Evolution of Process and Outcome Measures during an Enhanced Recovery after Thoracic Surgery Program.

BACKGROUND: A time course analysis was undertaken to evaluate how perioperative process-of-care and outcome measures evolved after implementation of an enhanced recovery after thoracic surgery (ERATS) program. METHODS: Outcome and process-of-care measures were compared between patients undergoing major elective thoracic surgery during a 9-month pre-ERATS implementation period to those at 1-3, 4-6, and 7-9 months post-ERATS implementation. Outcome measures included length of stay, the 30-day readmission rate, 30-day emergency department visits, and minor and major adverse events. Process measures included first time to activity, out-of-bed, ambulation, fluid diet, diet as tolerated, as well as removal of the first and last chest tube, epidural, patient-controlled analgesia, and Foley and intravenous catheters. RESULTS: In total, 704 patients (352 pre-ERATS, 352 post-ERATS) were included. Mobilization-related process measures, including time to first activity (16.5 vs. 6.8 hours, p<0.001), out-of-bed (17.6 vs. 8.9 hours, p<0.001), and ambulation (32.4 vs. 25.4 hours, p=0.04) saw statistically significant improvements by 1-3 months post-ERATS implementation compared to pre-ERATS. Time to Foley removal improved by 4-6 months post-ERATS (19.5 vs. 18.2 hours, p=0.003). Outcome measures, including the 30-day readmission rate and emergency department visits, steadily decreased post-ERATS. By 7-9 months post-ERATS, both minor (18.2% vs. 7.9%, p=0.009) and major (13.6% vs. 4.4%, p=0.007) adverse events demonstrated statistically significant improvements. Length of stay trended towards improvement from 6.2 days pre-ERATS to 4.8 days by 7-9 months post-ERATS (p=0.06). CONCLUSION: The adoption of ERATS led to improvements in multiple process-of-care measures, which may collectively and gradually achieve optimization of clinical outcomes.

The longitudinal impact of division-wide implementation of an enhanced recovery after thoracic surgery programme.

OBJECTIVES: Data regarding enhanced recovery after thoracic surgery (ERATS) are sparse and inconsistent. This study aims to evaluate the effects of implementing an enhanced ERATS programme on postoperative outcomes, patient experience and quality of life (QOL). METHODS: We conducted a prospective, longitudinal study evaluating 9 months before (pre-ERATS) and 9 months after (post-ERATS) a 3-month implementation of an ERATS programme in a single academic tertiary care centre. All patients undergoing major thoracic surgeries were included. The primary outcomes included length of stay (LOS), adverse events (AEs), 6-min walk test scores at 4 weeks, 30-day emergency room visits (without admission) and 30-day readmissions. The process-of-care outcomes included time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and removal of urinary catheter. Perioperative anaesthesia-related outcomes were examined as well as patient experience and QOL scores. RESULTS: The pre-ERATS group (n = 352 patients) and post-ERATS group (n = 352) demonstrated no differences in demographics. Post-ERATS patients had improved LOS (4.7 vs 6.2 days, P < 0.02), 6-min walk test scores (402 vs 371 m, P < 0.05) and 30-day emergency room visits (13.7% vs 21.6%, P = 0.03) with no differences in AEs and 30-day readmissions. Patients experienced shorter mean time to 'out-of-bed', independent ambulation, successful fluid intake, last chest tube removal and urinary catheter removal. There were no differences in postoperative analgesia administration, patient satisfaction and QOL scores. CONCLUSIONS: ERATS implementation was associated with improved LOS, expedited feeding, ambulation and chest tube removal, without increasing AEs or readmissions, while maintaining a high level of patient satisfaction and QOL.

A case report of severe nasal ischemia from cold agglutinin disease and a novel treatment protocol including HBOT.

Cold agglutinin disease (CAD) is a rare condition leading to blood agglutination and autoimmune hemolytic anemia. Cutaneous ischemia resulting from CAD in the head and neck is uncommon. Treatment regimens and outcomes vary widely in the literature and no clear protocol exists. This manuscript describes a patient with CAD who developed severe ischemia of the nose that resolved completely without sequellae following a medical regimen of aspirin, low molecular weight heparin, nitroglycerin ointment and hyperbaric oxygen therapy (HBOT). To our knowledge, this is the first reported case where nitroglycerin ointment or HBOT was successfully employed in the treatment of this complication.

Pain management within an enhanced recovery program after thoracic surgery.

Evidence for ERAS within thoracic surgery (ERATS) is building. The key to enabling early recovery and ambulation is ensuring that postoperative pain is well controlled. Surgery on the chest is considered to be one of the most painful of surgical procedures for both open and minimally invasive surgery (MIS) approaches. Increasing use of MIS and improved perioperative care pathways has resulted in shorter length of stay (LOS), requiring patients to achieve optimal pain control earlier and meet discharge criteria sooner, sometimes on the same day as surgery. This requires optimizing pain control earlier in the postoperative recovery phase in order to enable ambulation and a better recovery profile, as well as to minimize the risk for development of chronic persistent postoperative pain (CPPP). This review will focus on the options for pain management protocols within an ERAS program for thoracic surgery patients (ERATS).

Early Discharge after Laparoscopic Hysterectomy: a Prospective Study.

OBJECTIVE: To evaluate the feasibility of same-day discharge after laparoscopic hysterectomy without excluding patients with complex surgical pathology and medical comorbidities. These factors are often considered potential barriers to early discharge, and the literature is lacking prospective trials addressing the feasibility of same-day discharge after laparoscopic hysterectomy in this patient population. METHODS: All women undergoing laparoscopic hysterectomy by a member of the minimally invasive gynaecology team at The Ottawa Hospital, a tertiary academic referral centre, from May 2013 to February 2015 were eligible to participate regardless of patient comorbidities or surgical complexity. Strict perioperative protocols are presented. Factors associated with decreased success of same-day discharge and baseline and postoperative quality of life surveys were analyzed. RESULTS: Fifty-three patients were included. Overall success of same day discharge was 83.0%. Average age and BMI were 44.4 years and 29.8 kg/m2, respectively. Thirty-four patients (63.0%) had at least one prior abdominal surgery. Those who had their surgery as first case of the day had a 91.7% same-day discharge rate versus 64.7% if they did not (relative risk = 1.4 [range 1.0-2.0]; P = 0.02). Ninety-eight percent of participants would recommend same-day discharge. Clinically significant improvement in quality of life from baseline was observed in 5 of 8 of the Short Form 36 domains at 6 months. CONCLUSION: Same-day discharge from hospital is reasonable and well accepted for patients undergoing laparoscopic hysterectomy, even with complex surgical pathology. The implementation of a successful same-day discharge program would mean greater efficiency, economic benefits, and improved access to surgical care for women.

Long-term patient outcomes from the first year of a robotic surgery program using multi-surgeon implementation.

INTRODUCTION: There is concern that surgical quality initially declines during the learning phase of robotic surgery. At our institution, we used a multi-surgeon programmatic approach to the introduction of robotic surgery. The purpose of this study was to evaluate outcomes of patients treated during the first year of our program. METHODS: This is a historical cohort of all radical prostatectomy patients during a one-year period. Baseline, perioperative, and long-term followup data were prospectively and retrospectively collected. Treatment failure was a composite of any postoperative radiation, androgen-deprivation, or prostate-specific antigen (PSA) ≥0.2. RESULTS: During the study period, 225 radical prostatectomy procedures were performed (104 robotic and 121 open). Baseline characteristics were similar between groups (p>0.05). All patients were continent and 74% were potent prior to surgery. Mean estimated blood loss (280 cc vs. 760 cc; p<0.001) and blood transfusion (0% vs. 8.3%; p=0.002) was lower in the robotic cohort. Non-transfusion complications were similar between groups (13% vs. 12%; p=0.7). Mean hospital stay was shorter in the robotic cohort (1.4 vs. 2.5 days). There was no difference in overall positive margin rate (38% vs. 43%; p=0.4) or treatment failure at a median followup of 3.5 years (p=0.4). Robotically treated patients were more often continent (89% vs. 77%; p=0.02) and potent (48% vs. 32%; p=0.02). CONCLUSIONS: Using an inclusive multi-surgeon approach, robotic pros-tatectomy was introduced safely at a Canadian academic institution.

Interactive Online Learning for Attending Physicians in Ultrasound-guided Central Venous Catheter Insertion.

Evidence has demonstrated that the use of dynamic ultrasound guidance (USG) for central venous catheter (CVC) significantly decreases attempts, failures, and complication rates. Despite national organizations recommending the use of USG and its increasing availability, USG is used inconsistently and non-uniformly. We sought to determine if an online training module for CVC insertion with ultrasound guidance will improve acquisition and long-term retention of knowledge and skills for attending physicians. Participants were tested for declarative knowledge and skills on a simulator (pre-test) for ultrasound-guided CVC insertion at baseline. They then completed an online learning module followed by an immediate post-test and a six-month retention test. There were 16 attending physicians who participated in the study. The CVC training module increased declarative knowledge acquisition and retention. No significant difference in simulated CVC performance was found over the three time points.

Transition from multiple port to single port video-assisted thoracoscopic anatomic pulmonary resection: early experience and comparison of perioperative outcomes.

BACKGROUND: Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches. METHODS: Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery. RESULTS: Over 12 months, 50 S-VATS procedures were completed by one surgeon and compared to an equal number of VATS patients. The groups were similar in age, gender, BMI, comorbidity, tumor size and pulmonary function. There was no statistically significant difference in operative time. All tumors were completely resected (R0) and the median number of lymph nodes evaluated pathologically was equivalent {S-VATS=7 [4-10]; VATS=7 [4-10]; P=0.92}. There was no significant difference in conversion rate {S-VATS=2 (4%); VATS=1 (2%); P=0.56}. The median length of stay was similar in both groups {S-VATS=4 [3-7]; VATS=4 [3-7]; P=0.99}. There was no mortality and no significant difference in the rate of major complications {S-VATS=10/50 [20%]; VATS=5/50 [10%]; P=0.26}. There was no difference in patient reported pain as measured by a visual analog scale at 24 hours {S-VATS=4 [2-5]; VATS=4 [3-5]; P=0.63}. CONCLUSIONS: Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required. Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis.

OBJECTIVE: Although ultrasound guidance for subclavian vein catheterization has been well described, evidence for its use has not been comprehensively appraised. Thus, we conducted a systematic review and meta-analysis to determine whether ultrasound guidance of subclavian vein catheterization reduces catheterization failures and adverse events compared to the traditional "blind" landmark method. All forms of ultrasound were included (dynamic 2D ultrasound, static 2D ultrasound, and Doppler). DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL (from inception to September 2014). STUDY SELECTION: Randomized controlled trials of ultrasound compared to landmark technique for subclavian catheterization in adult populations were considered. Outcomes of interest included safety and failure of catheterization. DATA EXTRACTION: Adverse event data were analyzed according to Peto's method and expressed as odd ratios and 95% CIs. Failure of catheterization was analyzed with inverse variance random effects modeling and expressed as risk ratios and 95% CI. DATA SYNTHESIS: Six hundred and one studies were reviewed and 10 met inclusion criteria (n = 2,168 participants). Six used dynamic 2D ultrasound (n = 719), one used static 2D ultrasound (n = 821), and three used Doppler-guided insertion techniques (n = 628). Overall complication rates were reduced with ultrasound use compared to the landmark group (odd ratio, 0.53; 95% CI, 0.41-0.69). Subgroup analysis demonstrated that dynamic 2D ultrasound reduced inadvertent arterial puncture, pneumothorax, and hematoma formation. No difference in failure of catheterization was noted between the ultrasound group and the landmark method (risk ratio, 0.85; 95% CI, 0.48-1.51). Subgroup analysis of dynamic 2D ultrasound demonstrated a significant decrease in failed catheterization (risk ratio, 0.24; 95% CI, 0.06-0.92). CONCLUSIONS: Ultrasound-guided subclavian catheterization reduced the frequency of adverse events compared with the landmark technique. Our findings support the use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse events and failed catheterization.

Failed videolaryngoscope intubation in a patient with diffuse idiopathic skeletal hyperostosis and spinal cord injury.

PURPOSE: A case of difficult intubation in a patient with cervical spinal cord injury with diffuse idiopathic skeletal hyperostosis (DISH) is described. The trachea could not be intubated with a videolaryngoscope, and successful intubation was achieved with a laryngeal mask airway device (LMAD) and a fibreoptic bronchoscope (FOB). CLINICAL FEATURES: A 65-yr-old male developed sudden tetraplegia after a fall. Initial attempts at securing his airway were unsuccessful with a videolaryngoscope, but success was achieved with a LMAD and a FOB. Diagnostic imaging revealed no cervical spine fracture but demonstrated severe airway distortion from DISH and a spinal cord contusion accounting for his tetraplegia. Subcutaneous neck emphysema likely secondary to difficult intubation was also identified, but it did not result in additional morbidity. CONCLUSIONS: Although often considered to be a benign entity, DISH can predispose patients to catastrophic cervical injury and difficult airway management. Careful review of plain radiographs in the spinal cord injury patient may assist with appropriate selection of airway interventions. The videolaryngoscope is useful for difficult airways, but its effectiveness may be compromised with an anteriorly displaced airway in combination with restricted cervical movement and limited oropharyngeal airspace.

Effectiveness of a novel training program for emergency medicine residents in ultrasound-guided insertion of central venous catheters.

OBJECTIVE: Insertion of central venous catheters (CVCs) is an essential competency for emergency physicians. Ultrasound-guided (USG) insertion of CVCs has been shown to be safer than the traditional landmark technique. There is no clear consensus on effective methods for training physicians in USG insertion of CVCs. We developed and evaluated a novel educational training program in the USG technique for insertion of CVCs. METHODS: Sixteen emergency medicine residents volunteered for a pre- and postprogram evaluation study, which was approved by our research ethics board. After their previous experience was determined, each participant was videotaped inserting a USG CVC in the right internal jugular vein on models. Participants then reviewed a Web-based instructional module and had a practical session. Participants were again videotaped inserting a USG CVC. The primary outcome was the change in score before and after the training program, using an expert-validated performance evaluation tool used to review the videotaped performances in a blinded fashion. Participants also completed a questionnaire to measure their satisfaction with the training program and any change in their perceived competence. RESULTS: Participants ranged from residency year 1 to 5. Thirteen of 16 (81%) had never attempted USG insertion of a CVC. Participants reported that the models were realistic. Performance scores (12/19 to 13.2/19) and global ratings assessments (3.5/7 to 5.5/7) improved significantly (p < 0.01; the effect size, Cohen d = 1.12 before and 1.28 after) after the instruction. There was good interrater reliability between evaluators of the videotaped performances regarding performance scores (r = 0.68) and global rating scores (r = 0.75). All participants felt their confidence and technical skills were improved (p < 0.01) and all felt satisfied with the training program. CONCLUSION: This brief innovative multimethod training program was effective in enhancing emergency medicine resident competence in USG insertion of CVCs.

The addition of adrenaline to thoracic epidural meperidine does not improve analgesia following thoracotomy.

PURPOSE: Patient-controlled epidural analgesia (PCEA) with meperidine provides effective analgesia following thoracotomy. Accumulation of normeperidine, a meperidine metabolite with neuroexcitatory effects, has led to recommendations to limit the use of meperidine postoperatively. The purpose of this study was to determine if the addition of adrenaline to PCEA meperidine decreased meperidine consumption, reduced serum normeperidine levels, and improved analgesia following thoracotomy. METHODS: Following Research Ethics approval consenting patients were randomly assigned to PCEA with either meperidine (2 mgxmL(-1)) + adrenaline (2 microgxmL(-1)) or meperidine alone (2 mgxmL(-1)). All patients received a standardized anesthetic and similar perioperative care. Visual analogue pain scores (at rest and with activity), quality of recovery (QoR) scores, and side effects were documented six, 24, and 48 hr postoperatively. Serum levels of meperidine and normeperidine were measured at the same time points. RESULTS: Forty-six patients completed the study protocol. Meperidine consumption (mean+/-SD) was similar in the meperidine + adrenaline and the meperidine groups (601+/-211 mg vs 580+/-211 mg over 48 hr, respectively; P=0.744). Serum meperidine levels were similar at all study time points. Serum normeperidine was not detected in any sample. Pain scores, QoR scores, and adverse events were comparable in both study groups. CONCLUSION: The addition of adrenaline did not influence PCEA meperidine consumption, analgesia outcomes, or QoR. Normeperidine did not accumulate in patients of either study group during the 48-hr study period. Meperidine for patient controlled epidural analgesia, with or without adrenaline, provides effective post-thoracotomy analgesia in selected patients.

Limitations of preoperative dobutamine stress echocardiography in identifying severe left main coronary artery stenosis: a report of two cases and a brief review.

PURPOSE: Using case illustrations, to elucidate factors which increase the likelihood of false negative preoperative dobutamine stress echocardiography (DSE) studies in patients with severe left main coronary artery stenosis, and to provide criteria which must be met in order to ensure the accurate interpretation of these tests. CLINICAL FEATURES AND SOURCE: Two patients presented for elective abdominal aortic aneurysm repair within a one-month period of time. Both patients had DSE as part of their preoperative assessment, which were interpreted as normal. Nevertheless, both suffered major coronary events in the perioperative period, and both proved to have severe left main coronary artery stenosis on postoperative angiography. A narrative review is presented based on a selection of the current literature, and local experience with the technique. Some pitfalls in the interpretation of these tests are presented, along with modalities to increase their sensitivity and specificity. CONCLUSION: DSE is an important and useful modality in the preoperative cardiac evaluation of patients who are unable to exercise. However the reliable interpretation of the test depends on an understanding of the limitations of the procedure.