If the peri-operative patient pathway was right, what would it look like?

Background: Patients undergoing surgery deserve the best possible peri-operative outcomes. Each stage of the peri-operative patient journey offers opportunities to improve care delivery, with shorter lengths of stay, less complications, reduced costs and better value.

Methods: These opportunities were identified through narrative review of the literature, with consultation and consensus at the hidden pandemic (of postoperative complications) summit 2, July 2023 in Adelaide, Australia RESULTS: Before surgery: Some patients who receive timely alternative treatments may not need surgery at all.

Triiodothyronine supplementation in a sheep model of intensive care.

Triiodothyronine (T3) concentrations in plasma decrease during acute illness and it is unclear if this contributes to disease. Clinical and laboratory studies of T3 supplementation in disease have revealed little or no effect. It is uncertain if short term supplementation of T3 has any discernible effect in a healthy animals.

The Cost-Effectiveness of Early High-Acuity Postoperative Care for Medium-Risk Surgical Patients.

Background: Initiatives in perioperative care warrant robust cost-effectiveness analysis in a cost-constrained era when high-value care is a priority. A model of anesthesia-led early high-acuity postoperative care, advanced recovery room care (ARRC), has shown benefit in terms of hospital and patient outcomes, but its cost-effectiveness has not yet been formally determined.

Methods: Data from a previously published single-center prospective cohort study of ARRC in medium-risk patients were used to generate a Markov model, which described patient transition between care locations, each with different characteristics and costs.

Improving safety and outcomes in perioperative care: does implementation matter?

The IMPROVE study describes a large perioperative quality improvement project with reporting of both compliance with improvement activities and patient outcomes. It highlights the importance of such projects, as well as the challenges in implementing change and proving benefit. Challenges identified include the importance of effective training in practice change, selection of trial design and relevant quality measures, and how the context of quality improvement initiatives may influence outcomes.

Cost-Effectiveness in Perioperative Care: Application of Markov Modeling to Pathways of Perioperative Care.

Objectives: This study aimed to evaluate the application of cost-effectiveness modeling to redesign of perioperative care pathways, from a hospital perspective.

Methods: A Markov cost-effectiveness model of patient transition between care locations, each with different characteristics and cost, was developed. Inputs were derived from clinical trials piloting a preoperative call center and a postoperative medium-acuity care unit.

The Hidden Pandemic: the Cost of Postoperative Complications.

Purpose Of Review: Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing.

Recent Findings: Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible.

Anatomical and ultrasound description of two transmuscular quadratus lumborum block approaches at L2 level and their application in abdominal surgery.

The transmuscular quadratus lumborum (TQL) block is one of the recently evolved myofascial blocks utilised in abdominal surgery. It involves injecting local anaesthetic into the fascial plane anterior to the thoracolumbar fascia. This block has previously been described with a transverse oblique paramedian approach at the L2 level in the sitting position.

Intraoperative "Analgesia Nociception Index"-Guided Fentanyl Administration During Sevoflurane Anesthesia in Lumbar Discectomy and Laminectomy: A Randomized Clinical Trial.

Background: The "Analgesia Nociception Index" (ANI; MetroDoloris Medical Systems, Lille, France) is a proposed noninvasive guide to analgesia derived from an electrocardiogram trace. ANI is scaled from 0 to 100; with previous studies suggesting that values ≥50 can indicate adequate analgesia. This clinical trial was designed to investigate the effect of intraoperative ANI-guided fentanyl administration on postoperative pain, under anesthetic conditions optimized for ANI functioning.

Developing models to predict early postoperative patient deterioration and adverse events.

Background: Accurate identification of patients at risk of early postoperative deterioration allows needs-based allocation of patients to appropriate levels of care. This study aimed to record the incidence of early postoperative deterioration and identify factors predictive of at-risk patients. Doing so may assist future evidence-based perioperative planning and allocation of patients to high-acuity facilities.

Triiodothyronine Administration in a Model of Septic Shock: A Randomized Blinded Placebo-Controlled Trial.

Objectives: Triiodothyronine concentration in plasma decreases during septic shock and may contribute to multiple organ dysfunction. We sought to determine the safety and efficacy of administering triiodothyronine, with and without hydrocortisone, in a model of septic shock.

Design: Randomized blinded placebo-controlled trial.

The effect of blood pressure and cardiac output on the quality of the surgical field and middle cerebral artery blood flow during endoscopic sinus surgery.

Background: A clear surgical field is critical during endoscopic sinus surgery (ESS). Hypotensive anesthesia and cardiac output (CO) may optimize the surgical field; however, evidence of their effect on bleeding and cerebral blood flow is conflicting. The aim of this study was to evaluate the effect of blood pressure (BP) and CO on intraoperative bleeding and middle cerebral artery blood flow velocity (Vmca ) during ESS.

Pharmacokinetics of tramadol after subcutaneous administration in a critically ill population and in a healthy cohort.

Background: Tramadol is an atypical centrally acting analgesic agent available as both oral and parenteral preparations. For patients who are unable to take tramadol orally, the subcutaneous route of administration offers an easy alternative to intravenous or intramuscular routes. This study aimed to characterise the absorption pharmacokinetics of a single subcutaneous dose of tramadol in severely ill patients and in healthy subjects.

The relationship between hypotension, cerebral flow, and the surgical field during endoscopic sinus surgery.

Objectives/hypothesis: Hypotensive anesthesia is often used in endoscopic sinus surgery (ESS) to improve surgical visibility; however, its safety and efficacy in this role are yet to be justified. This study aimed to evaluate the effect of hypotensive anesthesia on both real-time middle cerebral artery blood flow velocity (Vmca) and the severity of surgical bleeding in patients undergoing ESS.

Study Design: Prospective, observational cohort study.

Randomized, double-blind, placebo-controlled, trial of transforaminal epidural etanercept for the treatment of symptomatic lumbar disc herniation.

Study Design: Multicenter, randomized, double-blind, placebo-controlled trial.

Objective: To examine the safety and efficacy of three different doses of the tumor necrosis factor alpha (TNF-α) inhibitor etanercept versus placebo for the treatment of symptomatic lumbar disc herniation (LDH).

Summary Of Background Data: TNF-α is considered to be a major cause of radicular leg pain associated with symptomatic LDH.

The pharmacokinetics and pharmacodynamics of liposome bupivacaine administered via a single epidural injection to healthy volunteers.

Background And Objectives: The objective of this study was to assess the pharmacokinetics, sensory/motor effects, and safety of epidurally administered liposome bupivacaine versus bupivacaine HCl in healthy volunteers.

Methods: Thirty subjects were randomized to receive liposome bupivacaine 89, 155, or 266 mg, or bupivacaine HCl 50 mg in a double-blind fashion. Occurrence/duration of motor blockade, pinprick/cold sensitivity, and plasma bupivacaine levels were assessed for 96 hours after study drug administration.

Pharmacokinetics of fentanyl after subcutaneous administration in volunteers.

Background And Objective: Pain relief using intermittent subcutaneous injections of an opioid (e.g. morphine) avoids the need for venous access and does not require complex or expensive pumps and devices.