Effect of intraperitoneal local anesthesia on enhanced recovery outcomes after bariatric surgery: a randomized controlled pilot study.

BACKGROUND: Patients with extreme obesity are at high risk for adverse perioperative events, especially when opioid-centric analgesic protocols are used, and perioperative pain management interventions in bariatric surgery could improve safety, outcomes and satisfaction. We aimed to evaluate the impact of intraperitoneal local anesthesia (IPLA) on enhanced recovery after bariatric surgery (ERABS) outcomes. METHODS: We conducted a prospective double-blind randomized controlled pilot study in adherence to an a priori peer-reviewed protocol. Patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) with an established ERABS protocol between July 2014 and February 2015 were randomly allocated to receive either IPLA with 0.2% ropivacaine (intervention group) or normal saline (control group). We measured pain scores, analgesic consumption and adverse effects. Functional prehabilitation outcomes, including peak expiratory flow (PEF) and the Six Minute Walk Test (6MWT) and Quality of Recovery Survey-40 (QoR-40) scores, were assessed before surgery, and 1 day and 7 days postoperatively. RESULTS: One hundred patients were randomly allocated to the study groups, of whom 92 completed the study, 46 in each group. There were no statistically significant differences between the 2 groups in baseline characteristics or any primary or secondary outcomes. Pain scores and analgesic consumption were low in both groups. There were no adverse events. Significant declines in PEF and 6MWT and QoR-40 scores were noted on postoperative day 1 in both groups; the values returned to baseline on postoperative day 7 in both groups. CONCLUSION: Intraperitoneal local anesthesia with ropivacaine did not reduce postoperative pain or analgesic consumption when administered intraoperatively to patients undergoing LRYGB. Standardization of the ERABS protocol benefited patients, with functional prehabilitation outcomes returning to baseline postoperatively. Trial registration: ClinicalTrials.gov no. NCT02154763.

Preinjury ASA score as an independent predictor of readmission after major traumatic injury.

BACKGROUND: Patients with trauma have a high predisposition for readmission after discharge. Unplanned solicitation of medical services is a validated quality of care indicator and is associated with considerable economic costs. While the existing literature emphasizes the severity of the injury, there is heterogeneity in defining preinjury health status. We evaluate the validity of the American Society of Anesthesiologists (ASA) Physical Status score as an independent predictor of readmission and compare it to the Charlson Comorbidity Index (CCI). METHODS: This is a single center, retrospective cohort study based on adult patients (>18 years of age) with trauma admitted to the Ottawa Hospital from January 1, 2004 to November 1, 2014. A multivariate logistic regression model is used to control for confounding and assess individual predictors. Outcome is readmission to hospital within 30 days, 3 months and 6 months. RESULTS: A total of 4732 adult patients were included in this analysis. Readmission rates were 6.5%, 9.6% and 11.8% for 30 days, 3 months and 6 months, respectively. Higher preinjury ASA scores demonstrated significantly increased risk of readmission across all levels in a dose-dependent manner for all time frames. The effect of preinjury ASA scores on readmission is most striking at 30 days, with patients demonstrating a 2.81 (1.88-4.22, P<0.0001), 3.59 (2.43-5.32, P<0.0001) and 7.52 (4.72-11.99, P<0.0001) fold odds of readmission for ASA class 2, 3 and 4, respectively, as compared with healthy ASA class 1 patients. The ASA scores outperformed the CCI at 30 days and 3 months. CONCLUSIONS: The preinjury ASA score is a strong independent predictor of readmission after traumatic injury. In comparison to the CCI, the preinjury ASA score was a better predictor of readmission at 3 and 6 months after a major traumatic injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological Study, Level III.

Assessing the feasibility of a randomised, double-blinded, placebo-controlled trial to investigate the role of intraperitoneal ropivacaine in gastric bypass surgery: a protocol.

INTRODUCTION: Postoperative pain control remains a major challenge for surgical procedures, including laparoscopic gastric bypass. Pain management is particularly relevant in obese patients who experience a higher number of cardiovascular and pulmonary events. Effective pain management may reduce their risk of serious postoperative complication, such as deep vein thrombosis and pulmonary emboli. The objective of this study is to evaluate the efficacy of intraperitoneal local anaesthetic, ropivacaine, to reduce postoperative pain in patients undergoing laparoscopic Roux-en-Y gastric bypass. METHODS AND ANALYSIS: A randomised controlled trial will be conducted to compare intraperitoneal ropivacaine (intervention) versus normal saline (placebo) in 120 adult patients undergoing bariatric bypass surgery. Ropivacaine will be infused over the oesophageal hiatus and throughout the abdomen. Patients in the control arm will undergo the same treatment with normal saline. The primary end point will be postoperative pain at 1, 2 and 4 h postoperatively. Pain measurements will then occur every 4 h for 24 h and every 8 h until discharge. Secondary end points will include opioid use, peak expiratory flow, 6 min walk distance and quality of life assessed in the immediate postoperative period. Intention-to-treat analysis will be used and repeated measures will be analysed using mixed modelling approach. Post-hoc pairwise comparison of the treatment groups at different time points will be carried out using multiple comparisons with adjustment to the type 1 error. Results of the study will inform the feasibility of recruitment and inform sample size of a larger definitive randomised trial to evaluate the effectiveness of intraperitoneal ropivacaine. ETHICS AND DISSEMINATION: This study has been approved by the Ottawa Health Science Network Research Ethics Board and Health Canada in April 2014. The findings of the study will be disseminated through national and international conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER: Clinicaltrial.gov NCT02154763.

Enhancing the quality of morbidity and mortality rounds: the Ottawa M&M model.

OBJECTIVES: The objective of this study was to determine the feasibility and acceptability of a structured morbidity and mortality (M&M) rounds model through an innovative educational intervention. METHODS: The authors engaged the Departments of Emergency Medicine (EM) and Trauma Services at a tertiary care teaching hospital. A needs assessment was performed; the Ottawa M&M rounds model was developed, implemented, and then evaluated as a four-part intervention. This consisted of: 1) physician training on case selection and analysis, 2) engaging interprofessional members, 3) disseminating lessons learned, and 4) creating an administrative pathway for acting on issues identified through the M&M rounds. The measures of intervention feasibility included the proportion of sessions adherent to the new model and M&M rounds attendance. Pre- and postintervention surveys of presenters and attendees were used to determine intervention acceptability. M&M presentation content was reviewed to determine the most frequently adopted components of the model. RESULTS: Nine of 14 (64.3%) sessions were adherent to three of four components of the Ottawa M&M Model. Of those M&M attendees who responded to the survey (796 of 912, 87.2%), improvements were found in M&M rounds attendance as well as perceived effect on clinical practice at both individual and departmental levels. Thirty-seven case presentations were analyzed and improvements postintervention were found in appropriate case selection and recognition of cognitive and system issues. CONCLUSIONS: The Ottawa M&M Model was a feasible intervention that was perceived to be effective by both presenters and attendees. The authors believe that this could be readily applied to any hospital department seeking to enhance quality of care and patient safety.

Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes.

BACKGROUND: Optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates mobilization and theoretically reduces associated complications. METHODS: We identified consecutive patients without neurologic injury requiring stabilization surgery for a spinal fracture at an academic tertiary-care hospital over a 12-year period. Incidences of postoperative complications were prospectively evaluated. We analyzed results based on the time elapsed before the final surgical stabilization procedure. Multivariate analyses were performed to explore the effects of potential confounders. RESULTS: A total of 83 patients (60 men, 23 women; mean age 39.4 yr) met the eligibility criteria and were enrolled. The mean Injury Severity Score (ISS) was 27.1 (range 12.0-57.0); 35% of patients had a cervical fracture and 65% had a thoraco-lumbar fracture. No statistically significant associations were uncovered between time to surgical stabilization and age, ISS or comorbidities. Comparing patients stabilized after 24 hours with those stabilized within 24 hours, there was an almost 8-fold greater risk of a complication related to prolonged recumbency (p = 0.007). We observed similar effects for other types of complications. Delays of more than 72 hours had a negative effect on complication rates; these effects remained significant after multivariate adjustments for age, comorbidity and ISS. CONCLUSION: This study demonstrates a strong relation between timing of surgical stabilization of spinal fractures in multitrauma patients without neurologic injuries and complications. Further studies with larger samples may allow for better adjustment of potentially confounding factors and identify subgroups in which this effect is most pronounced.

Emergency medical services intervals and survival in trauma: assessment of the "golden hour" in a North American prospective cohort.

STUDY OBJECTIVE: The first hour after the onset of out-of-hospital traumatic injury is referred to as the "golden hour," yet the relationship between time and outcome remains unclear. We evaluate the association between emergency medical services (EMS) intervals and mortality among trauma patients with field-based physiologic abnormality. METHODS: This was a secondary analysis of an out-of-hospital, prospective cohort registry of adult (aged > or =15 years) trauma patients transported by 146 EMS agencies to 51 Level I and II trauma hospitals in 10 sites across North America from December 1, 2005, through March 31, 2007. Inclusion criteria were systolic blood pressure less than or equal to 90 mm Hg, respiratory rate less than 10 or greater than 29 breaths/min, Glasgow Coma Scale score less than or equal to 12, or advanced airway intervention. The outcome was in-hospital mortality. We evaluated EMS intervals (activation, response, on-scene, transport, and total time) with logistic regression and 2-step instrumental variable models, adjusted for field-based confounders. RESULTS: There were 3,656 trauma patients available for analysis, of whom 806 (22.0%) died. In multivariable analyses, there was no significant association between time and mortality for any EMS interval: activation (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.95 to 1.05), response (OR 1.00; 95% CI 9.97 to 1.04), on-scene (OR 1.00; 95% CI 0.99 to 1.01), transport (OR 1.00; 95% CI 0.98 to 1.01), or total EMS time (OR 1.00; 95% CI 0.99 to 1.01). Subgroup and instrumental variable analyses did not qualitatively change these findings. CONCLUSION: In this North American sample, there was no association between EMS intervals and mortality among injured patients with physiologic abnormality in the field.

National survey of Canadian general surgery program directors regarding focused assessment with sonography for trauma.

INTRODUCTION: Focused assessment with sonography for trauma (FAST) is an important modality in the initial assessment of trauma patients. Information regarding the current status, availability, as well as educational and training processes in the use of FAST is limited. The purpose of this study was to survey Canadian general surgery residency program directors regarding FAST. METHODS: A Web-based survey was developed to assess the availability and use of FAST, education and training, as well as the role of FAST in general surgery residency training programs across Canada. Two experts reviewed the survey for validity and reliability. The survey was then pilot tested by 2 general surgeons. RESULTS: The survey response rate was 75.0% (12/16). FAST was available at all the institutions that responded. FAST was used 100% of the time in the initial assessment of the trauma patient. In all, 75.0% (9/12) respondents have no formal residency training in FAST, 91.7% (11/12) of respondents agreed or strongly agreed that training in FAST should be included in the residency curriculum, and 66.7% (8/12) of respondents perceive that general surgery residents are not competent in the use of FAST. CONCLUSIONS: Overall, Canadian general surgery program directors do not feel that surgical residents are competent in the use of FAST. Current training is limited, and program directors believe that training and education in FAST should be included in the postgraduate education curriculum.

Management of open abdominal wounds with a dynamic fascial closure system.

BACKGROUND: In damage-control surgery, definitive abdominal closure may not be possible for several days or weeks after laparotomy until the patient has stabilized. METHODS: We present 23 patients treated with the Canica ABRA dynamic wound closure system that re-approximated open abdomens with silicone elastomers placed transfascially across the wound. This study aimed to assess the results of using this system and to identify risk factors for unsuccessful closure. The system maintains a medially directed force across the wound. A traditional regimen of wound dressing changes was performed. RESULTS: The dynamic closure system remained in place an average of 48 days and was applied an average of 18 days after the beginning of treatment for the open abdominal wound. Delayed primary fascial closure was achieved in 14 of 23 patients (61%) without further surgery. Six patients (26%) healed with ventral hernias but with a smaller abdominal defect. Two patients (9%) developed enterocutaneous fistulae through the wound that required further surgery. An overall reduction in wound area of 95% was achieved. CONCLUSION: This dynamic wound closure technique permitted the delayed primary closure of open abdomens in 61% of cases when treatment was instituted an average of 18 days after initial laparotomy.

Advanced laparoscopic surgery in a free-standing ambulatory setting: lessons from the first 50 cases.

To decrease the impact and cost of surgery, there is a trend toward developing treatment models for complex conditions on a fully outpatient basis. This is a retrospective study of the initial experience of advanced laparoscopic procedures performed on a same-day outpatient basis in the ambulatory campus of a university hospital. Over 3 years, 55 patients underwent 50 Nissen fundoplications and 5 adrenalectomies. There were 2 intraoperative complications, with no mortality and no conversion. The median postoperative stay was 4.5 hours. Readmission at 1 month was 11%. Data on the nursing postoperative telephone follow-up were available for 50 patients; 34 (62%) were successfully contacted. Twenty four (70%) had no complaint. Preliminary high-level cost data indicate a cost advantage. Advanced laparoscopic procedures can be done safely in a pure ambulatory setting; the current readmission rate can be reduced with improved pain management and better telephone follow-up strategies. Cost savings are likely.

A prospective study to validate an impairment questionnaire for major trauma survivors.

OBJECTIVE: To develop and validate an impairment questionnaire that will provide an estimate of whole-person impairment in patients who have suffered major trauma. DESIGN: This was a multicenter prospective study involving a convenience sample of 43 volunteer participants who had sustained major trauma within 1 yr of study commencement. Patients were recruited from two trauma centers in Ontario, Canada. The impairment questionnaire was developed as a self-administered questionnaire based on the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition. RESULTS: Clinician assessments of whole-person impairment showed adequate interrater (r > or = 0.55, P < or = 0.03) and intrarater (r > or = 0.62, P < or = 0.055) reliabilities across dimensions. The impairment questionnaire correlated significantly with clinician assessments at the initial visit (r > or = 0.57, P < 0.001) and at follow-up (r > 0.60, P < 0.001). Comparison of the physical and emotional subcategories of the impairment questionnaire, whole-person impairment ratings by physicians, and the Short Form 36 demonstrated good convergent and divergent validity of the impairment questionnaire. CONCLUSIONS: The impairment questionnaire is a reliable and valid self-administered tool that can be used to evaluate physical impairment after major trauma.

Subacute tricuspid valve rupture after traumatic cardiac and pulmonary contusions.

Tricuspid valve rupture is a rare complication after blunt chest trauma. We report the unusual presentation of a patient that suffered traumatic cardiac and pulmonary contusions, contributing to the rupture of the posterior papillary muscle of the tricuspid valve 24 hours after presentation. We believe that this is the first reported case of subacute tricuspid valve rupture after a normal echocardiogram at admission after blunt chest trauma.

Isolated blunt splenic injury: do we transfuse more in an attempt to operate less?

OBJECTIVE: To determine if blood transfusion requirements in patients with isolated blunt splenic injury (BSI) are greater if they are managed nonoperatively, we did a retrospective case study of patients with isolated BSI who were seen at a Canadian university teaching hospital over a 10-year period. METHOD: Data such as number of units of packed erythrocytes transfused and mortality in the 75 patients with isolated BSI seen from 1992 to 2002 were separated into operative and nonoperative management groups. RESULTS: In the operative management group (n = 10), patients received more transfused erythrocytes (3.0 v. 0.7 units), and a higher proportion of patients were transfused (80% v. 20%). There were no deaths in either group. CONCLUSION: In the management of isolated BSI, initial nonoperative management does not increase patients' requirements for blood transfusion.