemia; Disseminated Intravascular Coagulation; Heparin; Humans; Platelet Count; Postoperative Period
PubMed: 32097460
DOI: 10.1182/bloodadvances.2019001414