Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection.

BACKGROUND: The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing a wide range of colorectal procedures. METHODS: Thirty-nine patients undergoing major elective colonic resection were recruited prospectively. Patients were randomized to receive a ten-point multimodal optimization package or conventional perioperative care. All patients were administered epidural analgesia and opiates were avoided. Outcome measures recorded related to length of hospital stay, physical and mental function, and gut function. RESULTS: Optimization was associated with a significantly shorter median (interquartile range) hospital stay compared with conventional care (5 (4-9) versus 7.5 (6-10) days; P = 0.027). Duration of catheterization (P = 0.022) and duration of intravenous infusion (P = 0.007) were also less. Optimization was associated with a quicker recovery of gut function (P = 0.042). Grip strength was maintained in the postoperative period in the optimized group (P = 0.241) but not in the control group (P = 0.049). There were no differences in morbidity or mortality between the groups. CONCLUSION: Optimization is safe and results in a significant reduction in postoperative stay along with other improved endpoints. This cannot be directly attributed to improvement in any single outcome measure or to the use of epidural analgesia. Improvements are more likely to be multifactorial and may relate to an earlier return of gut function.

Randomized clinical trial of multimodal optimization and standard perioperative surgical care.

BACKGROUND: Multimodal optimization of surgical care has been associated with reduced hospital stay and improved physical function. The aim of this randomized trial was to compare multimodal optimization with standard care in patients undergoing colonic resection. METHODS: Twenty-five patients requiring elective right or left hemicolectomy were randomized to receive a ten-point optimization programme (14 patients) or conventional care (11). The groups were similar in terms of age (64 versus 68 years), male : female sex ratio (6 : 8 versus 5 : 6) and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) score (both 26). Outcome measures were recorded before operation and on postoperative days 1, 7 and 30. They included hand grip strength, lung spirometry, and pain and fatigue scores. Further outcome measures included time to achieve a predetermined mobilization target, time to resumption of normal diet, and length of stay. RESULTS: Optimization was associated with maintained grip strength, earlier mobilization (46 versus 69 h; P = 0.043), and significantly lower pain and fatigue scores. Patients in the optimization group tolerated a regular hospital diet significantly earlier than controls (48 versus 76 h; P < 0.001). Optimization significantly reduced the median length of hospital stay (3 versus 7 days; P = 0.002). CONCLUSION: Optimization of surgical care significantly improved patients' physical and psychological function in the early postoperative period and facilitated early hospital discharge.

Admissions to the intensive care unit after complications of anaesthetic techniques over 10 years. 1. The first 5 years.

Fifty-three patients were admitted in a 5-year period to the intensive care unit as a result of a complication of an anaesthetic technique. These patients represented 1 in 1543 anaesthetics carried out in the District in the period and 2.0% of all admissions to the intensive care unit. The mortality rate was 17%. The complication was considered to be wholly or partially avoidable in 14 instances (26%). Five of these subjects died and two had a residual neurological deficit.

An investigation of premedication with morphine given by the buccal or intramuscular route.

1. Premedication with 30 mg buccal morphine or 10 mg intramuscular morphine was evaluated in 40 healthy women undergoing major gynaecological surgery. 2. Buccal administration of morphine produced lower plasma morphine concentrations than intramuscular injection of morphine (P less than 0.01). 3. The mean systemic availability of the buccal tablet, during the first 5 h after administration, was approximately 3% relative to that of the intramuscular preparation. 4. Poor absorption of buccal morphine resulted in inadequate sedation prior to surgery and poor post-operative analgesia. 5. Patients experienced difficulty with the buccal formulation of morphine; tablet bitterness and failure to dissolve were particular problems.

A single dose pharmacokinetic study of Gastrobid Continus and Maxolon in the perioperative period.

1. A single dose pharmacokinetic comparison of Gastrobid Continus and Maxolon was carried out perioperatively in two groups of 12 gynaecological patients; each group comprised six patients for major surgery and six patients for minor surgery. 2. The areas under the plasma drug concentration-time curves were similar after both preparations. 3. In the minor surgery group after Gastrobid Continus the plasma drug concentration-time curve was wider at half Cmax (P less than 0.01), Cmax was reduced (P less than 0.05) and delayed (median (range) 4 (3-6) vs 2.5 (2-4) h) compared with Maxolon, and the log of the metoclopramide concentration did not have a linear relationship with time from 2-9 h. 4. A flattening of the plasma drug concentration-time curve was the only difference between the two preparations in the major surgery groups. 5. The plasma drug concentration-time curve was wider (P less than 0.05) at at half Cmax in the minor compared with the major surgery groups receiving Gastrobid Continus. 6. Pharmacokinetic parameters were similar for Maxolon in both surgical groups. 7. Sustained release pharmacokinetic characteristics were most pronounced in the minor surgery group which did not receive opiate medication but in which there were more moderately anxious patients prior to induction and in whom anxiety may have delayed gastric emptying.