Background
This is the fourth updated Enhanced Recovery After Surgery (ERAS
®
) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded ...recommendations for each ERAS item within the ERAS
®
protocol.
Methods
A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.
Results
All recommendations on ERAS
®
protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.
Conclusions
The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS
®
Society in this comprehensive consensus review.
The biological perturbation associated with psychological and surgical stress is implicated in cancer recurrence. Preclinical evidence suggests that beta-blockers can be protective against cancer ...progression. We undertook a meta-analysis of epidemiological and perioperative clinical studies to investigate the association between beta-blocker use and cancer recurrence (CR), disease-free survival (DFS), and overall survival (OS).
Databases were searched until September 2017, reported hazard ratios (HRs) pooled, and 95% confidence intervals (CIs) calculated. Comparative studies examining the effect of beta-blockers (selective and non-selective) on cancer outcomes were included. The Newcastle Ottawa Scale was used to assess methodological quality and bias.
Of the 27 included studies, nine evaluated the incidental use of non-selective beta-blockers, and ten were perioperative studies. Beta-blocker use had no effect on CR. Within subgroups of cancer, melanoma was associated with improved DFS (HR 0.03, 95% CI 0.01–0.17) and OS (HR 0.04, 95% CI 0.00–0.38), while endometrial cancer had an associated reduction in DFS (HR 1.40, 95% CI 1.10–1.80) and OS (HR 1.50, 95% CI 1.12–2.00). There was also reduced OS seen with head and neck and prostate cancer. Non-selective beta-blocker use was associated with improved DFS and OS in ovarian cancer, improved DFS in melanoma, but reduced OS in lung cancer. Perioperative studies showed similar variable effects across cancer types, albeit from a limited data pool.
Beta-blocker use had no evident effect on CR. The beneficial effect of beta-blockers on DFS and OS in the epidemiological or perioperative setting remains variable, tumour-specific, and of low-level evidence at present.
Effective pain control enhances patient recovery after surgery. Laparoscopic techniques for major abdominal surgery are increasingly utilised to reduce surgical trauma. Intrathecal morphine is an ...attractive analgesic option that is gaining popularity. However, limited evidence guides its use in the setting of laparoscopic surgery. In addition, enhanced recovery after surgery pathways advocate opioid-sparing techniques. We conducted a feasibility trial to compare intrathecal morphine with non-neuraxial analgesia in laparoscopic or laparoscopic-assisted major abdominal surgery to inform the design of a future large clinical trial. This multicentre, double-blind, randomised controlled trial was conducted at two tertiary hospitals in Australia. Fifty-one patients were randomly allocated to receive either intrathecal morphine (intervention group) or a sham subcutaneous injection of normal saline in the lumbar area (control group) immediately before the induction of general anaesthesia. Co-primary outcomes were patient recruitment and successful adherence to treatment allocation as per the study protocol. The primary endpoints of feasibility and protocol adherence were met with a 46% recruitment rate (51 of 110 eligible patients) and 96% protocol adherence. There was only one patient with failed access to the intrathecal space. For secondary endpoints, fewer patients in the intrathecal morphine group required opioids in the post-anaesthesia care unit, their postoperative pain scores at rest were lower across the four time-points measured (p = 0.007), but not dynamic pain scores (p = 0.061), and pruritus was more common following intrathecal morphine (p = 0.007). Total oral morphine equivalents until postoperative day 3 were less in the intrathecal morphine group (median (95%CI) difference 82 (-13 to 168) mg), but this reduction was not statistically significant (p = 0.10). These findings support conducting a definitive clinical trial.
Oxygen depletion can lead to the collapse of benthic ecosystems, i.e. to dead zones, and large-scale biodiversity loss. Based on mortality and survival, we evaluated ranges of sensitivity and ...tolerance to hypoxia levels, duration of anoxia and H₂S exposure across taxa and key life habits. Experiments were conducted on a sublittoral soft-bottom under realisticin situconditions in a community setting featuring both a well-developed epi- and infauna. Overall, 495 individuals representing 40 species were examined over almost 1000 h (using time-lapse camera and sensor arrays). Mortality started at dissolved oxygen (DO) concentrations <0.5 ml l–1and centred at the transition from severe hypoxia to early anoxia. A total of 58% of the individuals belonging to 27 species died. Thirteen species (39 individuals) died exclusively during anoxia. All of the individuals that died during hypoxia, and most of those that died during anoxia, did so before the onset of hydrogen sulphide (H₂S). In 11 species, all individuals survived: survival rates were highest among molluscs, anthozoans and ascidians. In contrast, most polychaetes, decapods and echinoderms died. Epifauna was more vulnerable than infauna, mobile forms were more vulnerable than sessile forms, and predators more vulnerable than deposit-feeders and suspension-feeders. While hypoxia primarily affected total abundance, anoxia significantly reduced the number of species. The former represents a quantitative, the latter a qualitative decline in ecosystem function. Most of the macrofauna may initially survive shorter-term (day-long) or intermittent hypoxia, but the onset of anoxia marks community collapse and biodiversity loss.
Increasing evidence suggests that total intravenous anaesthesia (TIVA) may be the preferred anaesthetic for cancer resection surgery. To assist the preparation of a randomised controlled trial (RCT) ...examining Volatile (versus TIVA) Anaesthesia and Perioperative Outcomes Related to Cancer (VAPOR-C) we developed an 18-question electronic survey to investigate practice patterns and perspectives (emphasising indications, barriers, and impact on cancer outcomes) of TIVA versus inhalational general anaesthesia in Australasia. The survey was emailed to 1,000 (of 5,300 active Fellows) randomly selected Australian and New Zealand College of Anaesthetists (ANZCA) Fellows. The response rate was 27.5% (n=275). Of the respondents, 18% use TIVA for the majority of cases. In contrast, 46% use TIVA 20% of the time or less. Respondents described indications for TIVA as high risk of nausea, neurosurgery, and susceptibility to malignant hyperthermia. Lack of equipment, lack of education and cost were not considered barriers to TIVA use, and a significant proportion (41%) of respondents would use TIVA more often if setup were easier. Of the respondents, 43% thought that TIVA was associated with less cancer recurrence than inhalational anaesthesia, while 46% thought that there was no difference. Yet, only 29% of respondents reported that they use TIVA often or very often for cancer surgery. In Australasia, there is generally a low frequency of TIVA use despite a perception of benefit when compared with inhalational anaesthesia. Anaesthetists are willing to use TIVA for indications where sufficient evidence supports a meaningful level of improvement in clinical outcome. The survey explores attitudes towards use of TIVA for cancer surgery and demonstrates equipoise in anaesthetists' opinions regarding this indication. The inconsistent use of TIVA in Australasia, minimal barriers to its use, and the equipoise in anaesthetists' opinions regarding the effect of TIVA versus inhalational anaesthesia on cancer outcomes support the need for a large prospective RCT.
Summary
Background
Waiting for triage in overburdened emergency departments (ED) has become an increasing problem, which endangers patients. A fast triage system to rapidly identify low-acuity ...patients should divert care and resources to more urgent cases.
Aim
The objective of this study was to compare the performance of the Kitovu Hospital fast triage (KFT) score with the Emergency Severity Index (ESI), using mortality and hospital admission as proxies for the patients’ acuity.
Design
This is a prospective observational study of consecutive patients presenting to a Swiss academic ED.
Methods
Patients were prospectively triaged into one of five ESI strata and retrospectively assessed by the KFT score, which awards one point each for altered mental status, impaired mobility and oxygen saturation <94%.
Results
The KFT score had a lower discrimination than the ESI for hospital admission, but a higher discrimination for mortality from 24 h to 1 year after ED presentation. A total of 5544 (67%) patients were assigned to the lowest acuity by the KFT score compared with 2374 (28.7%) by the ESI; there was no significant difference in the 24-h mortality of patients who were deemed low acuity by either score.
Conclusion
Compared to the ESI, the KFT score identifies more than twice as many patients at low risk of early death. Therefore, this score might help to identify patients who could be managed through alternative pathways. This may be particularly helpful in situations of ED crowding and access block.
Quantitative criteria for insomnia Lichstein, K.L.; Durrence, H.H.; Taylor, D.J. ...
Behaviour research and therapy,
04/2003, Letnik:
41, Številka:
4
Journal Article
Recenzirano
Formal diagnostic systems (DSM-IV, ICSD, and ICD-10) do not provide adequate quantitative criteria to diagnose insomnia. This may not present a serious problem in clinical settings where extensive ...interviews determine the need for clinical management. However, lack of standard criteria introduce disruptive variability into the insomnia research domain. The present study reviewed two decades of psychology clinical trials for insomnia to determine common practice with regard to frequency, severity, and duration criteria for insomnia. Modal patterns established frequency (≥3 nights a week) and duration (≥6 months) standard criteria. We then applied four versions of severity criteria to a random sample and used sensitivity–specificity analyses to identify the most valid criterion. We found that severity of sleep onset latency or wake time after sleep onset of: (a) ≥31 min; (b) occurring ≥3 nights a week; (c) for ≥6 months are the most defensible quantitative criteria for insomnia.
Summary
Inflammation and immunosuppression contribute to the pathogenesis of cancer. An increased neutrophil–lymphocyte ratio reflects these processes and is associated with adverse cancer outcomes. ...Whether anaesthetic technique for breast cancer surgery influences these factors, and potentially cancer recurrence, remains unknown. We conducted a secondary analysis in patients enrolled in an ongoing trial of anaesthetic technique on breast cancer recurrence. The primary hypothesis was that postoperative neutrophil–lymphocyte ratio is lower in patients allocated to receive propofol‐paravertebral rather than inhalational agent‐opioid anaesthesia for primary breast cancer surgery. Among 397 patients, 116 had differential white cell counts performed pre‐operatively and postoperatively. Pre‐operative neutrophil–lymphocyte ratio was similar in the propofol‐paravertebral 2.3 (95%CI 1.8–2.8) and inhalational agent‐opioid anaesthesia 2.2 (1.9–3.2) groups, p = 0.72. Postoperative neutrophil–lymphocyte ratio was lower (3.0 (2.4–4.2) vs. 4.0 (2.9–5.4), p = 0.001) in the propofol‐paravertebral group. Propofol‐paravertebral anaesthesia attenuated the postoperative increase in the neutrophil‐lymphocyte ratio.
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