Postoperative Quality Of Recovery Research Articles

Validation of the Chinese Version of the Quality of Recovery-15 Score and Its Comparison with the Post-Operative Quality Recovery Scale.

The Quality of Recovery-15 scale (QoR-15) is an easy-to-use score for assessing the quality of post-operative recovery. The primary aim of the present study was to translate the QoR-15 into the Chinese language and validate it. The secondary aim was to compare it with the Post-operative Quality Recovery Scale (PQRS). The Chinese version of the QoR-15 (QoR-15C) was developed according to the methods adopted by the International Quality of Life Assessment project. A total of 470 patients undergoing surgery and general anesthesia completed the QoR-15C and the PQRS before or on the day of surgery, and on post-operative days (POD)-1, -3, and -30. To validate the QoR-15C, we assessed validity, reliability, responsiveness, and clinical feasibility and compared them with those of the PQRS. Convergent validity showed the Pearson's r coefficient of the QoR-15C with visual analog scale and the PQRS to be 0.63 and 0.10, respectively. Predictive validity showed it had significant correlations with duration of anesthesia, duration of operation, time in post-anesthesia care unit, time in intensive care unit, and length of hospital stay. Discriminant validity showed it differed between patients who had a good or poor recovery, and decreased with increasing grades (indicating difficulty and complexity) of surgery. The intraclass correlation coefficient, split-half coefficient, and Cronbach's α were 0.99, 0.70, and 0.76, respectively. The standardized effect size ranged from 0.85 to 1.20, and the standardized response mean ranged from 0.93 to 1.27. Compared with the QoR-15C, the PQRS may have inferior convergent validity (0.36 vs. 0.63), and split-half reliability (0.63 vs. 0.70). Furthermore, the PQRS took longer to complete: 4.20 (standard deviation 0.79) versus 1.57 (standard deviation 0.65) min. Similar to the original English version, the QoR-15C reveals satisfactory psychometric properties. Furthermore, it may be a more valid, reliable, and easy-to-use scale than the PQRS.

The importance of postoperative quality of recovery: influences, assessment, and clinical and prognostic implications.

Quality of recovery is a complex construct whose definition is influenced heavily by the opinions and biases of the individual patient, clinician, or institution. Asa result, recovery assessment tools differ in their fundamental definitions of recovery, breadth, and assessment time frame. Accurate assessment of recovery is essential as suboptimal recovery has both economic and prognostic implications. Quality of care is often substituted as a surrogate at the institutional level for quality of recovery, but it is ideologically distinct from patients' perceived quality of care, recovery, and satisfaction. Recovery tools also differ in their assessment of recovery as a continuous vs dichotomous variable and in their focus at the group vs individual level. Ideally, recovery measures should assess outcomes in a simple dichotomous fashion and maintain relevancy by assessing in multiple domains at various time points. Assessment of recovery in a dichotomous fashion also has both clinical and research applications. It allows identification of suboptimal recovery at both individual and group levels,respectively, and when performed in real time, it allows the opportunity for timely targeted intervention specific to individual patients as well as for resource rationalization.

The Effect of Preoperative Oral Carbohydrate or Oral Rehydration Solution on Postoperative Quality of Recovery: A Randomized, Controlled Clinical Trial

BackgroundNumerous studies have demonstrated the beneficial effects of preoperative administration of oral carbohydrate (CHO) or oral rehydration solution (ORS). However, the effects of preoperative CHO or ORS on postoperative quality of recovery after anesthesia remain unclear. Consequently, the purpose of the current study was to evaluate the effect of preoperative CHO or ORS on patient recovery, using the Quality of Recovery 40 questionnaire (QoR-40).MethodsThis prospective, randomized, controlled clinical trial included American Society of Anesthesiologists (ASA) physical status 1 and 2 adult patients, who were scheduled to undergo a surgical procedure of body surface. Subjects were randomized to one of the three groups: 1) preoperative CHO group, 2) preoperative ORS group, and 3) control group. The primary outcome was the global QoR-40 administered 24 h after surgery. Intraoperative use of vasopressor, intraoperative body temperature changes, and postoperative nausea and vomiting (PONV) were also evaluated.ResultsWe studied 134 subjects. The median [interquartile range (IQR)] global QoR-40 scores 24 h after the surgery were 187 [177–197], 186 [171–200], and 184 [171–198] for the CHO, ORS, and control groups, respectively (p = 0.916). No significant differences existed between the groups regarding intraoperative vasopressor use during the surgery (p = 0.475).ConclusionsResults of the current study indicated that the preoperative administration of either CHO or ORS did not improve the quality of recovery in patients undergoing minimally invasive body surface surgery.Trial Registration www.umin.ac.jp UMIN000009388 https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000011029&language=E

Effect of dexmedetomidine combined with seven isoflurane for elderly patients with rectal cancer radical operation on recovery quality

Objective To investigate the effects of dexmedetomidine combined with sevoflurane on elderly patients with postoperative recovery quality. Methods Selected 60 cases of abdominal rectal cancer resection for elderly patients,which were ASA I or II,were randomly divided into two groups by a random number table method,while each groupincluded 30 cases:the control group(group N)and the dexmedetomidine group(group D).Before the induction of anesthesia,group D vein was injected with micro pump(more than 10 min) of dexmedetomidine 1μg/kg (which was formulated with physiological saline as 4μg/mL),and then was given to maintain the dexmedetomidine 0.5μg/h and N group was injected with micro pump of the same volume of normal saline.The two groups of anesthesia were same,by which the static inhalation of composite general anesthesia.Observation were recorded before induction of anesthesia(T0),given dexmedetomidine(TI),after intubation 1 min(T1),5 min(T2),drawing tube immediately(T3),extubation after 5min(T4),30min(T5)the time of HR,BP,Sp O2,BIS;propofol and remifentanil dosage,operative time,operation time,a nesthesia time,recovery time,drawing tube time,extubation after Ramsay Sedation score,pain score,patient satisfaction and adverse reactions were recorded. Results In T3 period,the changes of HR (82±14)times/min,SBP(130±8)mm Hg,DBP(85±13)mm Hg in group N were more obvious than(70±12) timse/min,SBP(121±7)mm Hg,DBP(79±9)mm Hg in group D,the difference between the two groups had statistical significance(t= 6.28,4.63,2.08,all P 0.05).In group N,postoperative restlessness in 8 cases,nausea and vomiting in 10 cases,chills in 9 cases,which were significantly higher than 2 cases,2 cases,2 cases in group D(χ2= 4.32,6.67,5.45,all P< 0.05).At the same time,the satisfaction score of patient in group D(3.0±0.3) point,which was significant higher than(2.7±0.5)points in group N(t= 1.88,P<0.05). Conclusion Dexmedetomidine detomidine composite sevoflurane anesthesia can improve the postoperative recovery quality of elderly patients with rectal cancer radical surgery. Key words: Rectal Carcinoma; Dexmedetomidine; Seven halothane; Aged

Effect of superficial cervical plexus block on postoperative quality of recovery after anterior cervical discectomy and fusion: a randomized controlled trial.

Spine surgeries are increasingly being performed asa day or short-stay surgery programs. Peripheral nerve block provide site-specific pain relief with few side effects, thereby reducing surgical stress and enhancing quality of recovery. The aim of our study was to determine the effect of a superficial cervical plexus block (SCPB) on postoperative quality of recovery and analgesia in patients undergoing elective anterior cervical discectomy and fusion (ACDF). After Research Ethics Board approval, we enrolled adults (>18yr) scheduled for elective single- or two-level ACDF in this randomized double-blind clinical trial. Participants were randomized to receive either a SCPB (0.25% bupivacaine, 10mL) or No Block. The primary outcome measure was the quality of recovery at 24hr, measured using the 40-item quality of recovery questionnaire (QoR-40). In addition, comparisons between groups were also made for postoperative opioid consumption and discharge times. Forty-six patients were randomized to receive either a SCPB block (n=23) or No Block (n=23). Median [interquartile range] aggregated global QoR-40 scores at 24hr were significantly greater in the SCPB group, indicating good quality of recovery compared with the No Block group (179 [116-195] vs 157 [97-196], respectively; median difference, 22; 95% confidence interval [CI], 7 to 34; P=0.002]. There were no differences between the SCPB and the No Block group with regard to mean (standard deviation) postoperative opioid consumption at 24hr [22.9 (13.6) mg vs 24.6 (9.5)mg, respectively; mean difference 1.7; 95% CI, -5.2 to 8.7; P=0.620] and the number of patients discharged within 24hr (15 vs 12, respectively; P=0.550). We showed that preoperative SCPB is an effective strategy for improving the early quality of recovery in patients undergoing single- or two-level ACDF. Nevertheless, there was no impact on opioid consumption or discharge times. This trial was registered at www.clinicaltrials.gov (NCT01662219).

Effects of Preoperative Dexamethasone on Postoperative Quality of Recovery following Vaginal Reconstructive Surgery: A Randomized Controlled Trial

Effects of Preoperative Dexamethasone on Postoperative Quality of Recovery following Vaginal Reconstructive Surgery: A Randomized Controlled Trial

Using a Mobile App for Monitoring Post-Operative Quality of Recovery of Patients at Home: A Feasibility Study

BackgroundMobile apps are being viewed as a new solution for post-operative monitoring of surgical patients. Mobile phone monitoring of patients in the post-operative period can allow expedited discharge and may allow early detection of complications.ObjectiveThe objective of the current study was to assess the feasibility of using a mobile app for the monitoring of post-operative quality of recovery at home following surgery in an ambulatory setting.MethodsWe enrolled 65 consecutive patients (n=33, breast reconstruction surgery; n=32, orthopedic surgery) and asked them to use a mobile phone daily to complete a validated quality of recovery scale (QoR-9) and take photographs of the surgical site for the first 30 days post-op. Surgeons were asked to review patient-entered data on each patient in their roster daily. A semistructured questionnaire was administered to patients and surgeons to assess satisfaction and feasibility of the mobile device.ResultsAll 65 patients completed the study. The mean number of logins was 23.9 (range 7-30) for the breast patients and 19.3 (range 5-30) for the orthopedic patients. The mean number of logins was higher in the first 14 days compared to the 15-30 days post-op for both breast patients (13.4 vs 10.5; P<.001) and for the orthopedic patients (13.4 vs 6.0; P<.001). The mean score for overall satisfaction with using the mobile device was 3.9 for breast patients and 3.7 for orthopedic patients (scored from 1 (poor) to 4 (excellent)). Surgeons reported on the easy-to-navigate design, the portability to monitor patients outside of hospital, and the ability of the technology to improve time efficiency.ConclusionsThe use of mobile apps for monitoring the quality of recovery in post-operative patients at home was feasible and acceptable to patients and surgeons in the current study. Future large scale studies in varying patient populations are required.

Evidence Based Alternative Medicines in Pain Management.

Evidence Based Alternative Medicines in Pain Management.

Transcutaneous Electrical Acupoint Stimulation Improves the Postoperative Quality of Recovery and Analgesia after Gynecological Laparoscopic Surgery: A Randomized Controlled Trial.

Background. We conducted this prospective, randomized, double-blind, placebo-controlled study to evaluate the effects of transcutaneous electric acupoint stimulation (TEAS) on the quality of recovery (QoR) and postoperative analgesia after gynecological laparoscopic surgery. Methods. 74 American Society of Anesthesiologists physical status (ASA) I or II patients undergoing gynecological laparoscopic surgery were randomly allocated to TEAS or control groups. The primary outcome was the quality of recovery, which was assessed on the day before surgery and 24 h after surgery using a 40-item questionnaire. Secondary outcomes included postoperative pain scores, the incidence of postoperative nausea and vomiting (PONV), duration of postanesthesia care unit (PACU) stay, and patient's satisfaction. Results. The TEAS group had higher QoR scores than control group upon 24 h after surgery (177 versus 165; P < 0.001). Compared with the control group, postoperative pain scores and the cumulative number of opioids administered were lower in the TEAS group patients (P = 0.04). TEAS reduced the incidence of PONV and dizziness, as well as duration of PACU stay. Simultaneously, the patient's satisfaction scores were higher in the TEAS group (P = 0.002). Conclusion. Preoperative TEAS enhances QoR, improves postoperative analgesia and patient's satisfaction, alleviates postoperative side effects, and accelerates discharge after general anesthesia for gynecological laparoscopic surgery.

Cognitive recovery after ambulatory anaesthesia based on desflurane or propofol: a prospective randomised study.

The impact of anaesthetic agents on cognitive recovery during the first post-operative week in a middle-aged population undergoing general anaesthesia is insufficiently studied. We hypothesised that patients receiving anaesthesia based on desflurane would have a quicker recovery and regain cognitive capacity faster than patients receiving anaesthesia based on propofol. We performed a prospective, randomised, single-blinded study comparing the effects of desflurane and propofol as primary anaesthetic agents on cognitive recovery in 59 American Society of Anesthesiologists Physical Status Classification System I-II women undergoing breast surgery. Cognitive recovery was evaluated using the Cognitive Failure Questionnaire and a modified version of the Post-operative Quality of Recovery Scale. Post-operative cognitive recovery according to Cognitive Failure Questionnaire was 65% and 66% at 72 h, and 71% and 72% at 1 week for the desflurane and the propofol groups, respectively. Recovery according to Post-operative Quality of Recovery Scale was 52% and 50% at 2 h, increasing to 71% and 87% at 48 h for the desflurane and the propofol groups, respectively. At the final point of measurement (Cognitive Failure Questionnaire 1 week, Post-operative Quality of Recovery Scale 48 h), many of the patients had still not reached their baseline cognitive performance. There was no difference in overall cognitive recovery between the desflurane and propofol groups. Cognitive recovery was not complete 1 week after surgery in any of the groups. There was no difference in the rate of cognitive recovery in middle-aged patients receiving desflurane or propofol anaesthesia during ambulatory breast surgery.

A review of the scope and measurement of postoperative quality of recovery.

To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient-focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.

Prospective randomized controlled trial of conventional laparoscopic versus laparoendoscopic single-site radical nephrectomy for localized renal cell carcinoma: a preliminary report regarding quality of life.

The safety and efficacy of laparoendoscopic single-site surgery (LESS) for renal cell carcinoma (RCC) have not been clearly demonstrated. We aimed to present preliminary data from a prospective randomized controlled trial of LESS versus conventional laparoscopic radical nephrectomy for localized RCC. Patients with cT1-2 RCC were randomized to LESS (n = 17) or conventional laparoscopy (n = 18) group. The short-term outcome measures assessed were perioperative morbidity, postoperative pain, and quality of recovery as determined using QoR-40. No significant differences were observed between the LESS and conventional laparoscopy groups with respect to operative time (143.5 vs. 126.1 min, p = 0.218), blood loss (143.6 vs. 118.2 ml, p = 0.121), hospital stay (3.8 vs. 3.1 day s, p = 0.170), analgesic requirements (63.2 vs. 60.0 mg, p = 0.956), and complication rates (26.7 vs. 22.2 %, p = 0.767). However, postoperative quality of recovery was better in the LESS group (176.4 vs. 152.6, p = 0.005). Furthermore, quality of recovery, as measured using the QoR-40 dimensions of emotional state (39.9 vs. 34.0, p = 0.003), physical comfort (51.9 vs. 46.7, p = 0.034), psychological support (32.2 vs. 25.8, p = 0.003), and physical independence (20.7 vs. 17.5, p = 0.047), but not pain (31.8 vs. 29.6, p = 0.259), was significantly better in the LESS group. The preliminary results from this prospective trial suggest that LESS could be a safe and effective treatment option for localized RCC with equivalent surgical outcomes and improved postoperative quality of recovery compared with conventional laparoscopic surgery.

Ultrasound-guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection

Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection. Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1-T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time. Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas-based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced. Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery

BackgroundBoth peripheral nerve blocks with sedation or general anesthesia can be used for total knee replacement surgery.ObjectivesWe compared these anesthetic techniques on the postoperative quality of recovery early in elderly patients.Materials and methodsIn our study, 213 patients who were ≥65 years old and undergoing total knee replacement were randomized to peripheral nerve blocks (PNBs) – lumbar plexus and sciatic – with propofol sedation, or general anesthesia with combined propofol and remifentanil. Blocks were performed using nerve stimulation and 0.35% ropivacaine. All patients received postoperative multimodal analgesia. Postoperative recovery was assessed at 15 minutes, 40 minutes, 1 day, 3 days, and 7 days after surgery, with the Postoperative Quality of Recovery Scale, in physiological, nociceptive, emotive, modified activities of daily living, modified cognitive, and overall patient perspective domains.ResultsIntraoperative blood pressure and heart rate were more stable with PNBs (P<0.001). The recovery was better with PNBs in physiological (P<0.001), emotive (depression and anxiety) (P<0.001), nociceptive (pain and nausea) (P<0.001), modified cognitive (P<0.001), and all domains recovery (P<0.001), but not in activities of daily living (P=0.181). Intraoperative drugs and the postoperative sulfentanil requirement of the PNBs group were lower (all P<0.001). Differences were greatest early after surgery with equivalence by 1 week. Satisfaction was high and not different between groups (P=0.059).ConclusionLumbar plexus and sciatic blocks with sedation facilitates faster postoperative recovery than general anesthesia, but not at 1 week after total knee replacement in patients who were 65 years or older. The trial has been registered at ClinicalTrials.gov. (NCT01871012).

Use of quality of recovery score (QoR40) in the assessment of postoperative recovery and evaluation of enhanced recovery after surgery protocols

Surgery has become less invasive with technological advances in surgical instruments and imaging. In addition, safer anesthesia has been achieved with the use of airway management tools including the video laryngoscope and supraglottic airway device, perioperative assessment by transesophageal echocardiography during noncardiac and cardiac surgery, and new anesthetic agents and muscle relaxants such as remifentanil and rocuronium bromide. Nowadays, there is an emphasis on the quality of postoperative recovery [1]. Quality of recovery, an important postoperative outcome, is classified into two categories [2]: doctor-reported outcome (DRO) and patient-reported outcome (PRO). DRO includes survival, adverse events, and length of hospital stay; PRO includes quality of life (QoL), quality of recovery, and patient satisfaction. The Food and Drug Administration defines PRO as ‘‘any report on the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else’’ [2]. Litwin et al. [3] showed that physician ratings of patient symptoms do not correlate well with patient self-assessment of health-related QoL, suggesting that both DRO and PRO are important. Donabedian’s classical model of quality of care consists of three components: structure, process, and outcomes [4]. The Donabedian model is applicable to perioperative medicine (Fig. 1). Monitoring and evaluation of both DRO and PRO are essential for improving quality of care.

Effect of intravenous lidocaine on postoperative recovery of patients undergoing mastectomy: a double-blind, placebo-controlled randomized trial.

One of the modalities of treatment for breast cancer surgery pain is opioids, and opioids are associated with adverse effects such as itching and postoperative nausea and vomiting (PONV). Intravenous (IV) lidocaine has been shown to reduce opioid consumption and to improve overall postoperative outcomes in abdominal surgery. In this study, we tested the effect of intraoperative IV lidocaine infusion on the quality of postoperative recovery after breast cancer surgery. Seventy-one patients undergoing breast cancer surgery were randomly assigned to receive either placebo (group P; n = 34) or IV lidocaine (group L; n = 37, bolus 1.5 mg/kg at induction, then infusion at 2 mg/kg/h, stopped 2 hours after the end of surgery) in a prospective double-blind design. Intraoperative and postoperative morphine consumption was calculated. Postoperative pain scores, PONV, and fatigue were assessed at 2, 24, and 48 hours after surgery. Duration of postoperative hospital stay was recorded. Demographics were the same between the groups. There was no statistically significant difference in intraoperative or postoperative morphine consumption (P = 0.188 and P = 0.758) between groups. Overall pain scores either at rest or activity (P = 0.348 and P = 0.810, respectively), PONV (P = 0.350), fatigue (P = 0.758), or duration of postoperative hospital stay (P = 0.218) were not statistically different. Our findings did not show a significant effect of IV lidocaine during breast cancer surgery on opioid consumption, pain score, PONV, or fatigue, indicating that the benefit of this approach does not generalize across all types of surgery.

Validation of the Turkish version of the quality of recovery-40 questionnaire

BackgroundThe Quality of Recovery-40 questionnaire (QoR-40) is a self-rated questionnaire used to assess the postoperative recovery quality and health status of patients in the early stages following surgery; however, there is no Turkish version of the QoR-40. The aim of this study was to assess the reliability, validity, and responsiveness of the Turkish version of the QoR-40 (QoR-40 T).MethodsAfter the approval of the ethics committee, a total of 137 patients completed the questionnaire during the preoperative period, on the third day, and one month after surgery. The quality of life was evaluated by using a health-related quality of life questionnaire (Short-Form Health Survey-36; SF-36) on the third day and one month after surgery. Reliability, feasibility, and validity were assessed to validate the QoR-40 T.ResultsThe Cronbach’s alpha of the global QoR-40 T on the third day after surgery was 0.936. A positive moderate correlation was obtained between the physical comfort, emotional state, physical independence, and pain dimensions of the QoR-40 T and the physical component summary, mental health, physical functioning, and bodily pain subscales of the SF-36 on the third day after surgery, respectively (physical comfort - physical component summary, ρ = 0.292, p = 0.001; emotional state - mental health, ρ = 0.252, p = 0.003; physical independence - physical functioning, ρ = 0.340, p < 0.01; pain - bodily pain, ρ = 0.381, p < 0.01). The standardized responsive mean of the total QoR-40 T was 0.62.ConclusionsThe QoR-40 T showed satisfactory reliability and validity in evaluating the quality of recovery after surgery in the Turkish population.

Introduction of ERAS® program into clinical practice: from preoperative management to postoperative evaluation

We, the chairpersons, chose ‘‘Enhanced Recovery After Surgery’’ as a topic of the 2013 Journal of Anesthesia symposium held on May 23, 2013. After reviewing all the manuscripts assigned to the section editor (Y.O.) from 2011 to 2012, we found that a large number of anesthesiologists are interested in preoperative evaluation and intraand postoperative management for improving patient satisfaction and prognosis. Besides providing adequate postoperative analgesia and preventing nausea and vomiting, developing a program targeting enhanced recovery after surgery has been one of the most popular themes among us. The initial idea of enhanced recovery goes back almost half a century, as oral rehydration therapy for the treatment of infectious disease [1]. Based on a long history and cumulated knowledge, the multimodal ERAS protocol has been established and is still under evolution [2]. In this symposium, we aimed at a comprehensive review of the concept of enhanced recovery after surgery, from preoperative management to postoperative evaluation, by four outstanding symposists. Dr. Taniguchi, a co-founder of enhanced recovery programs in our country, elaborated the introduction of the modified ERAS protocol in his institute [3]. He developed this program, originally named ‘‘preoperative oral rehydration therapy,’’ for improving the perioperative safety and satisfaction of the patients. His lecture, describing the modified ERAS protocol according to the current medical system in Japan and improved patient prognosis after its introduction, would have been quite informative to every Japanese anesthesiologist who is starting these programs in their institutes. Dr. Yatabe showed that preoperative oral carbohydrate treatment, in addition to contributing to shortening the preoperative fasting period, improves insulin resistance and prevents a decrease of body temperature during anesthesia in clinical and experimental studies [4]. Adequate control of both blood glucose and body temperature is a part of the ERAS protocol and significantly influences the postoperative outcome. Dr. Kitayama presented the effects of intraoperative analgesia with peripheral nerve block including transversus abdominis plane block and rectus sheath block with local anesthetics as well as thoracic epidural block with opioids. He also validated its safety from the point of plasma concentration of local anesthetics [5]. Dr. Shibata reviewed various kinds of peripheral nerve block, including brachial plexus block, from the point of nerve injury. Anesthesiologists are responsible for neurological complications induced by nerve block. He explained the differential diagnosis of nerve injury for early detection and prompt treatment [6]. Dr. Tanaka [7] developed the Japanese version of the quality of recovery (QoR) 40, a score for evaluating the quality of postoperative recovery originally created by Myles [8]. He translated the original score into Japanese, with modifications according to the Japanese medical system and validated from numerous aspects. The Japanese version of the QoR40 will appear in this manuscript. We believe this symposium was informative and has provided practical knowledge to many anesthesiologists. Y. Oda (&) Department of Anesthesiology, Osaka City General Hospital and Children’s Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan e-mail: odayou@msic.med.osaka-cu.ac.jp

Lorazepam does not improve the quality of recovery in day-case surgery patients

In day-case surgery, the effects of the anxiolytic lorazepam as premedication on the quality of postoperative recovery are unknown. To evaluate whether lorazepam as a premedication beneficially affects quality of recovery (primary outcome) and psychological manifestations (secondary outcome) after day-case surgery. A randomised, double-blind, placebo-controlled clinical trial. Single tertiary centre. day-case surgery; age at least 18 years. insufficient knowledge of the Dutch language; intellectual disability; ophthalmology surgery; extracorporeal shock wave lithotripsy; endoscopy; botulinum toxin A treatment; abortion; chronic pain treatment; preceding use of psychopharmaceuticals; contraindication to lorazepam. Lorazepam (1 to 1.5 mg) intravenously vs. NaCl 0.9% as a premedication prior to surgery. Quality of Recovery-40 (QoR-40) score. State-Trait Anxiety Inventory (STAI-State/Trait); State-Trait Anger Scale (STAS-State/Trait); Multidimensional Fatigue Inventory (MFI); Hospital Anxiety and Depression Scale (HADS). Timing of evaluation: T0: preoperatively (all scales); T1: before discharge (STAI-State/Trait); T2: first postoperative working day (QoR-40); T3: 7th day after surgery (all scales). Robust regression analysis was applied. Statistical analyses were adjusted for the corresponding baseline value and sex. Four hundred patients were randomised; 398 patients were analysed. Postoperative mean QoR-40 scores were similar in both groups at T2 (174.5 vs. 176.4, P = 0.34) and T3 (172.8 vs.176.3, P = 0.38). Postoperative mean STAI-State/Trait scores decreased less in the group with lorazepam at T1 (32.3 vs. 29.3, P < 0.0001; 32.7 vs. 30.8, P = 0.0002). STAI-Trait and HADS-Anxiety decreased less in the group with lorazepam at T3 (31.1 vs. 30.0; P = 0.03, 3.3 vs. 2.5, P = 0.003). STAS-State increased in the group with lorazepam at T3 (10.8 vs. 10.3, P = 0.04). In day-case surgery, lorazepam as a premedication did not improve quality of recovery. Furthermore, this premedication may delay the decrease in postoperative anxiety and aggression. ClinicalTrials.gov identifier: NCT01441843.

Systemic magnesium to improve quality of post-surgical recovery in outpatient segmental mastectomy: a randomized, double-blind, placebo-controlled trial

It remains to be determined if perioperative systemic magnesium can improve postoperative quality of recovery of patients undergoing ambulatory procedures. The main objective of the current investigation was to evaluate the effect of systemic magnesium on postoperative quality of recovery in patients undergoing outpatient segmental mastectomies. The study was a prospective randomized, double-blind, placebo-controlled, clinical trial. Female subjects were randomized to receive intravenous magnesium (MgSO4 50mg/kg in 100 mL of normal saline over 15 min before anesthesia induction, followed by an infusion of 15 mg/kg/hour) or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. 50 subjects were recruited and 46 completed the study. Patients in the magnesium group had better global Quality of Recovery scores compared with the saline group, with a median difference of 24 (99% CI, 3 to 33), P<0.001. After discharge from hospital, subjects in the magnesium group required less oral opioids, median (IQR) of 10 (0 to 20) (oral milligrams of morphine equivalents) than the saline group, 30 (20 to 40) (P<0.001). The postoperative systemic magnesium concentrations were substantially higher in the magnesium group, 1.25 ± 0.28 mmol/L compared to control, 0.71 ± 0.11 mmol/L, P<0.0001. Simple linear regression demonstrated a direct linear relationship between the postoperative systemic magnesium concentrations and 24 hour postoperative quality of recovery scores (P = 0.004), and also an inverse relationship with pain burden in the postoperative care unit (P = 0.01). Systemic magnesium improves postoperative quality of recovery in patients undergoing outpatient segmental mastectomy. Systemic magnesium is a safe, inexpensive, efficacious strategy to improve quality of recovery after ambulatory surgery.