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Yuan CD, Zhou BZ, Wang NY, Wan QQ, Hu ZZ. Evidence-based control of stress response on intraoperative physiological indexes and recovery of patients undergoing gastrointestinal surgery. World J Gastroenterol 2025; 31:102331. [DOI: 10.3748/wjg.v31.i8.102331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2024] [Revised: 12/11/2024] [Accepted: 01/14/2025] [Indexed: 01/23/2025] Open
Abstract
BACKGROUND Although the 2021 Chinese Clinical Practice Guidelines for Enhanced Recovery after Surgery (ERAS) provide recommendations for ERAS in gastrointestinal surgery, the clinical application of standard ERAS nursing models is challenging due to the variety of diseases involved in gastrointestinal surgery and the complex factors contributing to patient stress responses. Moreover, stress responses are more severe in older adult patients. Therefore, precision medicine is required to improve the quality of nursing care and promote postoperative recovery in gastrointestinal surgery.
AIM To establish an evidence-based ERAS model based on stress response nursing care and demonstrate nursing benefits through clinical practice.
METHODS This randomized clinical trial first established an evidence-based nursing ERAS protocol in older adult patients based on literature related to perioperative nursing measures for gastrointestinal surgery stress response. Next, 392 older adult patients who underwent gastrointestinal surgery and were admitted to our hospital between December 2021 and June 2023 were categorized into two groups to receive evidence-based (study group) or conventional (control group) ERAS nursing models, respectively. Intraoperative physiological parameters during surgery and postoperative recovery indicators were compared between the groups.
RESULTS Among 64 domestic and international studies, the stress responses of older adult patients mainly included emotional anxiety, sleep disorders, gastrointestinal discomfort, physical weakness, pain, and swelling. The appropriate nursing interventions included comprehensive psychological counseling, pre- and postoperative nutritional support, temperature control, pain management, and rehabilitation training. Compared with the control group, the study group showed lower heart rate, mean arterial pressure, blood glucose level, and adrenaline level; shorter duration of drainage tube placement, time to first flatus, time to first ambulation, and postoperative hospital stay; lower anxiety scores on postoperative day 3; and lower incidences of postoperative infection, obstruction, poor wound healing, and gastrointestinal reactions were lower in the study group (all P < 0.05).
CONCLUSION The evidence-based nursing measures targeting stress responses based on the conventional ERAS nursing model resulted in stable intraoperative physiological parameters during surgery, promoted postoperative recovery, and reduced the incidence of complications.
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Affiliation(s)
- Chen-Dong Yuan
- Department of General Surgery, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Bao-Zhu Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Ning-Yan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Qing-Qing Wan
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Zhen-Zhen Hu
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Uchino H, Nguyen-Powanda P, Tokuno J, Kouyoumdjian A, Fiore JF, Grushka J. Enhanced recovery protocols in trauma and emergency abdominal surgery: a scoping review. Eur J Trauma Emerg Surg 2023; 49:2401-2412. [PMID: 37505285 DOI: 10.1007/s00068-023-02337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Abstract
PURPOSE Enhanced recovery protocols (ERP) have been shown to improve patient outcomes and is now regarded as standard of care in elective surgical setting. However, the literature addressing the use of ERP in trauma and emergency abdominal surgery (EAS) is limited and heterogenous. A scoping review was conducted to comprehensively assess the literature on ERP in trauma laparotomy and EAS. METHODS Three bibliographic databases were searched for studies addressing ERP in trauma laparotomy and EAS. We extracted the study characteristics including study design, country, year, surgical procedures, ERP components used, and outcomes. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. RESULTS After screening of 1631 articles for eligibility, 39 studies were included in the review. There has been an increase in the number of articles in the field, with 44% of the identified studies published between 2020 and 2022. Fourteen different protocols were identified, with varying components for each operative phase (preoperative; 29, intraoperative; 20, postoperative; 27). The majority of the studies addressed the effectiveness of ERP on clinical outcomes (31/39: 79%). Only two studies (5%) included purely trauma populations. CONCLUSIONS Studies on ERP implementations in the EAS populations were published across a range of countries, with improved outcomes. However, a clear gap in ERP research on trauma laparotomy was identified. This scoping review indicates that standardization of care through ERP implementation has potential to improve the quality of care in both EAS and trauma laparotomy.
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Affiliation(s)
- Hayaki Uchino
- Division of Experimental Surgery, McGill University, Montreal, QC, Canada.
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada.
| | - Philip Nguyen-Powanda
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Junko Tokuno
- Steinberg Centre for Simulation and Interactive Learning, McGill University, Montreal, QC, Canada
| | - Araz Kouyoumdjian
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Jeremy Grushka
- Department of Surgery, Division of General Surgery, McGill University, Montreal, QC, Canada
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Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
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Schena CA, de’Angelis GL, Carra MC, Bianchi G, de’Angelis N. Antimicrobial Challenge in Acute Care Surgery. Antibiotics (Basel) 2022; 11:1315. [PMID: 36289973 PMCID: PMC9598495 DOI: 10.3390/antibiotics11101315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 12/07/2022] Open
Abstract
The burden of infections in acute care surgery (ACS) is huge. Surgical emergencies alone account for three million admissions per year in the United States (US) with estimated financial costs of USD 28 billion per year. Acute care facilities and ACS patients represent boost sanctuaries for the emergence, development and transmission of infections and multi-resistant organisms. According to the World Health Organization, healthcare-associated infections affected around 4 million cases in Europe and 1.7 million in the US alone in 2011 with 39,000 and 99,000 directly attributable deaths, respectively. In this scenario, antimicrobial resistance arose as a public-health emergency that worsens patients' morbidity and mortality and increases healthcare costs. The optimal patient care requires the application of comprehensive evidence-based policies and strategies aiming at minimizing the impact of healthcare associated infections and antimicrobial resistance, while optimizing the treatment of intra-abdominal infections. The present review provides a snapshot of two hot topics, such as antimicrobial resistance and systemic inflammatory response, and three milestones of infection management, such as source control, infection prevention, and control and antimicrobial stewardship.
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Affiliation(s)
- Carlo Alberto Schena
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Gian Luigi de’Angelis
- Gastroenterology and Endoscopy Unit, Department of Medicine and Surgery, University Hospital of Parma, 43126 Parma, Italy
| | - Maria Clotilde Carra
- Rothschild Hospital, AP-HP, Université Paris Cité, U.F.R. of Odontology, 75006 Paris, France
| | - Giorgio Bianchi
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
| | - Nicola de’Angelis
- Unit of Digestive and HPB Surgery, CARE Department, Henri Mondor Hospital, AP-HP, 94010 Créteil, France
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Grant MC, Engelman DT. The journey to standardizing cardiac perioperative care. Anaesth Crit Care Pain Med 2022; 41:101099. [PMID: 35715023 DOI: 10.1016/j.accpm.2022.101099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health and University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
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Aggarwal G, Scott M, Peden CJ. Emergency Laparotomy. Anesthesiol Clin 2022; 40:199-211. [PMID: 35236580 DOI: 10.1016/j.anclin.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Emergency laparotomy is a high-risk surgical procedure with mortality and morbidity up to 10 times higher than for a similar procedure performed electively. An enhanced recovery approach has been shown to improve outcomes. A focus on rapid correction of underlying deranged acute physiology and proactive management of conditions associated with aging such as frailty and delirium are key. Patients are at high risk of complications and prevention and avoidance of failure to rescue are essential to improve outcomes. Other enhanced recovery components such as opioid-sparing analgesia and early postoperative mobilization are beneficial.
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Affiliation(s)
- Geeta Aggarwal
- Royal Surrey Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey, GU2 7XX, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
| | - Carol J Peden
- Keck School of Medicine, University of Southern California, 1975 Zonal Avenue, Los Angeles, CA 90033, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Clinical Quality the Blue Cross Blue Shield Association, Chicago, IL 60601, USA
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Eton RE, Highet A, Englesbe MJ. Every Emergency General Surgery Patient Deserves Pathway-Driven Care. J Am Coll Surg 2021; 231:764-765. [PMID: 33243402 DOI: 10.1016/j.jamcollsurg.2020.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 12/29/2022]
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Mc Geehan G, Edelduok IM, Bucholc M, Watson A, Bodnar Z, Johnston A, Sugrue M. Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement. Life (Basel) 2021; 11:life11020138. [PMID: 33670186 PMCID: PMC7916918 DOI: 10.3390/life11020138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/20/2021] [Accepted: 02/07/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy. METHODS An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included "emergency surgery", "laparotomy", "surgical site infection", "midline incision" and "wound bundle". Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI. RESULTS This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39-1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57-1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data. CONCLUSIONS This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle's ability to potentially improve outcome after emergency laparotomy.
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Affiliation(s)
- Gearóid Mc Geehan
- Donegal Clinical Research Academy, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
- School of Medicine, University of Limerick, V94T9PX Limerick, Ireland
| | - Itoro M Edelduok
- Department of Surgery, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University (Magee Campus), Northern Ireland BT48 7JL, UK
| | - Angus Watson
- Raigmore Hospital, NHS-Highland, Inverness IV2 3DZ, UK
| | - Zsolt Bodnar
- Department of Surgery, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
| | - Alison Johnston
- Donegal Clinical Research Academy, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
- Emergency Surgery Outcome Advancement Project, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
- Department of Surgery, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
- Emergency Surgery Outcome Advancement Project, Letterkenny University Hospital, F92AE81 County Donegal, Ireland
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