Ruchir Gupta

Peri‐operative fluid management to enhance recovery

‘Enhanced recovery after surgery’ protocols implement a series of peri‐operative interventions intended to improve recovery after major operations, one aspect of which is fluid management. The pre‐operative goal is to prepare a hydrated, euvolaemic patient by avoiding routine mechanical bowel preparation and by encouraging patients to drink clear liquids up to two hours before induction of anaesthesia. The intra‐operative goal is to achieve a ‘zero’ fluid balance at the end of uncomplicated surgery: goal‐directed fluid therapy is recommended for poorly prepared or sick patients or those undergoing more complex surgery. The postoperative goal is eating and drinking without intravenous fluid infusions. Postoperative oliguria should be expected and accepted, as urine output does not indicate overall fluid status.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

BackgroundColorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.MethodsWith input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.DiscussionAs a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).

Fat embolism syndrome.

Fat embolism syndrome is an often overlooked cause of breathlessness in trauma wards. Presenting in a wide range of clinical signs of varying severity, fat embolism is usually diagnosed by a physician who keeps a high degree of suspicion. The clinical background, chronology of symptoms and corroborative laboratory findings are instrumental in a diagnosis of fat embolism syndrome. There are a few diagnostic criteria which are helpful in making a diagnosis of fat embolism syndrome. Management is mainly prevention of fat embolism syndrome, and organ supportive care. Except in fulminant fat embolism syndrome, the prognosis is usually good.

Preoperative Nutrition and Prehabilitation

Enhanced recovery after surgery is the natural evolution of what were previously referred to as fast track programs and seeks to implement a series of interventions to improve and enhance recovery after major surgical procedures. Two important preoperative aspects are nutrition and prehabilitation. Identifying nutritionally deficient patients allows preoperative intervention to optimize their nutritional status. The contribution of cardiopulmonary exercise testing to the evaluation of perioperative risk, subsequent development of a training program, and the use of indices to risk stratify and measure improvement after a training program allow a personalized preoperative program to be developed for each patient.

Prilocaine spinal anesthesia for ambulatory surgery: A review of the available studies☆

Transient neurologic symptoms (TNS) led to the abandonment of intrathecal lidocaine. We reviewed the published literature for information about the duration of action and side effects of intrathecal prilocaine, which has been recently reintroduced in Europe. Medline and EMBASE databases were searched for the time period from 1966 to 2015. Fourteen prospective and one retrospective study were retrieved. The duration of the surgical block can be adjusted using doses between 40 and 80mg. Hyperbaric prilocaine in doses as low as 10mg can be used for perianal procedures. Four cases of TNS in 486 patients were reported in prospective studies, and none in 5000 cases in a retrospective data set. Spinal prilocaine appears to be safe and reliable for day case anesthesia. However, as chloroprocaine has a shorter duration and a lower risk of TNS and urinary retention, the indications for prilocaine remain to be defined.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery

The primary driver of length of stay after bowel surgery, particularly colorectal surgery, is the time to return of gastrointestinal (GI) function. Traditionally, delayed GI recovery was thought to be a routine and unavoidable consequence of surgery, but this has been shown to be false in the modern era owing to the proliferation of enhanced recovery protocols. However, impaired GI function is still common after colorectal surgery, and the current literature is ambiguous with regard to the definition of postoperative GI dysfunction (POGD), or what is typically referred to as ileus. This persistent ambiguity has impeded the ability to ascertain the true incidence of the condition and study it properly within a research setting. Furthermore, a rational and standardized approach to prevention and treatment of POGD is needed. The second Perioperative Quality Initiative brought together a group of international experts to review the published literature and provide consensus recommendations on this important topic with the goal to (1) develop a rational definition for POGD that can serve as a framework for clinical and research efforts; (2) critically review the evidence behind current prevention strategies and provide consensus recommendations; and (3) develop rational treatment strategies that take into account the wide spectrum of impaired GI function in the postoperative period.

Immunonutrition within enhanced recovery after surgery (ERAS): an unresolved matter

Preoperative malnutrition because of poor oral intake significantly increases the risk of adverse events after surgery and leads to increased length of stay. While immunonutrition has been utilized in the non-ERAS setting, its utility in both minimally invasive surgery and ERAS pathway procedures remain poorly defined. There are at least ten meta-analyses regarding the assessment of immunonutrition, but virtually, all of these were performed in an era prior to minimally invasive surgery, adoption of enhanced recovery protocols, and an understanding of the assessment and physiology of sarcopenia. In terms of immunonutrition within an ERAS pathway, the few studies that have been published have severe flaws in design and sample, bringing their overall conclusion into question. Furthermore, the optimal components of immunonutrition have yet to be adequately determined and may vary for patients based on comorbidities as well as the proposed procedures. Risk stratification based on markers of nutritionally deficient states such as image assessed sarcopenia, Glasgow Prognostic Score, prognostic nutrition index, or assessment of methylarginines are needed prior to the initiation of any such immunotherapy. Lastly, there is a need for properly designed randomized control trials that stratify patients appropriately and determine the optimal timing, composition, and duration of immunotherapy.

Prophylaxis and management of postoperative nausea and vomiting in enhanced recovery protocols: Expert Opinion statement from the American Society for Enhanced Recovery (ASER)

International experience and evidence-based practices have shown that reduction in variability through use of protocolized perioperative care improves surgical outcomes and reduces costs to patients and healthcare systems. In this series of Expert Opinions, we provide consensus recommendations for the various components of perioperative care to aid with the development of enhanced recovery after surgery protocols.

Erratum to: ‘Prophylaxis and management of postoperative nausea and vomiting in enhanced recovery protocols’

[This corrects the article DOI: 10.1186/s13741-016-0029-0.].

Retrograde Epidural Catheter Relieves Intractable Sacral Pain.

Pain caused by tumor infiltration of the sacral area remains a major clinical challenge. Patients with poor pain control despite comprehensive medical management may be treated with neuraxial techniques such as continuous epidural or spinal anesthetic. We report a case in which a patient with metastatic breast cancer experienced inadequate pain relief after multiple intravenous pain management regimens as well as intrathecal (IT) drug delivery. The concentration of local anesthetics delivered via the IT catheter was limited due to the patients baseline motor weakness which would be exacerbated with higher concentrations of local anesthetics. Thus, a decision was made to insert an epidural catheter via a retrograde technique to provide the patient with a “band of anesthesia” which would provide profound sensory blockade without concomitant motor weakness. Pain refractory to other modalities of pain control was successfully treated with the epidural technique.