Perioperative Care Plan Research Articles

Surgical site infection risk factors and risk stratification.

Preoperative identification of the risk factors for surgical site infection and patient risk stratification are essential for deciding whether surgery is appropriate, educating patients on their individual risk of complications, and managing postoperative expectations. Early identification of these factors is also necessary to help guide both patient medical optimization and perioperative care planning. Several resources are currently available to track and analyze healthcare-associated infections, including the Centers for Disease Control and Prevention's National Healthcare Safety Network. In addition, the Centers for Disease Control and Prevention and the American Academy of Orthopaedic Surgeons are exploring collaborative opportunities for the codevelopment of a hip and/or knee arthroplasty national quality measure for periprosthetic joint infection.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients. A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed. Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization. Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Perioperative care plan provides benefits for patients with diabetes

Perioperative care plan provides benefits for patients with diabetes

Enhanced recovery pathway following radical cystectomy

To evaluate perioperative enhanced recovery protocols for patients undergoing radical cystectomy and urinary diversion and describe our unique protocol. Radical cystectomy is a morbid procedure with rather long hospital stay and complication rates. The main reason for lengthy hospital stay is bowel complication including paralytic ileus. Different perioperative care plans have been recommended to decrease hospital stay and complication rate. Most of this recovery plans focus on enhancing gastrointestinal function recovery, pain management and early mobility. Enhanced recovery after surgery protocol includes pre, intra and postoperative evidence-based modifications for improving perioperative care of cystectomy patients. Significant shortening of hospital stay without increasing early complication or readmission rate could be achieved safely in most of the patients.

Enhanced Recovery Protocol after Radical Cystectomy for Bladder Cancer

Enhanced recovery after surgery protocols aim to improve patient care and decrease complications and hospital stay. We evaluated our enhanced recovery after surgery protocol, focusing on length of stay, early complication and readmission rates after radical cystectomy for bladder cancer. From May 2012 to July 2013 a perioperative protocol was applied in 126 consecutive patients who underwent open radical cystectomy and urinary diversion. Nonconsenting patients (2), those with previous diversion (2) and prolonged postoperative intubation (3), and those who underwent additional surgery (9) were excluded from study. The protocol focuses on avoiding bowel preparation and nasogastric tube, early feeding, nonnarcotic pain management and the use of cholinergic and μ-opioid antagonists. Outcomes were compared to those in matched controls from our bladder cancer database. A total of 110 patients with a median age of 69 years were included in analysis, of whom 68% underwent continent urinary diversion. Of the patients 82% had a bowel movement by postoperative day 2. Median length of stay was 4 days. The 30-day minor and major complication rates were 64% and 14%, respectively. The most common minor complication was anemia requiring transfusion in 19% of patients, urinary tract infection in 13% and dehydration in 10%. The latter 2 complications were the most common etiologies for readmission. The 30-day readmission rate was 21% (23 patients). Patients 75 years old or older had a longer length of stay (5 vs 4 days, p = 0.03) and a higher minor complication rate (72% vs 51%, p = 0.04) than younger patients. Our enhanced recovery after surgery protocol expedites bowel function recovery and shortens hospital stay after RC and urinary diversion without an increase in the hospital readmission rates.

Enhanced Recovery Pathways: Organization of Evidence-Based, Fast-Track Perioperative Care

Enhanced recovery pathways (ERPs) are standardized coordinated, multidisciplinary perioperative care plans that incorporate evidence-based interventions to minimize surgical stress, improve physiologic and functional recovery, reduce complications, and thereby facilitate earlier discharge from the hospital. Several perioperative elements contribute to enhance surgical recovery. Preoperative elements include patient education, optimization of medical conditions and functional status, nutritional support, smoking cessation programs, minimization of preoperative fasting and preoperative carbohydrate drinks, avoidance of mechanical bowel preparation when not indicated, and avoidance of long-active sedatives as premedication. Intraoperative elements aim to attenuate the surgical stress response and include regional or local anesthesia; pharmacologic adjuvants, nonopioid analgesics, and maintaining normothermia; intravenous fluid management; and opting to favor small incisions when possible. Postoperative elements include considering multimodal analgesia (opioid-sparing strategies); encouraging early postoperative feeding; stressing the importance of early mobilization; restricting the unnecessary use of intravenous fluids, drains, and catheters; and instituting a discharge and follow-up plan for patients. Tables describe the evolution of intraoperative fluid management, organization of a multimodal perioperative care plan for a specific procedure or group of procedures; key elements to include in developing an ERP; sample multimodal perioperative care plans for elective colorectal resection, esophageal resection, and ambulatory laparoscopic cholecystectomy. This review contains 1 figure, 6 tables, and 319 references.

Enhanced Recovery Pathways: Organization of Evidence-Based, Fast-Track Perioperative Care

Enhanced recovery pathways (ERPs) are standardized coordinated, multidisciplinary perioperative care plans that incorporate evidence-based interventions to minimize surgical stress, improve physiologic and functional recovery, reduce complications, and thereby facilitate earlier discharge from the hospital. Several perioperative elements contribute to enhance surgical recovery. Preoperative elements include patient education, optimization of medical conditions and functional status, nutritional support, smoking cessation programs, minimization of preoperative fasting and preoperative carbohydrate drinks, avoidance of mechanical bowel preparation when not indicated, and avoidance of long-active sedatives as premedication. Intraoperative elements aim to attenuate the surgical stress response and include regional or local anesthesia; pharmacologic adjuvants, nonopioid analgesics, and maintaining normothermia; intravenous fluid management; and opting to favor small incisions when possible. Postoperative elements include considering multimodal analgesia (opioid-sparing strategies); encouraging early postoperative feeding; stressing the importance of early mobilization; restricting the unnecessary use of intravenous fluids, drains, and catheters; and instituting a discharge and follow-up plan for patients. Tables describe the evolution of intraoperative fluid management, organization of a multimodal perioperative care plan for a specific procedure or group of procedures; key elements to include in developing an ERP; sample multimodal perioperative care plans for elective colorectal resection, esophageal resection, and ambulatory laparoscopic cholecystectomy. This review contains 1 figure, 6 tables, and 319 references.

The Evidence against Prophylactic Nasogastric Intubation and Oral Restriction

Evidence-based perioperative care plans after colorectal surgery serve to improve quality outcome, decrease complications, and reduce medical cost. The benefits of routine nasogastric decompression and prolonged enteral restriction after bowel resection are not supported in this new era of evidence-based surgical care. Prophylactic nasogastric decompression fails to improve bowel function, length of stay, and prevent anastomotic leak, wound complications (infection, fascial dehiscence, incisional hernia), pulmonary complications (atelectasis, aspiration, pneumonia, fever, pharyngolaryngitis), and abdominal discomfort (distension, nausea, vomiting). Patients have earlier return of bowel function without the use of a nasogastric tube (NGT). Early refeeding within 24 hours after bowel resection is well tolerated in 80 to 90% of patients, and associated with earlier hospital discharge, decreased risk of infection, and improved postoperative hyperglycemic control. Abdominal discomfort is the most common complication observed in patients treated with early feeding and without a NGT, but does not result in higher therapeutic nasogastric intubation, postoperative ileus, aspiration, or other complications. The use of multimodal adjuncts in combination with these guidelines should be considered to improve outcome. The current literature is reviewed with suggestions for achieving better outcomes after colorectal resection.

Changes in perioperative management of radical prostatectomy using clinical pathways according to a standardized care plan: A multi‐institutional study

To improve the perioperative care for radical prostatectomy patients at a multi-institutional level and practice. A prospective multi-institutional study involving 50 hospitals was carried out in cooperation with the Japanese Society of Endourology. As the first step, a consensus meeting was held to establish a standardized perioperative care plan. Second, the clinical pathways were individually developed and revised according to the standardized care plan in each of the participating hospitals. Patterns of perioperative care, including preoperative hospital stay, resuming meals and ambulation, removal of pelvic drain and urethral catheter, antimicrobial administration, and postoperative hospital stay, were compared before (2007) and after developing/revising pathways (2009). Furthermore, actual practice and complications before and after implementing the pathways were investigated. Except for resuming ambulation, all perioperative pathways were significantly shortened with the adoption of the newly defined clinical pathway (P < 0.001). Furthermore, all settings except for postoperative hospital stay significantly decreased in terms of variance (P < 0.002). In 2009, the overall complication rate significantly decreased (P < 0.001), and all of the outcomes except urethral catheter removal were also significantly shortened (P ≤ 0.008) and decreased in variance after implementation of the new pathways (P ≤ 0.006). In multivariate analyses, implementation of the refined clinical pathways was an important factor to improve perioperative care. When standardized goals in perioperative care are recommended to hospitals and care plans are developed/revised in individual hospitals, both settings and practice are significantly improved. It is to be investigated whether a similar intervention could be useful to achieve a standardization of surgical pathway for other diseases.

Influence of hospital surgical volume of radical prostatectomy on quality of perioperative care

We investigated the relationships between hospital surgical volume, surgical outcome, care plans indicated in critical pathways and actual perioperative care using data from a nationwide survey for radical prostatectomy. In this study, urologists from 155 hospitals in Japan cooperated in submitting the data of 4,029 patients who underwent radical prostatectomy in 2007, and the perioperative care plan in critical pathways. Of these, we analyzed data of 3,499 patients undergoing open radical prostatectomy and minimum incision endoscopic radical prostatectomy. Increasing hospital volume was associated with decreased proportion of open radical prostatectomy (p < 0.001). As the hospital volume increased, surgical duration was significantly shorter (p < 0.001) and bleeding volume decreased (p < 0.004). Analyses of perioperative care suggested that low-volume hospitals (<15 patients annually) were likely to have longer care than medium-volume (15-29 patients per year) or high-volume (≥30 patients per year) hospitals, and the length of actual care was prolonged in the low-volume hospitals. Multivariate logistic regression analysis suggested that the occurrence of postoperative complications was significantly associated with surgeon's volume (p = 0.004), patient age (p = 0.001), preoperative anticoagulant therapy (p = 0.045), coexistent diabetes mellitus (p = 0.009), surgical duration (p = 0.002) and bleeding volume (p < 0.001), but not hospital volume. Urologists in high-volume hospitals appeared to attempt new types of surgery. Hospital surgical volume was strongly associated with the surgical duration, bleeding volume and planned and actual perioperative care; however, it was not associated with postoperative complications.

Totally laparoscopic resection of the splenic flexure for tumor

Colonic tumors located at the splenic flexure are rare and show a higher occlusive risk than other colorectal cancers. The totally laparoscopic segmental resection of splenic flexure represents a challenging procedure that requires adequate technical skills and for this reason it is still not widespread and validated. Between October 2010 and March 2012, a consecutive unselected series of eight (N = 8) patients underwent totally laparoscopic splenic flexure resection at our Institute. Data on patients' demographics, disease features, operative details and short-term follow-up were prospectively recorded in a specific database and retrospectively analyzed. All the operations were performed or supervised by the same surgeon (I.S.). We used a four-port medial-to-lateral standardized technique with intracorporeal anastomosis. A selective vascular ligation was performed in all cases and the specimens were extracted through a protected incision. Perioperative care plan and surgical instrumentations were standardized. Complications were classified using the Clavien-Dindo classification system. No conversion to open surgery was registered. All cases achieved an adequate number of lymph nodes harvested (22.9 ± 5.2) and an oncologically correct resection of the tumor (proximal margin 7.0 ± 2.4 cm, distal margin 7.1 ± 2.8 cm). The mean hospital stay was 6.1 ± 1.3 days. Postoperative complication rate according to the Clavien-Dindo system was 37.5 %, but all the complications reported were grade I. We did not observe any reoperation or readmission within 60 days after discharge. Totally laparoscopic splenic flexure resection is a feasible and reproducible technique. A correct surgical indication and a standardized technique allow to perform an oncologically safe and functionally effective treatment.

Totally laparoscopic versus laparoscopic assisted right colectomy for cancer

IntroductionColorectal cancer (CRC) is one of the leading causes of cancer death all over the world and right-sided colon cancer represents approximately 15% of all cases of CRC. Laparoscopic colectomies produce advantages in short-term outcome compared to open procedures and have recently benefited by a long term oncologic validation. This study was designed to compare the short- and medium-term surgical outcomes of totally laparoscopic (TLRC) and laparoscopic-assisted right colectomy (LARC) for neoplasia, hypothesizing they may be at least similar. MethodsA consecutive unselected series of 72 patients undergone elective surgery for right-sided colon cancer from April 2006 to April 2011 was retrospectively evaluated. All patients were treated by laparoscopic medial-to-lateral right colectomy. In 42 patients a TLRC was performed, in 30 a LARC. Perioperative care plan, operative steps and surgical instrumentations were standardized. All the operations were performed or supervised by the same Surgeon (I.S.). Data on the patients' demographics, disease features, operative details and follow up were recorded and analyzed. Complications were classified using the Clavien–Dindo classification system. Continuous variables were expressed as mean ± standard deviation and analyzed with the Student t test. Categorical ones were expressed as percent value and analyzed with Fischer test or Chi-square test, where appropriate. P < 0.05 were considered statistically significant. ResultsThere was no significant difference in term of age, sex, body mass index and American Society of Anesthesiology score between the two groups. Comorbidities, site of tumor and stage of disease were similar too.No conversion to laparotomy was registered. Median operative time (186.3 ± 40.1 min vs 176.5 ± 40.0 min; not significant (NS)) and estimated blood loss (43.3 ± 89.8 ml vs 31.2 ± 51.3 ml; NS) were statistically comparable in both groups. Timing of first defecation (3.4 ± 0.9 dd vs 2.9 ± 0.9; P = 0.023) and length of hospital stay (7.2 ± 1.3 dd vs 6.2 ± 1.1 dd; P < 0.001) were statistically lower in TLRC cohort. A significantly longer length of skin incision characterized LARC group compared with TLRC group (71.0 ± 13.5 mm vs 48.2 ± 10.2 mm; P < 0.001). Both groups achieved an adequate number of lymph nodes harvested (22.0 ± 8.2 vs 25.9 ± 9.0; P = 0.036) and oncological resection of the tumor (proximal margin 7.6 ± 7.7 vs 6.1 ± 3.8; NS – distal margin 13.3 ± 7.7 vs 13.6 ± 5.8; NS). Post-operative complications according to Clavien–Dindo classification were statistically comparable in both cohorts. No readmission within 60 days of discharge was observed. The mean follow-up recorded was 27.7 ± 16.6 months. Late complications consisted in 1 case of incisional hernia (3.8%) in LARC group. ConclusionsAlthough more appropriate indications must be set by future studies, we encourage the choice of a TLRC for the treatment of cancer of the right colon. TLRC is actually a feasible and safe technique, which has resulted in an encouraging short-term outcome, low incidence of major complications and preservation of oncologic principles, without affecting operative times.

The Implementation of a Standardized Approach to Laparoscopic Rectal Surgery

The purpose of this study was to audit our results after implementation of a standardized operative approach to laparoscopic surgery for rectal cancer within a fast-track recovery program. From January 2009 to February 2011, 100 consecutive patients underwent laparoscopic surgery on an intention-to-treat basis for rectal cancer. The results were retrospectively reviewed from a prospectively collected database. Operative steps and instrumentation for the procedure were standardized. A standard perioperative care plan was used. The following procedures were performed: low anterior resection (n = 26), low anterior resection with loop-ileostomy (n = 39), Hartmann's operation (n = 14), and abdominoperineal resection (n = 21). The median length of hospital stay was 7 days; 9 patients were readmitted There were 9 cases of conversion to open surgery. The overall complication rate was 35%, including 6 cases (90/%) of anastomotic leakages requiring reoperation. The 30-day mortality was 5%. The median number of harvested lymph nodes was 15 (range, 2 to 48). There were 6 cases of positive circumferential resection margins. The median follow-up was 9 (range, 1 to 27) months. One patient with disseminated cancer developed port-site metastasis. The results confirm the safety of a standardized approach, and the oncological outcomes are comparable to those of similar studies.

Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay

The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery, and shorten hospital stay. This study was designed to determine which ERAS strategies contribute to overall shortened length of hospital stay in patients undergoing elective colorectal surgery in hospitals. A retrospective cohort study of 336 consecutive patients at seven hospitals was performed. Demographic and data on 18 ERAS components identified from a systematic review of the literature were collected. A multiregression analysis was performed to assess for factors independently associated with a total length of hospital stay of 5 days or less. Fifty-five percent were male (mean age, 62 years), 57.5% had an ASA III or IV, 76.9% had cancer, and 28.6% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On bivariate analysis, strategies associated with a stay ≤ 5 days were preoperative counseling, avoidance of oral bowel preparation, use of a laparoscopic approach, use of a transverse incision, introduction of clear fluids on day of surgery, and early discontinuation of the Foley catheter (all P < 0.05). On multivariate analysis, factors that remained significantly associated with a stay ≤ 5 days included use of a laparoscopic approach (odds ratio (OR), 1.24; 95% confidence interval (CI), 1.12-1.38), preoperative counseling (OR, 1.26; 95% CI, 1.15-1.38), intraoperative fluid restriction (OR, 1.26; 95% CI, 1.15-1.37), clear fluids on day of surgery (OR, 1.09; 95% CI, 1.00-1.2), and Foley urinal catheter discontinued within 24 h of colon surgery and 72 h of rectal surgery (OR, 1.13; 95% CI, 1.01-1.27). In hospitals with variable uptake of ERAS strategies, preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, and early discontinuation of the Foley catheter are all independently associated with shortened length of stay.

A prospective randomized multicenter study of Turkish Society of Urooncology comparing two different mechanical bowel preparation methods for radical cystectomy

ObjectiveTo investigate the outcomes and complication rates of urinary diversion using mechanical bowel preparation (BP) with 3 day conventional and limited BP method through a standard perioperative care plan. Materials and methodsThis study was designed as a prospective randomized multicenter trial. All patients were randomized to 2 groups. Patients in standard 3-day BP protocol received diet restriction, oral antibiotics to bowel flora, oral laxatives, and saline enemas over a 3-day period, whereas limited the BP arm received liberal use of liquid diet, sodium phosphate laxative, and self administered enema the day before surgery. All patients received same perioperative treatment protocol. The endpoints for the assessment of outcome were anastomotic leakage, wound infection, wound dehiscence, intraperitoneal abscess, peritonitis, sepsis, ileus, reoperation, and mortality. Bowel function recovery, including time to first bowel movement, time to first oral intake, time to regular oral intake, and length of hospital stay were also assessed. ResultsFifty-six patients in 3-day BP and 56 in limited BP arm were evaluable for the study end points. Postoperatively, 1 patient in limited BP and 2 patients in 3-day BP arm died. There was no statistical difference in any of the variables assessed throughout the study, however, a favorable return of bowel function and time to discharge as well as lower complication rate were observed in limited BP group. ConclusionsRegarding all endpoints, including septic and nonseptic complications, current clinical research offers no evidence to show any advantage of 3-day BP over limited BP.

Cardiopulmonary exercise testing and length of stay in patients undergoing major surgery

We read with interest the review published in Anaesthesia analysing studies that assessed the value of cardiopulmonary exercise testing (CPET) in evaluating risk in patients undergoing non-cardiopulmonary surgery [1]. Cardiopulmonary exercise testing is increasingly used in the pre-operative assessment of patients undergoing major surgery. Studies have shown a relationship between pre-operative CPET values and mortality [2], postoperative complications and length of hospital stay [3]. Our aim was to determine whether CPET measures might predict postoperative length of stay in both the critical care unit and hospital, in patients undergoing major surgery. We hoped CPET might then assist in better planning and organisation of peri-operative care. We retrospectively analysed data of all 325 patients who had undergone CPET at a large tertiary centre over a 26-month period (January 2008 to March 2010). To achieve some homogeneity in our sample, we selected a subgroup of patients undergoing major vascular or upper gastro-intestinal surgery for further analysis (n = 112). We acquired length of stay data from critical care admission records, hospital notes and discharge letters. We then estimated Spearman correlation coefficients for typical pre-operative CPET measures (anaerobic threshold, peak oxygen consumption and ventilatory equivalents for carbon dioxide (VE/VCO2)) and postoperative length of stay for critical care and hospital. A value of p < 0.05 was considered significant (two-sided). Two out of the 112 patients (1.8%) undergoing major vascular or upper gastro-intestinal surgery died. Median (IQR [range]) length of stay in critical care was 70 (46–110 [18–928]) h and in hospital was 10 (7–15 [3–51]) days. There were no significant correlations between any of the CPET measures and length of stay in either critical care or hospital (Table 1). Therefore, in our series, pre-operative CPET data were not useful in predicting lengths of stay in critical care or hospital. Our negative results may be explained by two reasons. Firstly, the factors influencing a patient’s length of stay are numerous and complex, for example a lack of beds, day of the week, social circumstances and the patient’s surgical team. Secondly, although efforts were made to correct for patients’ heterogeneity, this could have been improved further by comparing patients undergoing more similar procedures, for example, upper gastro-intestinal surgery only, as previous authors have suggested that different types of surgery may differ in sensitivity to CPET values [1]. We look forward to the results of further studies looking in more detail at the outcomes of surgical patients who have undergone pre-operative CPET testing. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com. Published with the permission of the Trust's Caldicott guardian.

1853 A STANDARDIZED PERIOPERATIVE CARE PLAN DECREASES LENGTH OF STAY IN PATIENTS UNDERGOING ROBOTIC PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized1 Apr 20111853 A STANDARDIZED PERIOPERATIVE CARE PLAN DECREASES LENGTH OF STAY IN PATIENTS UNDERGOING ROBOTIC PARTIAL NEPHRECTOMY Kenneth Jacobsohn, Peter Langenstroer, Mark Waples, and William See Kenneth JacobsohnKenneth Jacobsohn Milwaukee, WI More articles by this author , Peter LangenstroerPeter Langenstroer Milwaukee, WI More articles by this author , Mark WaplesMark Waples Milwaukee, WI More articles by this author , and William SeeWilliam See Milwaukee, WI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1900AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic-assisted partial nephrectomy (RPN) is gaining acceptance and being performed with increasing volume for small renal masses. There are no widely-accepted perioperative management guidelines for these patients. In January 2010 we implemented a perioperative care plan for our RPN patients with the goal of standardizing and improving their outcomes. METHODS Following IRB approval we retrospectively reviewed the charts of all patients undergoing RPN by a single surgeon at our facilities from August 2008 until September 2010 and was performed using a 3 or 4 arm approach with the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA). Our perioperative care plan was implemented in January 2010 and consisted of preoperative counseling, pathway orders, oral analgesia, and early ambulation. RESULTS 71 patients underwent RPN at our institution, 48 prior to implementation of the plan and 23 after. Mean length of stay (LOS) was 2.9 days prior to implementation of the care plan and 1.4 days after (p=0.0002). 79% of patients were discharged on post operative day #1 following the implementation of the plan compared to 12.5% prior. There was no difference in complication, readmission or emergency room visit rates. Patient age, BMI, mean tumor size and warm ischemia time were 58 years, 30.1, 3.2cm and 17 minutes, and there was no statistically significant difference between the two groups. CONCLUSIONS Implementation of a perioperative care plan results in a significantly decreased LOS for patients undergoing RPN without impacting complication rates. Multi-institution studies of this care plan are needed to confirm its efficacy. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e743 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kenneth Jacobsohn Milwaukee, WI More articles by this author Peter Langenstroer Milwaukee, WI More articles by this author Mark Waples Milwaukee, WI More articles by this author William See Milwaukee, WI More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Fast Track Program in Patients Undergoing Radical Cystectomy: Results in 362 Consecutive Patients

This article outlines our current perioperative management of patients undergoing cystectomy and urinary diversion using advancements in perioperative care to allow for early institution of an oral diet and early hospital discharge. Three hundred sixty-two consecutive patients underwent radical cystectomy and urinary diversion with curative intent (2001 through 2008). Each underwent a perioperative care plan ("fast track" program). Throughout our experience, evidence-based modifications to this program were instituted. We analyzed the impact of these modifications and report the outcomes with the most recent 100 patients in whom no additional modification has been used. Mean age of patients is 66.3 years, with 44% of the patients older than age 70 years and 12% older than age 80 years. We found no detrimental effects to immediate removal of the orogastric tube at the end of the procedure, but found a beneficial effect of empiric metoclopramide use, with lower rates of nausea and vomiting. Perioperative antibiotic coverage has been reduced to 24 hours as per American Urological Association guidelines. Gum-chewing has also been shown to be of benefit with regard to a more rapid recovery of bowel function. Use of nonnarcotic analgesics (eg, ketrolac) has also been central in the pathway. Finally, early institution of an oral diet has been an original and central component to our fast track program. Successful application of a fast track program has been applied to our patients undergoing radical cystectomy and urinary diversion, with the potential to use evidence-based modifications to reduce morbidity and improve recovery.

P65 A multi-modality peri-operative care plan for radical cystectomy and urinary intestinal diversion. Comparison of results and complications in patients aged less than 75 years, and 75 years and older

Purpose of the study: To compare the results and complications in radical cystectomy patients younger than 75 years of age and 75 and older treated within a multi modality perioperative plan aimed at reducing, or preventing, the incidence of post operative ileus. Method(s): The core measures intended to prevent post-operative ileus consisted in the abolition of mechanical bowel preparation and fasting before surgery, the administration of opiod-sparing general, and combined thoracic epidural anaesthesia, prevention of hypovolemia, substitution of saline with dextrose, protracted post-operative epidural analgesia, and early provision of nutrients. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of postoperative ileus, incidence and nature of complications, constituted the study endpoints. Result(s): From Jan 2003 to Dec 2008 a total of 107 consecutive patients underwent radical cystectomy with some form of intestinal urinary reconstruction that were evaluable for results and complications 66 were aged 74 years or younger, median age 64.3, and 41 were 75, or older, median age 78.9. Bowel movements returned after a median time of 2 days, range 1 to 6, and the median time to re-institution of a regular diet was 4 days, range 3 to 9, in both groups. POI was observed in 17.7%. The overall complication rate was 24.2%, mortality rate 3.4%. Conclusion(s): Short time to resumption of normal intestinal function and low incidence of post operative ileus were attained in both age groups by applying a peri-operative plan aimed at enhancing the post-operative recovery of intestinal function. Further studies on peri-operative regimens are needed.

Risk factors for perioperative adverse events in children with myotonic dystrophy

This study was conducted to identify patient-related, surgical, and anesthetic factors that would help predict adverse events and allow for better planning of perioperative care in children with myotonic dystrophy. This is a retrospective chart review from a large tertiary pediatric hospital. Data were collected on demographics, disease severity, surgical procedure, and anesthetic technique. Perioperative adverse events were recorded. Records on 27 patients having 78 anesthetics over a 17.5-year period were reviewed. The overall frequency of postoperative respiratory complications was 10%. Significant risk factors were high muscular impairment rating scale (MIRS) grade (P = 0.007), at least 2300 cytosine, thymine, guanine (CTG) repeats on the protein kinase gene of chromosome 19q (P = 0.009), a longer duration of surgery (RR = 14.0 for surgery lasting at least 1 h; P = 0.002), perioperative morphine use (RR = 7.7, 95% CI 2.2-12.8; P = 0.005), intubation (P = 0.02), and the use of muscle relaxant without reversal (RR = 15.5, P = 0.0002). Using a multivariate risk model, only MIRS grade and the use of muscle relaxant without reversal were shown to be significant independent risk factors (RR = 24.9, P < 0.0001). The MIRS is a statistically significant and clinically useful tool for predicting high perioperative risk. Patients with a high MIRS grade should therefore be considered for postoperative intensive care. The use of muscle relaxant without reversal was also shown to be a significant risk factor. Patients who require morphine infusions postoperatively might also be most safely managed in a high dependency unit.