Anthony M. Roche

Reduced Length of Hospital Stay in Colorectal Surgery after Implementation of an Enhanced Recovery Protocol

BACKGROUND:Enhanced recovery after surgery (ERAS) is a multimodal approach to perioperative care that combines a range of interventions to enable early mobilization and feeding after surgery. We investigated the feasibility, clinical effectiveness, and cost savings of an ERAS program at a major U. S. teaching hospital. METHODS:Data were collected from consecutive patients undergoing open or laparoscopic colorectal surgery during 2 time periods, before and after implementation of an ERAS protocol. Data collected included patient demographics, operative, and perioperative surgical and anesthesia data, need for analgesics, complications, inpatient medical costs, and 30-day readmission rates. RESULTS:There were 99 patients in the traditional care group, and 142 in the ERAS group. The median length of stay (LOS) was 5 days in the ERAS group compared with 7 days in the traditional group (P < 0.001). The reduction in LOS was significant for both open procedures (median 6 vs 7 days, P = 0.01), and laparoscopic procedures (4 vs 6 days, P < 0.0001). ERAS patients had fewer urinary tract infections (13% vs 24%, P = 0.03). Readmission rates were lower in ERAS patients (9.8% vs 20.2%, P = 0.02). DISCUSSION:Implementation of an enhanced recovery protocol for colorectal surgery at a tertiary medical center was associated with a significantly reduced LOS and incidence of urinary tract infection. This is consistent with that of other studies in the literature and suggests that enhanced recovery programs could be implemented successfully and should be considered in U.S. hospitals.

A Head-to-Head Comparison of the In Vitro Coagulation Effects of Saline-Based and Balanced Electrolyte Crystalloid and Colloid Intravenous Fluids

Both fluid composition (e.g., type of hydroxyethyl starch) and formulation (e.g., saline or balanced salt carrier solution) may alter whole blood coagulation. We therefore enrolled 10 healthy volunteers to test ex vivo, thrombelastograph®-based blood coagulation differences of eight crystalloid and colloid solutions at 20%, 40%, and 60% dilutions. Saline and lactated Ringers solution produced a hypercoagulable state at 20%–40% dilutions. Saline, hetastarch in saline, pentastarch in saline, tetrastarch in saline, and human albumin solutions all produced a hypocoagulable state at 60% dilution. Hetastarch in saline also produced a hypocoagulable state at 40% dilution. The larger molecular weight starches produced more intense coagulation abnormalities than the medium molecular weight compounds formulated similarly (i.e., suspended in saline or balanced salt solution). The balanced salt solutions caused fewer coagulation abnormalities, especially pentastarch in balanced salt solution. This balanced salt pentastarch preparation produced the least derangement of coagulation of the colloid solutions at all dilutions, causing hypercoagulability at the lower dilutions and minimal coagulation derangement at 60% dilution. These data support the theory that smaller molecular weight hydroxyethyl starches and colloids suspended in balanced salt solutions preserve coagulation better than large molecular weight starches and saline-based colloids, as judged by thrombelastography.

Poor adoption of hemodynamic optimization during major surgery: are we practicing substandard care?

Hemodynamic optimization of surgical patients during the perioperative period aims to improve outcomes. This is frequently referred to as goaldirected therapy (GDT), a term that has been used for nearly 30 years to describe methods of optimizing fluid and hemodynamic status. Unfortunately, the term has never been standardized, and therefore can mean different things to different people, causing a significant amount of confusion. It can refer to supramaximal oxygen delivery using a pulmonary artery catheter (PAC), early treatment of sepsis in the emergency department, or perioperative optimization of fluid status, all different goals directing different therapies. It could be said that we all practice a form of GDT intraoperatively every day, except that our goals are normally related to arterial blood pressure (BP), heart rate, and occasionally central venous pressure (CVP). These are all known to be poor indicators of intravascular volume and cardiac output (CO). In healthy volunteers, heart rate and BP remain relatively unchanged despite a 25% hemorrhage of blood volume. One systematic review showed that CVP is unable to identify which patients need more fluid, and concluded that CVP should no longer be routinely measured in the intensive care unit, operating room, or emergency department. This leads to a key question: Can monitoring of stroke volume (SV) and CO improve our ability to optimize fluid and hemodynamic status? This issue of Anesthesia & Analgesia includes 2 excellent systematic reviews by Hamilton et al. and Gurgel and do Nascimento on hemodynamic optimization of patients undergoing major surgery. The authors avoided the term GDT, and instead described the techniques as “preemptive hemodynamic intervention” and “optimizing tissue perfusion.” It is clear that the reviews examined the same subject, with 26 studies (of 29 and 31, respectively) common to both articles. Perioperative hemodynamic optimization was first described in the 1980s, when the PAC was used to guide fluid and inotrope administration. This enabled clinicians to augment tissue oxygen delivery to supranormal levels (DO2 600 mL/min/m ) in high-risk surgery patients, the target being based on earlier work by Shoemaker et al. observing survivors after high-risk surgery. As both systematic reviews have shown, oxygen-targeted approaches were generally successful, and when mortality in high-risk surgery was approaching 20%, most studies were able to show a survival benefit. Despite these promising results, the technique was not widely adopted. Oxygen-targeted approaches required significant resources, were very labor intensive, and most importantly were reliant on information from the PAC. Catheterization of the right heart began falling out of favor in intensive care units in the 1990s after the publication of several observational studies showing increased mortality. Because early GDT was linked so closely with the use of PACs, it became embroiled in this controversy. The last 20 years have seen the arrival of a number of minimally invasive CO technologies such as esophageal Doppler, arterial pressure waveform analysis devices providing SV variation (SVV) and pulse pressure variation (PPV), and monitors based on bioimpedance and bioreactance technology. This has enabled clinicians to monitor and optimize SV, SVV, CO, and other hemodynamic variables without the need for a PAC. These monitors are easy to operate and minimally invasive, so they have gained wider use than PAC optimization in high-risk patients. They are also frequently used in patients undergoing major but not necessarily high-risk surgery, for example, elective abdominal surgery, extensive cancer surgery, hip arthroplasty, or major spinal surgery. Hemodynamic optimization in this patient population can usually be obtained by optimization of preload alone. The change in SV, SVV, or CO in response to a fluid challenge is used to assess volume responsiveness. When a patient is hypovolemic, an IV fluid challenge will typically result in a 10% increase in SV or CO, or a reduction in SVV. This patient has “recruitable” SV and is in a fluid-responsive state. In the perioperative setting, fluid challenges should be considered until the SV no longer increases by 10% and preload has been optimized. SVV and PPV alone have also been shown to be superior to static indices in predicting From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina. Accepted for publication February 28, 2011. Conflict of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Tong J. Gan, MD, MHS, FRCA, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to tjgan@duke.edu. Copyright

Processed electroencephalogram during donation after cardiac death.

We present a case series of increased bispectral index values during donation after cardiac death (DCD). During the DCD process, a patient was monitored with processed electroencephalogram (EEG), which showed considerable changes traditionally associated with lighter planes of anesthesia immediately after withdrawal of care. Subsequently, to validate the findings of this case, processed EEG was recorded during 2 other cases in which care was withdrawn without the use of hypnotic or anesthetic drugs. We found that changes in processed EEG immediately after withdrawal of care were not only reproducible, but can happen in the absence of changes in major electromyographic or electrocardiographic artifact. It is well documented that processed EEG is prone to artifacts. However, in the setting of DCD, these changes in processed EEG deserve some consideration. If these changes are not due to artifact, dosing of hypnotic or anesthetic drugs might be warranted. Use of these drugs during DCD based primarily on processed EEG values has never been addressed.

Evaluating international global health collaborations: Perspectives from surgery and anesthesia trainees in Uganda

BACKGROUND The number of international academic partnerships and global health programs is expanding rapidly worldwide. Although the benefits of such programs to visiting international partners have been well documented, the perceived impacts on host institutions in resource-limited settings have not been assessed adequately. We sought to describe the perspectives of postgraduate, Ugandan trainees toward international collaborations and to discuss how these perceptions can be used to increase the positive impact of international collaborations for the host institution. METHODS We conducted a descriptive, cross-sectional survey among anesthesia and surgery trainees at Makerere College of Health Sciences (Kampala, Uganda) using a pretested, self-administered questionnaire. Data were summarized as means or medians where applicable; otherwise, descriptive statistical analyses were performed. RESULTS Of 43 eligible trainees, 77% completed the questionnaire. The majority (75%) agreed that visiting groups improve their training, mostly through skills workshops and specialist camps. A substantial portion of trainees reported that international groups had a neutral or negative impact on patient care (40%). Only 15% agreed that research projects conducted by international groups are in priority areas for Uganda. Among those surveyed, 28% reported participation in these projects, but none has published as a coauthor. Nearly one-third of trainees (31%) reported discomfort with the ethics of some clinical decisions made by visiting faculty. CONCLUSION The current perspective from the surgery and anesthesia trainees of Makerere College of Health Sciences demonstrates rich ground for leveraging international collaborations to improve training, primarily through skills workshops, specialist camps, and more visiting faculty involvement. This survey also identified potential challenges in collaborative research and ethical dilemmas that warrant further examination.

Colloids and crystalloids: does it matter to the kidney?

Purpose of reviewTo highlight some of the recent key issues surrounding crystalloid and colloid fluid management of critically ill patients. Recent findingsSignificant developments have been made in the understanding of ionic balance of fluids and their effects on acid–base, the role of hydration and overhydration, alkalinization of fluids in patients at high risk for contrast induced nephropathy, and finally the role of colloids in acute kidney injury. SummaryDespite hydration remaining a key principle in fluid management in many patients, volume overload is of considerable concern. Recent evidence also suggests that balanced electrolyte formulations are preferable to saline-based formulations in a variety of clinical settings. Furthermore, alkalinization of fluids is protective in the setting of contrast-induced nephropathy. Oncotic load appears to be the most important factor in acute kidney injury associated with colloid fluid therapy.

Impact of point-of-care ultrasound training on surgical residents' confidence.

OBJECTIVE Point-of-care ultrasound (POCUS) is a vital tool for diagnosis and management of critically ill patients, particularly in resource-limited settings where access to diagnostic imaging may be constrained. We aimed to develop a novel POCUS training curriculum for surgical practice in the United States and in resource-limited settings in low- and middle-income countries and to determine its effect on surgical resident self-assessments of efficacy and confidence. DESIGN We conducted an observational cohort study evaluating a POCUS training course that comprised 7 sessions of 2 hours each with didactics and proctored skills stations covering ultrasound applications for trauma (Focused Assessement with Sonography for Trauma (FAST) examination), obstetrics, vascular, soft tissue, regional anesthesia, focused echocardiography, and ultrasound guidance for procedures. Surveys on attitudes, prior experience, and confidence in point-of-care ultrasound applications were conducted before and after the course. SETTING General Surgery Training Program in Seattle, Washington. PARTICIPANTS A total of 16 residents participated in the course; 15 and 10 residents completed the precourse and postcourse surveys, respectively. RESULTS The mean composite confidence score from pretest compared with posttest improved from 23.3 (±10.2) to 37.8 (±6.7). Median confidence scores (1-6 scale) improved from 1.5 to 5.0 in performance of FAST (p < 0.001). Residents reported greater confidence in their ability to identify pericardial (2 to 4, p = 0.009) and peritoneal fluid (2 to 4.5, p < 0.001), to use ultrasound to guide procedures (3.5 to 4.0, p = 0.008), and to estimate ejection fraction (1 to 4, p = 0.004). Both before and after training, surgical residents overwhelmingly agreed with statements that ultrasound would improve their US-based practice, make them a better surgical resident, and improve their practice in resource-limited settings. CONCLUSIONS After a POCUS course designed specifically for surgeons, surgical residents had improved self-efficacy and confidence levels across a broad range of skills.

Goal-directed or goal-misdirected - how should we interpret the literature?

Goal-directed therapy (GDT) can be a vague term, meaning different things to different people and, depending on the clinical environment, sometimes even different things to the same person. It can refer to perioperative fluid management, clinicians driving oxygen delivery to supramaximal values, early treatment of sepsis in the emergency department, and even to restriction of perioperative crystalloids with the goal of maintaining preadmission body weight. Understandably, strong opinions about GDT vary; some clinicians consider it essential for perioperative care, others completely ineffective in critically ill patients. This commentary aims to further position the excellent review by Lees and colleagues in the context of the critical care and perioperative setting.

Just scratching the surface: varied coagulation effects of polymer containers on TEG variables.

Background and objective: Different types of polymer surfaces affect the activation of platelets and coagulation pathway containers depending on their surface qualities. Importantly, this could produce variability of coagulation results obtained with thrombelastographical analysis. We assessed the effects of blood storage on thrombelastograph, TEG®, variables using polypropylene and polycarbonate containers. Methods: An in vitro experiment was performed, with eight volunteers in each limb. Fresh whole blood was stored in polypropylene or polycarbonate tubes prior to TEG® analysis, to assess the role of these plastics in the TEG® results obtained. Results: The polycarbonate tubes displayed slower onset of coagulation and greater variability of data for all four basic TEG variables (r‐time, k‐time, α‐angle and maximum amplitude, P < 0.05). Polycarbonate results fell outside manufacturer reference ranges. Conclusions: It is likely that this is due to the altered surface properties and charge effects of the containers affecting proteins and platelets differently. Caution should be used in choosing which containers are used for storage of fresh blood prior to coagulation assessment, as variable results will follow where different types of plastic containers are employed.

Hepatic parenchymal transection with vascular staplers: a comparative analysis with the crush-clamp technique.

BACKGROUND This retrospective study compares the safety and efficacy of hepatic parenchymal transection using vascular staplers (VS) and the crush-clamp (CC) technique. METHODS Demographics, clinicopathologic data, treatments, and postoperative outcomes from patients who underwent VS or CC hepatic parenchymal transection were compared. RESULTS From 1996-2006, 99 and 112 patients underwent hepatic transection with VS and CC, respectively. Compared to CC, VS transection was associated with less operative time (median 210 vs 275 minutes), blood loss (median 250 vs 500 mL), and postoperative red blood cell (RBC) transfusion (29% vs 44%), all P < .05. VS transection was not associated with RBC transfusion on multivariate analysis. There were no differences in rates of positive resection margins (9% vs 13%), postoperative mortality (2% vs 4%), overall morbidity (32% vs 29%), and severe morbidity (20% vs. 23%), all P > .05. CONCLUSION Hepatic parenchymal transection with VS can be accomplished with similar safety and efficacy as CC transection.