BACKGROUND:Several quality of recovery (QoR) health status scales have been developed to quantify the patient’s experience after anesthesia and surgery, but to date, it is unclear what constitutes ...the minimal clinically important difference (MCID). That is, what minimal change in score would indicate a meaningful change in a patient’s health status?
METHODS:The authors enrolled a sequential, unselected cohort of patients recovering from surgery and used three QoR scales (the 9-item QoR score, the 15-item QoR-15, and the 40-item QoR-40) to quantify a patient’s recovery after surgery and anesthesia. The authors compared changes in patient QoR scores with a global rating of change questionnaire using an anchor-based method and three distribution-based methods (0.3 SD, standard error of the measurement, and 5% range). The authors then averaged the change estimates to determine the MCID for each QoR scale.
RESULTS:The authors enrolled 204 patients at the first postoperative visit, and 199 were available for a second interview; a further 24 patients were available at the third interview. The QoR scores improved significantly between the first two interviews. Triangulation of distribution- and anchor-based methods results in an MCID of 0.92, 8.0, and 6.3 for the QoR score, QoR-15, and QoR-40, respectively.
CONCLUSION:Perioperative interventions that result in a change of 0.9 for the QoR score, 8.0 for the QoR-15, or 6.3 for the QoR-40 signify a clinically important improvement or deterioration.
Risk factors for mortality were patient age of 70 years or older, male sex, poor preoperative physical health status, emergency versus elective surgery, malignant versus benign or obstetric ...diagnosis, and more extensive (major vs minor) surgery. Protocols for laboratory testing and radiological investigation were not standardised. ...there is a risk of ascertainment bias because patients who had an uneventful postoperative course were unlikely to be tested for SARS-CoV-2 or have radiological investigations and so were not counted in the analysis. Some elective (eg, cancer surgery or caesarean section) and most non-elective surgery must continue throughout any pandemic, and if the prevalence of COVID-19 is low and hospital resources are coping with demand for ward and ICU beds, more elective surgery can recommence.12 Globally, many governments and professional bodies are moving from a position of curtailment to reopening of elective surgery.13,14 This requires a low prevalence in the community and access to SARS-CoV-2 testing, and ensuring there are sufficient trained staff, hospital and ICU beds, PPE, and all other necessary medical supplies.6,7 COVID-19 might affect access to safe surgery, especially in low-income and middle-income countries and for homeless people, migrants, and refugees—this is a great concern that needs to be addressed.
Patients undergoing major abdominal surgery received restrictive or liberal intravenous fluids during surgery and up to 24 hours thereafter. The restrictive regimen did not improve disability-free ...survival and resulted in increased acute kidney injury.
A moderately liberal IV fluid regimen, using a balanced crystalloid, and consideration of the use of an advanced hemodynamic monitor in a setting of an enhanced recovery pathway are recommended for ...major surgery.
Supplemental Digital Content is available in the text.
Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, ...and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Research into how and why this transition occurs has led to a stronger appreciation of opioid-induced hyperalgesia, use of more effective and safer opioid-sparing analgesic regimens, and non-pharmacological interventions for pain management. This Series provides an overview of the epidemiology and societal effect, basic science, and current recommendations for managing persistent postsurgical pain. We discuss the advances in the prevention of this transitional pain state, with the aim to promote safer analgesic regimens to better manage patients with acute and chronic pain.
BACKGROUND:Blood transfusions are associated with morbidity and mortality. However, restrictive thresholds could harm patients less able to tolerate anemia. Using a context-specific approach ...(according to patient characteristics and clinical settings), the authors conducted a systematic review to quantify the effects of transfusion strategies.
METHODS:The authors searched MEDLINE, EMBASE, CENTRAL, and grey literature sources to November 2015 for randomized controlled trials comparing restrictive versus liberal transfusion strategies applied more than 24 h in adult surgical or critically ill patients. Data were independently extracted. Risk ratios were calculated for 30-day complications, defined as inadequate oxygen supply (myocardial, cerebral, renal, mesenteric, and peripheral ischemic injury; arrhythmia; and unstable angina), mortality, composite of both, and infections. Statistical combination followed a context-specific approach. Additional analyses explored transfusion protocol heterogeneity and cointerventions effects.
RESULTS:Thirty-one trials were regrouped into five context-specific risk strata. In patients undergoing cardiac/vascular procedures, restrictive strategies seemed to increase the risk of events reflecting inadequate oxygen supply (risk ratio RR, 1.09; 95% CI, 0.97 to 1.22), mortality (RR, 1.39; 95% CI, 0.95 to 2.04), and composite events (RR, 1.12; 95% CI, 1.01 to 1.24—3322, 3245, and 3322 patients, respectively). Similar results were found in elderly orthopedic patients (inadequate oxygen supplyRR, 1.41; 95% CI, 1.03 to 1.92; mortalityRR, 1.09; 95% CI, 0.80 to 1.49; composite outcomeRR, 1.24; 95% CI, 1.00 to 1.54—3465, 3546, and 3749 patients, respectively), but not in critically ill patients. No difference was found for infections, although a protective effect may exist. Risk estimates varied with successful/unsuccessful transfusion protocol implementation.
CONCLUSIONS:Restrictive transfusion strategies should be applied with caution in high-risk patients undergoing major surgery.
Fibrinolysis and COVID‐19: A plasmin paradox Medcalf, Robert L.; Keragala, Charithani B.; Myles, Paul S.
Journal of thrombosis and haemostasis,
September 2020, Letnik:
18, Številka:
9
Journal Article
Recenzirano
Odprti dostop
The COVID‐19 pandemic has provided many challenges in the field of thrombosis and hemostasis. Among these is a novel form of coagulopathy that includes exceptionally high levels of D‐dimer. D‐dimer ...is a marker of poor prognosis, but does this also imply a causal relationship? These spectacularly raised D‐dimer levels may actually signify the failing attempt of the fibrinolytic system to remove fibrin and necrotic tissue from the lung parenchyma, being consumed or overwhelmed in the process. Indeed, recent studies suggest that increasing fibrinolytic activity might offer hope for patients with critical disease and severe respiratory failure. However, the fibrinolytic system can also be harnessed by coronavirus to promote infectivity and where antifibrinolytic measures would also seem appropriate. Hence, there is a clinical paradox where plasmin formation can be either deleterious or beneficial in COVID‐19, but not at the same time. Hence, it all comes down to timing.
Perioperative studies increasingly report patient-centered outcomes, but few provide a valid, global measure of a patient's health status after surgery and anesthesia. This review considers three ...quality of recovery (QoR) scales.
The 9-item (QoR Score), 15-item (QoR-15), and 40-item (QoR-40) QoR scales have been extensively validated in perioperative settings, and have also been used as outcome measures in numerous surgery and anesthesia studies. A range of clinical trials are presented to illustrate the value of the QoR scales in perioperative medicine research.
The QoR Score, QoR-15, and QoR-40 are valid and recommended endpoints for perioperative clinical trials, and there is guidance as to what constitutes a minimal clinically important difference. These recovery scales are sensitive to a change in health status and, as numerical data, optimize statistical power when used in the design of a clinical trial. They are closely correlated with conventional measures of outcome such as analgesic consumption, pain scores, nausea and vomiting, and hospital stay. Although conventional measures may be considered patient-centered, each are incomplete by themselves. QoR scores provide a meaningful overall evaluation of a patient's recovery after surgery and anesthesia.
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