RESUMEN
BACKGROUND: The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery. METHODS: A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups. RESULTS: Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period. CONCLUSIONS: Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.
RESUMEN
BACKGROUND: The Israeli physician workforce faces multiple challenges. These include planned policies reducing physician on-call from 26 to 18 h and, from 2026, allowing only graduates of Ministry of Health approved foreign medical schools to take the Israeli licensing examination and an ongoing physician shortage (2019: Israel had 3.19 physicians/1000 persons vs. OECD average of 3.49 physicians/1000 persons). This study examines the potential impact of these planned policies on the Israeli anesthesiology workforce. METHODS: Surveys conducted among 34 public and private Israeli hospital anesthesiology department chairs collected data on their department's number of weekday on-call anesthesiologists and current shortage of anesthesiologists. A subsequent survey collected data on each anesthesiologist in the workforce, including the country where they studied medicine. RESULTS: Each weekday night there were 114 on-call anesthesiologists; 72 residents and 42 attendings. Using productive work coefficients, this translates to 104 resident and 51 attending anesthesiologists. Furthermore, 21 departments had existing anesthesia workforce shortages totaling 110 anesthesiologists. There were 873 anesthesiologists from non-OECD countries whose medical schools are not accredited by the World Federation for Medical Education, of whom 332 were residents (61.9% of residents). Only 20.1% of anesthesiology residents were Israeli medical school graduates. CONCLUSIONS: Descriptive survey data assessed the immediate and long-term consequences for the healthcare system and anesthesiology workforce of two new Health Ministry policies. Implementing the 18-h policy will immediately remove from the daytime workforce 155 anesthesiologists and who will be unavailable to staff elective surgery operating rooms. This will compound the current national shortage of 110 anesthesiologists. It is unclear how to replace this shortfall since there are no surplus Israeli physicians and very few Israeli graduates choose anesthesiology as a specialty. This situation will be exacerbated after 2026 when graduates of certain foreign medical schools will be unable to enter the medical workforce, further reducing the pool of potential anesthesiology residents. Both policies were promulgated without adequate operational and budgetary planning or fiscal or workforce resources; implementation of the 18-h on-call policy has already been postponed. Therefore, new or updated policies must be accompanied by specific operational plans, budgetary allocations and funds for additional workforce.