Timothy E. Miller

Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey.

Abstract Objective: During the past two decades, professional associations, accrediting bodies, and payors have made post-surgical pain treatment a high priority. In light of the disappointing findings in previous surveys, a survey was conducted to assess patient perceptions and characterize patient experiences/levels of satisfaction with post-surgical pain management. Research design and methods: Survey included a random sample of US adults who had undergone surgery within 5 years from the survey date. Participants were asked about their concerns before surgery, severity of perioperative pain, pain treatments, perceptions about post-surgical pain and pain medications, and satisfaction with treatments they received. Results: Of the 300 participants, ∼86% experienced pain after surgery; of these, 75% had moderate/extreme pain during the immediate post-surgical period, with 74% still experiencing these levels of pain after discharge. Post-surgical pain was the most prominent pre-surgical patient concern, and nearly half reported they had high/very high anxiety levels about pain before surgery. Approximately 88% received analgesic medications to manage pain; of these, 80% experienced adverse effects and 39% reported moderate/severe pain even after receiving their first dose. Study limitations: Key study limitations include the relatively small population size, potential for recall bias associated with the 14-month average time delay from surgery date to survey date, and the inability to account for influences of type of surgery and intraoperative anesthetic/analgesic use on survey results. Conclusions: Despite heightened awareness and clinical advancements in pain management, there has been little improvement in post-surgical analgesia as measured by this survey of post-surgical patients.

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.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

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

A prospective comparison of a noninvasive cardiac output monitor versus esophageal doppler monitor for goal-directed fluid therapy in colorectal surgery patients

BACKGROUND:Goal-directed fluid therapy (GDFT) is associated with improved outcomes after surgery. The esophageal Doppler monitor (EDM) is widely used, but has several limitations. The NICOM, a completely noninvasive cardiac output monitor (Cheetah Medical), may be appropriate for guiding GDFT. No prospective studies have compared the NICOM and the EDM. We hypothesized that the NICOM is not significantly different from the EDM for monitoring during GDFT. METHODS:One hundred adult patients undergoing elective colorectal surgery participated in this study. Patients in phase I (n = 50) had intraoperative GDFT guided by the EDM while the NICOM was connected, and patients in phase II (n = 50) had intraoperative GDFT guided by the NICOM while the EDM was connected. Each patient’s stroke volume was optimized using 250-mL colloid boluses. Agreement between the monitors was assessed, and patient outcomes (postoperative pain, nausea, and return of bowel function), complications (renal, pulmonary, infectious, and wound complications), and length of hospital stay (LOS) were compared. RESULTS:Using a 10% increase in stroke volume after fluid challenge, agreement between monitors was 60% at 5 minutes, 61% at 10 minutes, and 66% at 15 minutes, with no significant systematic disagreement (McNemar P > 0.05) at any time point. The EDM had significantly more missing data than the NICOM. No clinically significant differences were found in total LOS or other outcomes. The mean LOS was 6.56 ± 4.32 days in phase I and 6.07 ± 2.85 days in phase II, and 95% confidence limits for the difference were −0.96 to +1.95 days (P = 0.5016). CONCLUSIONS:The NICOM performs similarly to the EDM in guiding GDFT, with no clinically significant differences in outcomes, and offers increased ease of use as well as fewer missing data points. The NICOM may be a viable alternative monitor to guide GDFT.

Association between Initial Fluid Choice and Subsequent In-hospital Mortality during the Resuscitation of Adults with Septic Shock

Background:Currently, guidelines recommend initial resuscitation with intravenous (IV) crystalloids during severe sepsis/septic shock. Albumin is suggested as an alternative. However, fluid mixtures are often used in practice, and it is unclear whether the specific mixture of IV fluids used impacts outcomes. The objective of this study is to test the hypothesis that the specific mixture of IV fluids used during initial resuscitation, in severe sepsis, is associated with important in-hospital outcomes. Methods:Retrospective cohort study includes patients with severe sepsis who were resuscitated with at least 2 l of crystalloids and vasopressors by hospital day 2, patients who had not undergone any major surgical procedures, and patients who had a hospital length of stay (LOS) of at least 2 days. Inverse probability weighting, propensity score matching, and hierarchical regression methods were used for risk adjustment. Patients were grouped into four exposure categories: recipients of isotonic saline alone (“Sal” exclusively), saline in combination with balanced crystalloids (“Sal + Bal”), saline in combination with colloids (“Sal + Col”), or saline in combination with balanced crystalloids and colloids (“Sal + Bal + Col”). In-hospital mortality was the primary outcome, and hospital LOS and costs per day (among survivors) were secondary outcomes. Results:In risk-adjusted Inverse Probability Weighting analyses including 60,734 adults admitted to 360 intensive care units across the United States between January 2006 and December 2010, in-hospital mortality was intermediate in the Sal group (20.2%), lower in the Sal + Bal group (17.7%, P < 0.001), higher in the Sal + Col group (24.2%, P < 0.001), and similar in the Sal + Bal + Col group (19.2%, P = 0.401). In pairwise propensity score–matched comparisons, the administration of balanced crystalloids by hospital day 2 was consistently associated with lower mortality, whether colloids were used (relative risk, 0.84; 95% CI, 0.76 to 0.92) or not (relative risk, 0.79; 95% CI, 0.70 to 0.89). The association between colloid use and in-hospital mortality was inconsistent, and survival was not uniformly affected, whereas LOS and costs per day were uniformly increased. Results were robust in sensitivity analyses. Conclusions:During the initial resuscitation of adults with severe sepsis/septic shock, the types of IV fluids used may impact in-hospital mortality. When compared with the administration of isotonic saline exclusively during resuscitation, the coadministration of balanced crystalloids is associated with lower in-hospital mortality and no difference in LOS or costs per day. When colloids are coadministered, LOS and costs per day are increased without improved survival. A large randomized controlled trial evaluating crystalloid choice is warranted. Meanwhile, the use of balanced crystalloids seems reasonable. (Anesthesiology 2015; 123:1385-93)

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery

BackgroundEnhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery “bundles” because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain.MethodsIn the “Perioperative Quality Initiative (POQI) Fluids” workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP.DiscussionWe discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid.

New evidence in trauma resuscitation - is 1:1:1 the answer?

Traumatic injury is a common problem, with over five million worldwide deaths from trauma per year. An estimated 10 to 20% of these deaths are potentially preventable with better control of bleeding. Damage control resuscitation involves early delivery of plasma and platelets as a primary resuscitation approach to minimize trauma-induced coagulopathy. Plasma, red blood cell and platelet ratios of 1:1:1 appear to be the best substitution for fresh whole blood; however, the current literature consists only of survivor bias-prone observational studies.

Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs

BACKGROUND The purpose of this study was to examine the impact of the sequential implementation of the enhanced recovery program (ERP) and surgical site infection bundle (SSIB) on short-term outcomes in colorectal surgery (CRS) to determine if the presence of multiple standardized care programs provides additive benefit. STUDY DESIGN Institutional ACS-NSQIP data were used to identify patients who underwent elective CRS from September 2006 to March 2013. The cohort was stratified into 3 groups relative to implementation of the ERP (February 1, 2010) and SSIB (July 1, 2011). Unadjusted characteristics and 30-day outcomes were assessed, and inverse proportional weighting was then used to determine the adjusted effect of these programs. RESULTS There were 787 patients included: 337, 165, and 285 in the pre-ERP/SSIB, post-ERP/pre-SSIB, and post-ERP/SSIB periods, respectively. After inverse probability weighting (IPW) adjustment, groups were balanced with respect to patient and procedural characteristics considered. Compared with the pre-ERP/SSIB group, the post-ERP/pre-SSIB group had significantly reduced length of hospitalization (8.3 vs 6.6 days, p = 0.01) but did not differ with respect to postoperative wound complications and sepsis. Subsequent introduction of the SSIB then resulted in a significant decrease in superficial SSI (16.1% vs 6.3%, p < 0.01) and postoperative sepsis (11.2% vs 1.8%, p < 0.01). Finally, inflation-adjusted mean hospital cost for a CRS admission fell from

State-of-the-art fluid management in the operating room

31,926 in 2008 to