Surgery school-who, what, when, and how: results of a national survey of multidisciplinary teams delivering group preoperative education.

BACKGROUND: Group education is increasing in popularity as a means of preparing patients for surgery. In recent years, these 'surgery schools' have evolved from primarily informing patients of what to expect before and after surgery, to providing support and encouragement for patients to 'prehabilitate' prior to surgery, through improving physical fitness, nutrition and emotional wellbeing. METHOD: A survey aimed at clinicians delivering surgery schools was employed to capture a national overview of activity to establish research and practice priorities in this area. The survey was circulated online via the Enhanced Recovery after Surgery UK Society and the Centre for Perioperative Care mailing lists as well as social media. RESULTS: There were 80 responses describing 28 active and 4 planned surgery schools across the UK and Ireland. Schools were designed and delivered by multidisciplinary teams, contained broadly similar content and were well attended. Most were funded by the National Health Service. The majority included aspects of prehabilitation most commonly the importance of physical fitness. Seventy five percent of teams collected patient outcome data, but less than half collected data to establish the clinical effectiveness of the school. Few describe explicit inclusion of evidence-based behavior change techniques, but collaboration and partnerships with community teams, gyms and local charities were considered important in supporting patients to make changes in health behaviors prior to surgery. CONCLUSION: It is recommended that teams work with patients when designing surgery schools and use evidence-based behavior change frameworks and techniques to inform their content. There is a need for high-quality research studies to determine the clinical effectiveness of this type of education intervention.

Impact of a peri-operative quality improvement programme on postoperative pulmonary complications.

Postoperative pulmonary complications are common, with a reported incidence of 2-40%, and are associated with adverse outcomes that include death, longer hospital stay and reduced long-term survival. Enhanced recovery is now a standard of care for patients undergoing elective major surgery. Despite the high prevalence of pulmonary complications in this population, few elements of enhanced recovery specifically address reducing these complications. In 2013, a prevalence audit confirmed a postoperative pulmonary complication rate of 16/83 (19.3%) in patients undergoing elective major surgery who were admitted to critical care postoperatively. A quality improvement team developed and implemented ERAS+, an innovative model of peri-operative care combining elements of enhanced recovery with specific measures aimed at reducing pulmonary complications. ERAS+ was introduced in June 2014, with full implementation in September 2014. Patients were screened during full ERAS+ implementation and again one year following implementation. Following ERAS+ implementation, postoperative pulmonary complications reduced to 24/228 (10.5%). Sustained improvement was evident one year after implementation, with a pulmonary complication rate of 16/183 (8.7%). Median (IQR [range]) length of hospital stay one year after implementation of ERAS+ also improved from 12 (9-15 [4-101]) to 9 (5.5-10.5 [3-81]) days. The ERAS+ pathway is applicable to patients undergoing elective major surgery and appears effective in reducing postoperative pulmonary complications.

Feasibility and impact of a structured, exercise-based rehabilitation programme for intensive care survivors.

Our objective was to assess the impact of an outpatient physiotherapy-led rehabilitation programme on exercise capacity and anxiety and depression scores in a cohort of adult intensive care survivors. In a prospective study in a teaching hospital, 38 general intensive care survivors following hospital discharge underwent an established physiotherapy-led outpatient rehabilitation programme. The programme involved 2 hours of supervised exercise and education sessions each week and two unsupervised exercise sessions each week for 6 weeks. Assessments took place 1 week before and 1 week after completing the programme. Primary outcome measures were changes in exercise capacity measured using the 6-minute walk test (6MWT) and incremental shuttle walk test (ISWT). Secondary outcome measures were changes in anxiety and depression scores using the Hospital Anxiety and Depression Scale (HADS). Median distance covered in the 6MWT improved by 160 metres (p<0.001), and median distance covered in the ISWT also improved by 160 metres (p < 0.001). Significant improvement in anxiety (p = 0.001) and depression (p = 0.001) scores were also seen. Outpatient, physiotherapy-lead rehabilitation appears to improve both exercise capacity and anxiety and depression scores in a cohort of intensive care survivors. A similar programme should be tested in a randomised controlled trial.

The effect of electromagnetic interference from mobile communication on the performance of intensive care ventilators.

UNLABELLED: Electromagnetic interference produced by wireless communication can affect medical devices and hospital policies exist to address this risk. During the transfer of ventilated patients, these policies may be compromised by essential communication between base and receiving hospitals. Local wireless networks (e.g. Bluetooth) may reduce the 'spaghetti syndrome' of wires and cables seen on intensive care units, but also generate electromagnetic interference. The aim of this study was to investigate these effects on displayed and actual ventilator performance. METHODS: Five ventilators were tested: Drager Oxylog 2000, BREAS LTV-1000, Respironics BiPAP VISION, Puritan Bennett 7200 and 840. Electromagnetic interference was generated by three devices: Simoco 8020 radio handset, Nokia 7210 and Nokia 6230 mobile phone, Nokia 6230 communicating via Bluetooth with a Palm Tungsten T Personal Digital Assistant. We followed the American National Standard Recommended Practice for On-Site, Ad Hoc Testing (ANSI C63) for electromagnetic interference. We used a ventilator tester, to simulate healthy adult lungs and measure ventilator performance. The communication device under test was moved in towards each ventilator from a distance of 1 m in six axes. Alarms or error codes on the ventilator were recorded, as was ventilator performance. RESULTS: All ventilators tested, except for the Respironics VISION, showed a display error when subjected to electromagnetic interference from the Nokia phones and Simoco radio. Ventilator performance was only affected by the radio which caused the Puritan Bennett 840 to stop functioning completely. The transfer ventilators' performance were not affected by radio or mobile phone, although the mobile phone did trigger a low-power alarm. Effects on intensive care ventilators included display reset, with the ventilator restoring normal display function within 2 s, and low-power/low-pressure alarms. Bluetooth transmission had no effect on the function of all the ventilators tested. CONCLUSION: In a clinical setting, high-power-output devices such as a two-way radio may cause significant interference in ventilator function. Medium-power-output devices such as mobile phones may cause minor alarm triggers. Low-power-output devices such as Bluetooth appear to cause no interference with ventilator function.

The effects of tracheostomy cuff deflation during continuous positive airway pressure.

Continuous flow positive pressure devices bridge the gap between mechanical and unsupported ventilation in patients recovering from critical illness. At this point, patients are often fully awake, yet the inflated tracheostomy cuff prevents them from speaking or swallowing. The aim of this study was to investigate the effects of cuff deflation. After ethics committee approval and informed consent, we recorded airway pressures with catheters placed 3 cm beyond the distal tracheostomy tip, respiratory rate, heart rate and peripheral oxygen saturation with continuous positive airway pressures set at 5, 7.5 and 10 cmH(2)O with the cuff inflated and deflated. Sixteen patients completed the study. There were small falls in end expiratory pressure on cuff deflation. The median (interquartile range) pressure drop with set airway pressure of 5 cmH(2)O was 0.25 (0-1.4) mmHg, which increased to 1 (0-3) mmHg at 7.5 cmH(2)O and 1.5 (0-4) mmHg at 10 cmH(2)O. These changes were not clinically significant and cardiopulmonary parameters remained stable. All patients were able to vocalise following cuff deflation. Twelve patients passed a blue dye swallow screen within a day of tolerating cuff deflation. These results suggest that pressures fall slightly following cuff deflation but this is associated with respiratory stability and may allow patients to talk and swallow.

Target-controlled propofol requirements at induction of anaesthesia: effect of remifentanil and midazolam.

BACKGROUND AND OBJECTIVE: Target-controlled infusions of anaesthetic agents have become increasingly available. They can involve the use of propofol in combination with an opioid or a benzodiazepine. The effect site concentration of propofol infusions has been advocated as a method of estimating drug distribution. We investigated the influence of co-induction with remifentanil and midazolam on effect site propofol requirements at induction of anaesthesia using target-controlled infusions. METHODS: Sixty-six consenting adult patients were randomly allocated to three treatment groups. Each group received induction of anaesthesia with a different total intravenous technique. One group was induced with target-controlled propofol alone; another received target-controlled propofol and target-controlled remifentanil (3 ng mL-1); and the last received midazolam (0.03 mg kg-1), target-controlled remifentanil (3 ng mL-1) and target-controlled propofol. Computer simulation was used to calculate effect site concentrations. We recorded propofol dose and effect site concentration at loss of verbal response. RESULTS: The effect site concentration (Ce50) of propofol alone was 2.19 micrograms mL-1. This was reduced to 1.55 micrograms mL-1 during co-induction with remifentanil and further reduced to 0.64 microgram mL-1 with midazolam premedication (P < 0.001; ANOVA). CONCLUSIONS: We conclude that co-induction with remifentanil alone or with midazolam can be used to reduce propofol doses at induction of anaesthesia using target-controlled infusions. We believe that using effect site concentration may prove a useful tool in routine clinical practice.

Randomised controlled trial investigating the influence of intravenous fluid titration using oesophageal Doppler monitoring during bowel surgery.

Oesophageal Doppler monitoring allows non-invasive estimation of stroke volume and cardiac output. We studied the impact of Doppler guided fluid optimisation on haemodynamic parameters, peri-operative morbidity and hospital stay in patients undergoing major bowel surgery. Fifty-seven patients were randomly assigned to Doppler (D) or control (C) groups. All patients received intra-operative fluid therapy at the discretion of the non-investigating anaesthetist. In addition, Group D were given fluid challenges (3 ml x kg(-1)) guided by oesophageal Doppler. Group D received significantly more intra-operative colloid than Group C (mean 28 (SD 16) vs. 19.4 (SD 14.7) ml x kg(-1), p = 0.02). Cardiac output increased significantly for Group D whilst that of controls remained unchanged. The mean difference between the groups in final cardiac output was 0.87 l x min(-1) (95% confidence interval 0.31-1.43 l x min(-1), p = 0.003). Five control patients required postoperative critical care admission. Fluid titration using oesophageal Doppler during bowel surgery can improve haemodynamic parameters and may reduce critical care admissions postoperatively.

Truncus arteriosus and other lethal internal anomalies in Goltz syndrome.

An infant girl of 36 weeks gestational age was found to have cardiovascular and other lethal internal anomalies in addition to characteristic external abnormalities of focal dermal hypoplasia (Goltz syndrome). The internal anomalies included truncus arteriosus type II with truncal origin of hypoplastic pulmonary arteries, cardiac ventricular septal defect, severe hypoplasia of lungs and pulmonary veins, massive diaphragmatic hernia, and absence of the right kidney. Such a combination of severe anomalies has not been reported previously in Goltz syndrome.

Hippocampal place units in the freely moving rat: why they fire where they fire.

Place units in the dorsal hippocampus of the freely-moving rat signal the animal's position in an environment (place field). In the present experiments, thirty four place units were recorded in two different environments: one, a small platform where the rat had received neither training nor reward; the other, an elevated T-maze inside a set of black curtains where the rat had been trained on a place discrimination. The places within the curtained enclosure were specified by four cues (a light, a card, a fan, and a buzzer) in addition to the food. Other cues were eliminated by rotating the maze and the four controlled cues relative to the external world from trial-to-trial. Some units had place fields in both environments while others only had a place field in one. No relationship could be seen between the place fields of units with fields in both environments. All twelve units tested extensively in the controlled enclosure had place fields related to the controlled cues. Probe experiments in which only some of the controlled cues were available showed that some of these units were being excited by one or two cues while others were influenced in a more complex way. The fields of these latter units were maintained by any two of the 4 cues and were due to inhibitory influences which suppressed the unit firing over the rest of the maze.