Framework, component, and implementation of enhanced recovery pathways.

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss 'special cases' in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Efficacy of palonosetron-dexamethasone combination compared to palonosetron alone for prophylaxis against postoperative nausea and vomiting.

OBJECTIVES: Postoperative nausea and vomiting (PONV) is a common complication following surgery, and may be one of the most distressing parts of the surgical journey. With combination pharmacological therapy recommended for PONV prophylaxis, this systematic review and meta-analysis evaluates whether perioperative palonosetron and dexamethasone is more efficacious than palonosetron administered alone. METHODS: We searched CENTRAL; EMBASE; CINAHL; Google Scholar; Web of Science citation index; the US clinical trials register; UK clinical trials register; Australia and New Zealand Clinical trials register; and conference abstracts for major anaesthesia conferences in the last three years.We included randomized controlled trials that compared adult patients undergoing surgery who received palonosetron and dexamethasone, against those who received palonosetron. RESULTS: A total of 12 studies (1152 patients) were included. Medium-grade evidence showed that the palonosetron and dexamethasone combination significantly reduced 24-hour rescue anti-emetic requirement (RR: 0.59, 95% confidence interval (CI): 0.41-0.86). There was however no significant difference in the 6-hour (RR: 0.82, 95% CI: 0.61-1.09) and 24-hour PONV incidences (RR: 0.60, 95% CI: 0.33-1.10). Similarly, PONV incidences after 24 h did not differ between groups (RR:0.82, 95% CI: 0.59-1.14). Headache and dizziness were the most common side-effects reported. CONCLUSIONS: Combination prophylaxis with palonosetron and dexamethasone reduces post-operative anti-emetic requirement, although is not associated with a significant difference in PONV. There was considerable heterogeneity in the studies, and trial sequential analysis indicates that further studies are needed to strengthen the clinical evidence.

Risk factors for excessive tidal volumes delivered during intraoperative mechanical ventilation, a retrospective study.

BACKGROUND: Lung Protective Ventilation (LPV) refers to a combination of measures aimed at reducing ventilator-associated lung injury. This includes: delivering tidal volumes of 6-8 ml/kg of ideal body weight, use of positive end expiratory pressure and recruitment maneuvers. With Postoperative Pulmonary Complications (PPCs) contributing towards significant morbidity and mortality following surgery, evidence indicates that effective use of LPV measures intraoperatively has been associated with reduced rates of PPCs. METHODS: We conducted a post-hoc analysis using data from a recent clinical audit on departmental ventilation practices. Potential risk factors for excessive tidal volume ventilation were assessed using univariable and multivariable regression models. RESULTS: Obesity and gender are independently associated with risk of excessive ventilation. In contrast, the urgency and length of surgery, the choice of airway devices and the mode of ventilation were not associated with excessive ventilation. CONCLUSION: There is an association between female gender, obesity and excessive tidal volume ventilation. This may be addressed through formal, protocolized intraoperative ventilation setting.