British journal of anaesthesia最新文献

Background

Regional anaesthesia techniques, including the erector spinae fascial plane (ESP) block, reduce postoperative pain after video-assisted thoracoscopic surgery (VATS). Fascial plane blocks rely on spread of local anaesthetic between muscle layers, and thus, intermittent boluses might increase their clinical effectiveness. We tested the hypothesis that postoperative ESP analgesia with a programmed intermittent bolus (PIB) regimen is better than a continuous infusion (CI) regimen in terms of quality of recovery after VATS.

Methods

We undertook a prospective, double-blinded, randomised, controlled trial involving 60 patients undergoing VATS. All participants received ESP block catheters and were randomly assigned to CI or PIB of local anaesthetic regimen for postoperative analgesia. The primary outcome was Quality of Recovery-15 (QoR-15) score 24 h after surgery. Secondary outcomes included postoperative respiratory function, opioid consumption, verbal rating pain score, time to first mobilisation, nausea, vomiting, and length of hospital stay.

Results

Overall QoR-15 scores at 24 h after VATS were similar (PIB 115.5 [interquartile range 107–125] vs CI 110 [93–128]; Δ<6, P=0.29). The only quality of recovery descriptor showing a significant difference was nausea and vomiting, which was favourable in the PIB group (10 [10–10] vs 10 [7–10]; P=0.03). Requirement for rescue antiemetics up to 24 h after surgery was lower in the PIB group (4 [14%] vs 11 [41%]; P=0.04). There were no differences in other secondary outcomes between groups.

Conclusions

Delivering ESP block analgesia after VATS via a PIB regimen resulted in similar QoR-15 at 24 h compared with a CI regimen.

Background

Mortality after surgery in Africa is twice that in high-income countries. Most deaths occur on wards after patients develop postoperative complications. Family members might contribute meaningfully and safely to early recognition of deteriorating patients.

Methods

This was a stepped-wedge cluster-randomised trial of an intervention training family members to support nursing staff to take and record patient vital signs every 4 h after surgery. Adult inpatients across four surgical wards (clusters) in a Ugandan hospital were included. Clusters crossed once from routine care to the SMARTER intervention at monthly intervals. The primary outcome was frequency of vital sign measurements from arrival on the postoperative ward to the end of the third postoperative day (3 days).

Results

We enrolled 1395 patients between April and October 2021. Mean age was 28.2 (range 5–89) yr; 85.7% were female. The most common surgical procedure was Caesarean delivery (74.8%). Median (interquartile range) number of sets of vital signs increased from 0 (0–1) in control wards to 3 (1–8) in intervention wards (incident rate ratio 12.4, 95% confidence interval [CI] 8.8–17.5, P<0.001). Mortality was 6/718 (0.84%) patients in the usual care group vs 12/677 (1.77%) in the intervention group (odds ratio 1.32, 95% CI 0.1–14.7, P=0.821). There was no difference in length of hospital stay between groups (usual care: 2 [2–3] days vs intervention: 2 [2–4] days; hazard ratio 1.11, 95% CI 0.84–1.47, P=0.44).

Conclusions

Family member supplemented vital signs monitoring substantially increased the frequency of vital signs after surgery. Care interventions involving family members have the potential to positively impact patient care.

Clinical trial registration

NCT04341558.

Despite the general agreement that implementation of Enhanced Recovery After Surgery (ERAS) pathways decrease hospital length of stay, a continuous challenge that has often been neglected is a procedure- and patient-specific approach. For example, asking ‘Why is the patient still in hospital?’ is the original premise for ERAS. Outcomes improve with increased compliance with recommended elements, but overcomplication of pathways can lead to cherry picking of elements that are convenient, resulting in ‘partial ERAS’. As there are few high-quality randomised clinical trials (RCTs) that evaluate the specific role of individual preoperative, intraoperative, and postoperative elements, challenges lie ahead to identify essential ERAS elements to facilitate more widespread implementation. To achieve this goal, the balance between large RCTs and smaller detailed hypothesis-generating observational studies needs to be addressed in order to enhance knowledge and limit waste of research resources.