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International Journal of Nursing Studies Feb 2020The increasing numbers of surgeries involving high risk, multi-morbid patients, coupled with inconsistencies in the practice of perioperative surgical wound care,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The increasing numbers of surgeries involving high risk, multi-morbid patients, coupled with inconsistencies in the practice of perioperative surgical wound care, increases patients' risk of surgical site infection and other wound complications.
OBJECTIVES
To synthesise and evaluate the recommendations for nursing practice and research from published systematic reviews in the Cochrane Library on nurse-led preoperative prophylaxis and postoperative surgical wound care interventions used or initiated by nurses.
DESIGN
Meta-review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
DATA SOURCES
The Cochrane Library database.
REVIEW METHODS
All Cochrane Systematic Reviews were eligible. Two reviewers independently selected the reviews and extracted data. One reviewer appraised the methodological quality of the included reviews using A MeaSurement Tool to Assess Systematic Reviews 2 checklist. A second reviewer independently verified these appraisals. The review protocol was registered with the Prospective Register of Systematic Reviews.
RESULTS
Twenty-two Cochrane reviews met the inclusion criteria. Of these, 11 reviews focused on preoperative interventions to prevent infection, while 12 focused on postoperative interventions (one review assessed both pre-postoperative interventions). Across all reviews, 14 (63.6%) made at least one recommendation to undertake a specific practice, while two reviews (9.1%) made at least one specific recommendation not to undertake a practice. In relation to recommendations for further research, insufficient sample size was the most predominant methodological issue (12/22) identified across reviews.
CONCLUSIONS
The limited number of recommendations for pre-and-postoperative interventions reflects the paucity of high-quality evidence, suggesting a need for rigorous trials to address these evidence gaps in fundamentals of nursing care.
Topics: Humans; Postoperative Care; Preoperative Care; Surgical Wound; Surgical Wound Infection
PubMed: 31810020
DOI: 10.1016/j.ijnurstu.2019.103486 -
Physical Therapy Aug 2020A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of...
A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.
Topics: Arthroplasty, Replacement, Knee; Cryotherapy; Electric Stimulation Therapy; Exercise; Humans; Motion Therapy, Continuous Passive; Movement; Osteoarthritis, Knee; Patient Discharge; Peer Review; Physical Therapists; Postoperative Care; Preoperative Care; Prognosis; Quality Improvement; Range of Motion, Articular; Resistance Training; Risk Factors
PubMed: 32542403
DOI: 10.1093/ptj/pzaa099 -
Lancet (London, England) May 2014Individual participant data meta-analyses of postoperative chemotherapy have shown improved survival for patients with non-small-cell lung cancer (NSCLC). We aimed to do... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Individual participant data meta-analyses of postoperative chemotherapy have shown improved survival for patients with non-small-cell lung cancer (NSCLC). We aimed to do a systematic review and individual participant data meta-analysis to establish the effect of preoperative chemotherapy for patients with resectable NSCLC.
METHODS
We systematically searched for trials that started after January, 1965. Updated individual participant data were centrally collected, checked, and analysed. Results from individual randomised controlled trials (both published and unpublished) were combined using a two-stage fixed-effect model. Our primary outcome, overall survival, was defined as the time from randomisation until death (any cause), with living patients censored on the date of last follow-up. Secondary outcomes were recurrence-free survival, time to locoregional and distant recurrence, cause-specific survival, complete and overall resection rates, and postoperative mortality. Prespecified analyses explored any variation in effect by trial and patient characteristics. All analyses were by intention to treat.
FINDINGS
Analyses of 15 randomised controlled trials (2385 patients) showed a significant benefit of preoperative chemotherapy on survival (hazard ratio [HR] 0·87, 95% CI 0·78-0·96, p=0·007), a 13% reduction in the relative risk of death (no evidence of a difference between trials; p=0·18, I(2)=25%). This finding represents an absolute survival improvement of 5% at 5 years, from 40% to 45%. There was no clear evidence of a difference in the effect on survival by chemotherapy regimen or scheduling, number of drugs, platinum agent used, or whether postoperative radiotherapy was given. There was no clear evidence that particular types of patient defined by age, sex, performance status, histology, or clinical stage benefited more or less from preoperative chemotherapy. Recurrence-free survival (HR 0·85, 95% CI 0·76-0·94, p=0·002) and time to distant recurrence (0·69, 0·58-0·82, p<0·0001) results were both significantly in favour of preoperative chemotherapy although most patients included were stage IB-IIIA. Results for time to locoregional recurrence (0·88, 0·73-1·07, p=0·20), although in favour of preoperative chemotherapy, were not statistically significant.
INTERPRETATION
Findings, which are based on 92% of all patients who were randomised, and mainly stage IB-IIIA, show preoperative chemotherapy significantly improves overall survival, time to distant recurrence, and recurrence-free survival in resectable NSCLC. The findings suggest this is a valid treatment option for most of these patients. Toxic effects could not be assessed.
FUNDING
Medical Research Council UK.
Topics: Adult; Aged; Antineoplastic Combined Chemotherapy Protocols; Carcinoma, Non-Small-Cell Lung; Female; Humans; Kaplan-Meier Estimate; Lung Neoplasms; Male; Middle Aged; Neoplasm Recurrence, Local; Preoperative Care; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 24576776
DOI: 10.1016/S0140-6736(13)62159-5 -
JAMA Network Open Feb 2021Preoperative and postoperative exercise interventions are commonly used in patients with total hip arthroplasty despite a lack of established efficacy. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Preoperative and postoperative exercise interventions are commonly used in patients with total hip arthroplasty despite a lack of established efficacy.
OBJECTIVE
To explore clinical outcomes associated with exercise training before and after hip arthroplasty.
DATA SOURCES
PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Google Scholar were searched from their inception to March 2020. Reference lists of included trials and related reviews were also searched.
STUDY SELECTION
Randomized clinical trials of land-based exercise interventions before or after total hip arthroplasty were included.
DATA EXTRACTION AND SYNTHESIS
This systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was independently performed in duplicate. Random-effects meta-analyses with restricted maximum likelihood were performed for pooling the data.
MAIN OUTCOMES AND MEASURES
The primary prespecified outcome was self-reported physical function. Secondary prespecified outcomes were self-reported pain intensity, quality of life, gait speed, lower body muscle strength, lower body flexibility, anxiety, hospital length of stay, and adverse events.
RESULTS
A total of 32 randomized clinical trials with 1753 patients were included in the qualitative synthesis, and 26 studies with 1004 patients were included in the meta-analysis. Compared with usual care or no or minimal intervention, postoperative exercise training was not associated with improved self-reported physical function, with a moderate level of certainty, at 4 weeks (standardized mean difference [SMD], 0.01; 95% CI, -0.18 to 0.20), 12 weeks (SMD, -0.08; 95% CI, -0.23 to 0.07) and 26 weeks (SMD, -0.04; 95% CI, -0.31 to 0.24) postoperatively, and low level of certainty at 1 year after surgical treatment (SMD, 0.01; 95% CI, -0.09 to 0.12). For preoperative exercise interventions, there was no association of exercised training with self-reported physical function compared with the control at the 12-week (SMD, -0.14; 95% CI, -0.61 to 0.32) or 1-year follow-ups (SMD, 0.01; 95% CI, -0.37 to 0.40) with very low certainty, and no association with length of stay (mean difference, -0.21; 95% CI, -0.74 to 0.31) at moderate certainty. Results for postoperative hip muscle strength were rated at very low certainty, with no statistical significance. Meta-analysis could not be performed for other outcomes.
CONCLUSIONS AND RELEVANCE
This systematic review and meta-analysis found low- to moderate-quality evidence that postoperative exercise interventions were not associated with improved self-reported physical function compared with usual care or no or minimal intervention. Furthermore, there was very low-quality evidence that preoperative exercise programs were not associated with higher self-reported physical function and hospital length of stay compared with usual care or no or minimal intervention.
Topics: Anxiety; Arthroplasty, Replacement, Hip; Exercise Therapy; Humans; Length of Stay; Muscle Strength; Osteoarthritis, Hip; Pain; Physical Functional Performance; Postoperative Care; Postoperative Complications; Preoperative Exercise; Quality of Life; Range of Motion, Articular; Walking Speed
PubMed: 33635329
DOI: 10.1001/jamanetworkopen.2021.0254 -
JAMA Otolaryngology-- Head & Neck... Mar 2017Head and neck cancers often require complex, labor-intensive surgeries, especially when free flap reconstruction is required. Enhanced recovery is important in this... (Review)
Review
Optimal Perioperative Care in Major Head and Neck Cancer Surgery With Free Flap Reconstruction: A Consensus Review and Recommendations From the Enhanced Recovery After Surgery Society.
IMPORTANCE
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.
OBJECTIVE
To provide a consensus-based protocol for optimal perioperative care of patients undergoing head and neck cancer surgery with free flap reconstruction.
EVIDENCE REVIEW
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.
FINDINGS
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 care of patients undergoing major head and neck cancer surgery with free flap reconstruction. Best practice includes several elements of perioperative care. Among these elements are the provision of preoperative carbohydrate treatment, pharmacologic thromboprophylaxis, perioperative antibiotics in clean-contaminated procedures, corticosteroid and antiemetic medications, short acting anxiolytics, goal-directed fluid management, opioid-sparing multimodal analgesia, frequent flap monitoring, early mobilization, and the avoidance of preoperative fasting.
CONCLUSIONS AND RELEVANCE
The evidence base for specific perioperative care elements in head and neck cancer surgery is variable and in many cases information from different surgerical procedures form the basis for these recommendations. Clinical evaluation of these recommendations is a logical next step and further research in this patient population is warranted.
Topics: Free Tissue Flaps; Head and Neck Neoplasms; Humans; Nutritional Support; Patient Education as Topic; Perioperative Care; Plastic Surgery Procedures
PubMed: 27737447
DOI: 10.1001/jamaoto.2016.2981 -
Journal of Clinical Nursing Dec 2022Games are increasingly being used as a means of alleviating pain and anxiety in paediatric patients, in the view that this form of distraction is effective, non-invasive... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Games are increasingly being used as a means of alleviating pain and anxiety in paediatric patients, in the view that this form of distraction is effective, non-invasive and non-pharmacological.
AIMS
To determine whether a game-based intervention (via gamification or virtual reality) during the induction of anaesthesia reduces preoperative pain and anxiety in paediatric patients.
METHODS
A systematic review with meta-analysis of randomised controlled trials was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using RevMan software. The review was based on a search of the EMBASE, CINAHL, Medline, SciELO and Scopus databases, conducted in July 2021. No restriction was placed on the year of publication.
RESULTS
26 studies were found, with a total study population of 2525 children. Regarding pain reduction, no significant differences were reported. For anxiety during anaesthesia induction, however, a mean difference of -10.62 (95% CI -13.85, -7.39) on the Modified Yale Preoperative Anxiety Scale, in favour of game-based intervention, was recorded.
CONCLUSIONS
Game-based interventions alleviate preoperative anxiety during the induction of anaesthesia in children. This innovative and pleasurable approach can be helpful in the care of paediatric surgical patients.
RELEVANCE TO CLINICAL PRACTICE
In children, preoperative management is a challenging task for healthcare professionals, and game-based strategies could enhance results, improving patients' emotional health and boosting post-surgery recovery. Distractive games-based procedures should be considered for incorporation in the pre-surgery clinical workflow in order to optimise healthcare.
Topics: Humans; Child; Anxiety; Anesthesia, General; Anxiety Disorders; Emotions; Pain
PubMed: 35075716
DOI: 10.1111/jocn.16227 -
British Journal of Anaesthesia Jul 2014Pulmonary aspiration of gastric content is a serious anaesthetic complication that can lead to significant morbidity and mortality. Aspiration risk assessment is usually... (Review)
Review
Pulmonary aspiration of gastric content is a serious anaesthetic complication that can lead to significant morbidity and mortality. Aspiration risk assessment is usually based on fasting times. However, fasting guidelines do not apply to urgent or emergent situations and to patients with certain co-morbidities. Gastric content and volume assessment is a new point-of-care ultrasound application that can help determine aspiration risk. This systematic review summarizes the current literature on bedside ultrasound assessment of gastric content and volume relevant to anaesthesia practice. Seventeen articles were identified using predetermined criteria. Studies were classified into those describing the sonographic characteristics of different types of gastric content (empty, clear fluid, solid), and those describing methods for quantitative assessment of gastric volume. A possible algorithm for the clinical application of this new tool is proposed, and areas that require further research are highlighted.
Topics: Algorithms; Anesthesia; Gastrointestinal Contents; Humans; Pneumonia, Aspiration; Point-of-Care Systems; Preoperative Care; Risk Assessment; Stomach; Ultrasonography
PubMed: 24893784
DOI: 10.1093/bja/aeu151 -
European Journal of Surgical Oncology :... Dec 2020Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by...
Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management.
BACKGROUND
Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.
METHODS
The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.
RESULTS
Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.
CONCLUSION
The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
Topics: Cytoreduction Surgical Procedures; Delphi Technique; Enhanced Recovery After Surgery; Humans; Hyperthermic Intraperitoneal Chemotherapy; Intraoperative Care; Perioperative Care; Peritoneal Neoplasms; Preoperative Care
PubMed: 32873454
DOI: 10.1016/j.ejso.2020.07.041 -
World Journal of Surgery Jan 2023Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present... (Review)
Review
BACKGROUND
Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.
METHODS
A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.
RESULTS
A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.
CONCLUSIONS
These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.
Topics: Humans; Enhanced Recovery After Surgery; Preoperative Exercise; Teaching Rounds; Liver
PubMed: 36310325
DOI: 10.1007/s00268-022-06732-5 -
JAMA Network Open Apr 2023Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Prehabilitation programs for patients undergoing orthopedic surgery have been gaining popularity in recent years. However, the current literature has produced varying results.
OBJECTIVE
To evaluate whether prehabilitation is associated with improved preoperative and postoperative outcomes compared with usual care for patients undergoing orthopedic surgery.
DATA SOURCES
Bibliographic databases (MEDLINE, CINAHL [Cumulative Index to Nursing and Allied Health Literature], AMED [Allied and Complementary Medicine], Embase, PEDRO [Physiotherapy Evidence Database], and Cochrane Central Register of Controlled Trials) were searched for published trials, and the Institute for Scientific Information Web of Science, System for Information on Grey Literature in Europe, and European clinical trials registry were searched for unpublished trials from January 1, 2000, to June 30, 2022.
STUDY SELECTION
Randomized clinical trials (RCTs) comparing prehabilitation with standard care for any orthopedic surgical procedure were included.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers screened trials. Data were pooled using a random-effects model. Recommendations were determined using the Grading of Recommendations Assessment, Development and Evaluation system and the study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline.
MAIN OUTCOMES AND MEASURES
Pain, function, muscle strength, and health-related quality of life (HRQOL).
RESULTS
Forty-eight unique trials involving 3570 unique participants (2196 women [61.5%]; mean [SD] age, 64.1 [9.1] years) were analyzed. Preoperatively, moderate-certainty evidence favoring prehabilitation was reported for patients undergoing total knee replacement (TKR) for function (standardized mean difference [SMD], -0.70 [95% CI, -1.08 to -0.32]) and muscle strength and flexion (SMD, 1.00 [95% CI, 0.23-1.77]) and for patients undergoing total hip replacement (THR) for HRQOL on the 36-item Short Form Health Survey (weighted mean difference [WMD], 7.35 [95% CI, 3.15-11.54]) and muscle strength and abduction (SMD, 1.03 [95% CI, 0.03-2.02]). High-certainty evidence was reported for patients undergoing lumbar surgery for back pain (WMD, -8.20 [95% CI, -8.85 to -7.55]) and moderate-certainty evidence for HRQOL (SMD, 0.46 [95% CI, 0.13-0.78]). Postoperatively, moderate-certainty evidence favoring prehabilitation was reported for function at 6 weeks in patients undergoing TKR (SMD, -0.51 [95% CI, -0.85 to -0.17]) and at 6 months in those undergoing lumbar surgery (SMD, -2.35 [95% CI, -3.92 to -0.79]). Other differences in outcomes favoring prehabilitation were of low to very low quality of evidence.
CONCLUSIONS AND RELEVANCE
In this systematic review and meta-analysis of RCTs, moderate-certainty evidence supported prehabilitation over usual care in improving preoperative function and strength in TKR and HRQOL and muscle strength in THR, high-certainty evidence in reducing back pain, and moderate-certainty evidence in improving HRQOL in lumbar surgery. Postoperatively, moderate-certainty evidence supported prehabilitation for function following TKR at 6 weeks and lumbar surgery at 6 months. Prehabilitation showed promising results for other outcomes, although high risk of bias and heterogeneity affected overall quality of evidence. Additional RCTs with a low risk of bias investigating preoperative and postoperative outcomes for all orthopedic surgical procedures are required.
Topics: Female; Humans; Middle Aged; Preoperative Exercise; Orthopedic Procedures; Quality of Life; Europe
PubMed: 37052919
DOI: 10.1001/jamanetworkopen.2023.8050