Development of a management algorithm for post-operative pain (MAPP) after total knee and total hip replacement: study rationale and design

Evidence from clinical practice and the extant literature suggests that post-operative pain assessment and treatment is often suboptimal. Poor pain management is likely to persist until pain management practices become consistent with guidelines developed from the best available scientific evidence. This work will address the priority in healthcare of improving the quality of pain management by standardising evidence-based care processes through the incorporation of an algorithm derived from best evidence into clinical practice. In this paper, the methodology for the creation and implementation of such an algorithm that will focus, in the first instance, on patients who have undergone total hip or knee replacement is described.

Nutritional status, nutrition practices and post-operative complications in patients with gastrointestinal cancer

Background: Malnutrition and its associated complications are a considerable issue for surgical patients with upper gastrointestinal and colorectal cancer.The present study aimed to determine whether specific perioperative nutritional practices and protocols are associated with improved patient outcomes in this group.
Methods: Patients admitted for elective upper gastrointestinal or colorectal cancer surgery (n = 95) over a 19-month period underwent a medical history audit assessing weight changes, nutritional intake, biochemistry, post-operative complications and length of stay. A subset of patients (n = 25) underwent nutritional assessment by subjective global assessment prior to surgery in addition to assessment of post-operative medical outcomes, nutritional intake and timing of dietetic intervention.
Results: Mean (SD) length of stay for patients was 14.0 (12.2) days, with complication rates at 35%. Length of stay was significantly longer in patients who experienced significant preoperative weight loss compared to those who did not [17.0 (15.8) days versus 10.0 (6.8) days, respectively; P < 0.05]. Low albumin and post-operative weight loss were also predictive of increased length of stay. Of patients who underwent nutritional assessment, 32% were classified as mild–moderately malnourished and 16% severely malnourished. Malnourished patients were hospitalised twice as long as well-nourished patients [15.8 (12.8) days versus 7.6 (3.5) days; P < 0.05]. Time taken [6.9 (3.6) days] to achieve adequate nutrition post surgery was a factor in post-operative outcomes, with a positive correlation with length of stay (r = 0.493; P < 0.01), a negative correlation with post-operative weight change (r = —0.417; P < 0.05) and a greater risk of complications (52% versus 13%; P < 0.01).
Conclusions: Malnutrition is prevalent among surgical patients with gastrointestinal cancer. Poor nutritional status coupled with delayed and inadequate post-operative nutrition practices are associated with worse clinical outcomes.

Minimising post-operative risk using a Post-Anaesthetic Care Tool (PACT): protocol for a prospective observational study and cost-effectiveness analysis

Introduction: While the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of the evidence and an expert consensus study in post-anaesthetic care identified essential criteria for nursing assessment of patient readiness for discharge from the Post-Anaesthetic Care Unit. These criteria were included in a new nursing assessment tool, the Post-Anaesthetic Care Tool (PACT), and incorporated into the post-anaesthetic documentation at a large health service. The aim of this study is to test the clinical reliability of the PACT and evaluate whether use of PACT will i) enhance the recognition and response to patients at risk of deterioration in PACU; ii) improve documentation for handover from PACU nurse to ward nurse; iii) result in improved patient outcomes; and iv) reduce health care costs.

Methods and analysis: A prospective, non-randomised, pre- and post-implementation design comparing: (i) patients (n=750) who have surgery prior to the implementation of the PACT and (ii) patients (n=750) who have surgery after PACT. The study will examine the use of the tool through the observation of patient care and nursing handover. Patient outcomes and cost effectiveness will be determined from health service data and medical record audit. Descriptive statistics will be used to describe the sample and compare the two patient groups (pre- and post-intervention). Differences in patient outcomes between the two groups will be compared using the Cochran-Mantel-Haenszel test and regression analyses and reported as odds ratios with the corresponding 95% confidence intervals.

Conclusion: This study will test the clinical reliability and cost-effectiveness of the PACT. It is hypothesised that the PACT will enable nurses to recognise and respond to patients at risk of deterioration, improve handover to ward nurses, improve patient outcomes, and reduce health care costs.

Psychosocial issues facilitating recovery post-CABG surgery

Background
The acute illness phase following coronary artery bypass graft (CABG) surgery is a difficult time for patients as they try to adjust to the physical and emotional changes brought about by surgery.
Aims
To conduct an indepth examination of psychosocial issues experienced by patients post-CABG surgery and how patients manage these psychosocial issues during their recovery.
Methods
A qualitative research approach, naturalistic inquiry, guided the study. Thirty patients were interviewed 4–5 weeks following discharge from hospital after CABG surgery and at 12 months after the initial interview.
Results
esults found that adjusting to life after surgery was difficult, and patients experienced some form of physical pain or change. An unexpected finding was the extent to which many of the patients were attuned to their post-operative physical adjustments. Patients spoke of mental and emotional changes, and coming to terms with lifestyle adjustments.
Conclusion
Study findings suggest the need for a re-examination of hospital discharge preparation and further provision and monitoring of home support services.

Recovery from gynaecological day surgery : are we underestimating the process

This paper reports a study investigating the post operative experiences of 80 women following gynaecological day surgery. Women kept a diary for the first 4 days following surgery. The diary included a recovery rating scale and a symptom management index focusing particularly on symptoms. A telephone interview conducted on post-operative day 10 further explored experiences. Results at day 4 indicated women experienced significant problems with pain, moving around and tiredness. By day 10, women were still experiencing tiredness, pain and other lingering problems. The study indicates that patients experience more problems than discharge education assumes.

Complications associated with operative fixation of acute midshaft clavicle fractures

The aim of this study was to review the complication rate and profile associated with surgical fixation of acute midshaft clavicle fracture in a large cohort of patients treated in a level I trauma centre.Patients and methods: We identified all patients who underwent surgical treatment of acute midshaft clavicle fracture between 2002 and 2010. The study group consisted of 138 fractures (134 patients). There were 107 males (78%) and 31 females (22%) and median age of 35 years (IQR 24-45). The most common mechanism of injury was a road traffic accident (78%). Sixty percent (n = 83) had an injury severity score of ≥ 15 indicating major trauma. The most common fracture type (75%) was simple or wedge comminuted (2B1) according to the Edinburgh classification. The median interval between the injury and operation was 3 days (IQR 1-6). Plate fixation was performed in 110 fractures (80%) and intramedullary fixation was performed in 28 fractures (20%). There were 85 males and 25 females in the plate fixation group with median age of 35 years (IQR: 25-45) There were 22 males and 6 females in intramedullary fixation group with median age of 31 years (IQR 24-42 years). Statistical analysis was performed using Independent sample t-test, Mann-Whitney test, and Chi-square test. Significant P-value was < 0.05.Results: The overall incidence of complication was 14.5% (n = 20). The overall nonunion rate 6%. Post operative wound infection occurred in 3.6% of cases. The incidence of complication associated with plate fixation was 10% (11 of 110 cases) compared to 32% associated with intramedullary fixation (9 of 28 cases) (P = 0.003). Thirty five percent of complications were related to inadequate surgical technique and potentially avoidable. Symptomatic hardware requiring removal occurred in 23% (n = 31) of patients. Symptomatic metalware was more frequent after plate fixation compared to intramedullary fixation (26% vs 7%, P = 0.03).Conclusions: Intramedullary fixation of midshaft clavicle fracture is associated with higher incidence of complications. Plate fixation is associated with a higher rate of symptomatic metalware requiring removal compared to intramedullary fixation. Approximately one in three complications may be avoided by attention to adequate surgical technique.

Variable definitions: implications for the prediction of pulmonary complications after adult cardiac surgery

Aim: The aim of this paper was to review the implications that variable definitions have for the prediction of post-operative pulmonary complications after cardiac surgery.

Method: A review of the literature from 1980 to 2002. Selected studies demonstrated an original attempt to examine multivariate associations between pre, intra or post-operative antecedents and pulmonary outcomes in patients undergoing coronary artery bypass grafting (CABG). Reports that described the validation of established clinical prediction rules, testing interventions or research conducted in non-human cohorts were excluded from this review.

Results: Consistently, variable factor and outcome definitions are combined for the development of multivariate prediction models that subsequently have limited clinical value. Despite being prevalent there are very few attempts to examine post-operative pulmonary complications (PPC) as endpoints in isolation. The trajectory of pulmonary dysfunction that precedes complications in the post-operative context is not clear. As such there is little knowledge of post-operative antecedents to PPC that are invariably excluded from model development.

Conclusion: Multivariate clinical prediction rules that incorporate antecedent patient and process factors from the continuum of cardiovascular care for specific pulmonary outcomes are recommended. Models such as these would be useful for practice, policy and quality improvement.

Utilising silk fibroin membranes as scaffolds for the growth of tympanic membrane keratinocytes, and application to myringoplasty surgery

Background: Chronic tympanic membrane perforations can cause significant morbidity. The term myringoplasty describes the operation used to close such perforations. A variety of graft materials are available for use in myringoplasty, but all have limitations and few studies report post-operative hearing outcomes. Recently, the biomedical applications of silk fibroin protein have been studied. This material’s biocompatibility, biodegradability and ability to act as a scaffold to support cell growth prompted an investigation of its interaction with human tympanic membrane keratinocytes. Methods and materials: Silk fibroin membranes were prepared and human tympanic membrane keratinocytes cultured. Keratinocytes were seeded onto the membranes and immunostained for a number of relevant protein markers relating to cell proliferation, adhesion and specific epithelial differentiation. Results: The silk fibroin scaffolds successfully supported the growth and adhesion of keratinocytes, whilst also maintaining their cell lineage. Conclusion: The properties of silk fibroin make it an attractive option for further research, as a potential alternative graft in myringoplasty.

Implementation of a quality care management system for patients with arthritis of the hip and knee

The Orthopaedic Unit of the Repatriation General Hospital (RGH) in Adelaide, South Australia has implemented a quality care management system for patients with arthritis of the hip and knee. The system not only optimises conservative management but ensures that joint replacement surgery is undertaken in an appropriate and timely manner. This new service model addresses identified barriers to service access and provides a comprehensive, coordinated strategy for patient management. Over 4 years the model has reduced waiting times for initial outpatient assessment from 8 to 3 months and surgery from 18 to 8 months, while decreasing length of stay from 6.3 to 5.3 days for hips and 5.8 to 5.3 days for knees. The service reforms have been accompanied by positive feedback from patients and referring general practitioners in relation to the improved coordination of care and enhanced efficiency in service delivery.

What is known about the topic? Several important initiatives both overseas and within Australia have contributed significantly to the development of this model of care. These include the UK National Health Service ‘18 weeks’ Project, the Western Canada Waiting List Project, the New Zealand priority criteria project, the Queensland Health Orthopaedic Physiotherapy Screening Clinic, and most importantly the Melbourne Health–University of Melbourne Orthopaedic Waiting List Project where a wide range of models were explored across Victorian hospitals from 2005 and the Multi-Attribute Prioritisation Tool (MAPT) was developed, validated and tested. This project became the Osteoarthritis Hip and Knee Service (OAHKS) and was operationalised in the Victorian healthcare system from 2012. These initiatives examined and addressed various aspects of management systems for patients with arthritis of the hip and knee in their particular setting.

What does this paper add? The development of this system is an extension of what is already known and is the first to encompass a comprehensive and coordinated strategy across all stages of the care management pathway for this patient group. Their management extends from the initial referral to development and implementation of a management plan, including surgery if assessed as necessary and organisation of long-term post operative follow up as required. By detailing the elements, key processes and measurable outcomes of the service redesign this paper provides a model for other institutions to implement a similar initiative.

What are the implications for practitioners? An important aspect of the design process was practitioner acceptance and engagement and the ability to improve their capacity to deliver services within an efficient and effective model. Intrinsic to the model’s development was assessment of practitioner satisfaction. Data obtained including practitioner surveys indicated an increased level of both satisfaction with the redesigned management service, and confidence in it to deliver its intended improvements.

A comparison of the psychological outcomes of cosmetic surgical procedures

Studies of psychological outcomes of cosmetic surgery generally provide low standards of evidence due to significant methodological limitations and few studies have explored the outcomes of surgery types other than breast reduction or have compared post-operative outcomes for different surgery types. This study therefore aimed to explore the psychological outcomes and post-operative satisfaction of cosmetic surgery and compare the outcomes and satisfaction of participants undergoing different procedures.

Surveys were administered to a sample of 142 elective cosmetic surgery patients prior to surgery and six months after surgery. The surveys included standardised measures of body image (appearance evaluation, appearance orientation, body areas satisfaction), self-esteem, and mental health (psychiatric disturbance, anxiety, depression, dysmorphic concerns).

The findings revealed high rates of post-operative satisfaction and significant improvements in several dimensions of body image (appearance evaluation and body area satisfaction) and mental health (anxiety, depression, and dysmorphic concerns), but not self-esteem. Breast augmentation patients reported significantly higher improvement on appearance evaluation, significantly higher ratings of how likely they thought it was that they had achieved, or would achieve, what they were looking for in having the procedure, and a trend to report that the overall result of surgery was better than or as expected than rhinoplasty patients.

It is recommended that future research clarifies the degree to which self-esteem and indices of mental health improve after cosmetic surgery and fully establishes the impact of different procedures on psychological outcomes.

Femoroacetabular impingement osteoplasty is any resected amount safe? A laboratory based experiment with sawbones

There is an increased risk of fracture following osteoplasty of the femoral neck for cam-type femoroacetabular impingement (FAI). Resection of up to 30% of the anterolateral head–neck junction has previously been considered to be safe, however, iatrogenic fractures have been reported with resections within these limits. We re-evaluated the amount of safe resection at the anterolateral femoral head–neck junction using a biomechanically consistent model.In total, 28 composite bones were studied in four groups: control, 10% resection, 20% resection and 30% resection. An axial load was applied to the adducted and flexed femur. Peak load, deflection at time of fracture and energy to fracture were assessed using comparison groups.There was a marked difference in the mean peak load to fracture between the control group and the 10% resection group (p < 0.001). The control group also tolerated significantly more deflection before failure (p < 0.04). The mean peak load (p = 0.172), deflection (p = 0.547), and energy to fracture (p = 0.306) did not differ significantly between the 10%, 20%, and 30% resection groups.Any resection of the anterolateral quadrant of the femoral head–neck junction for FAI significantly reduces the load-bearing capacity of the proximal femur. After initial resection of cortical bone, there is no further relevant loss of stability regardless of the amount of trabecular bone resected.Based on our findings we recommend any patients who undergo anterolateral femoral head–neck junction osteoplasty should be advised to modify their post-operative routine until cortical remodelling occurs to minimise the subsequent fracture risk.

Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals

Aim: Poor nutritional status has negative effects on post-operative outcomes, further compounded by surgical stress and fasting, places gastrointestinal surgery patients at high risk of malnutrition. Recent published research has challenged historic surgical nutrition practices; however, changes to practice in Australia have been slow. The aim of this study was to investigate current nutritional management of gastrointestinal surgery patients and compare this with the best practice guidelines, while exploring enablers to implementation of best practice. Methods: A 30-question telephone survey was developed to explore demographics and nutritional management of gastrointestinal surgical patients during pre-admission, inpatient stay and post-operative care. Forty-one gastrointestinal surgery dietitians were identified and contacted from 31 public hospitals in Victoria, Australia, and invited to participate. Results: Twenty-five dietitians participated in the survey (response rate 61%). Very few dietitians (12%) were funded for pre-admission clinics or outpatient clinics, and, overwhelmingly, dietitians reported not being involved in nutritional decision-making, and reported feeling unsatisfied with current nutritional management of patients. Despite half the hospitals reporting following best practice guidelines, only 22% implemented guidelines completely. There was no correlation observed between dietitian experience, department size or full-time equivalents allocated to surgery and nutritional intervention; however, the presence of a care pathway made a significant difference to the dietitian's overall satisfaction with dietetic care (P = 0.002). Conclusions: Current nutritional management of gastrointestinal surgery patients in Victorian hospitals is far from best practice. The implementation of a care pathway is the most effective way of ensuring best practice nutritional management of gastrointestinal surgical patients.

Sodium bicarbonate infusion in patients undergoing orthotopic liver transplantation: a single center randomized controlled pilot trial

BACKGROUND: Liver transplantation-associated acute kidney injury (AKI) carries significant morbidity and mortality. We hypothesized that sodium bicarbonate would reduce the incidence and/or severity of liver transplantation-associated AKI. METHODS: In this double-blinded pilot RCT, adult patients undergoing orthotopic liver transplantation were randomized to an infusion of either 8.4% sodium bicarbonate (0.5 mEq/kg/h for the first hour; 0.15 mEq/kg/h until completion of surgery); (n = 30) or 0.9% sodium chloride (n = 30). Primary outcome: AKI within the first 48 h post-operatively.RESULTS: There were no significant differences between the two treatment groups with regard to baseline characteristics, model for end-stage liver disease and acute physiology and chronic health evaluation (APACHE) II scores, and pre-transplantation renal function. Intra-operative factors were similar for duration of surgery, blood product requirements, crystalloid and colloid volumes infused and requirements for vasoactive therapy. Eleven patients (37%) in the bicarbonate group and 10 patients (33%) in the sodium chloride group developed a post-operative AKI (p = 0.79). Bicarbonate infusion attenuated the degree of immediate post-operative metabolic acidosis; however, this effect dissipated by 48 h. There were no significant differences in ventilation hours, ICU or hospital length of stay, or mortality. CONCLUSIONS: The intra-operative infusion of sodium bicarbonate did not decrease the incidence of AKI in patients following orthotopic liver transplantation.