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Hirai S, Ida M, Kawaguchi M. Comparison of prophylaxis strategy for postoperative nausea and vomiting and its incidence before and after the implementation of 5-hydroxytryptamine 3 in surgical setting: a single-center, retrospective study. J Anesth 2024; 38:398-404. [PMID: 38436772 DOI: 10.1007/s00540-024-03327-3] [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: 12/04/2023] [Accepted: 02/13/2024] [Indexed: 03/05/2024]
Abstract
PURPOSE To investigate the association between adherence to guideline-recommended risk-based postoperative nausea and vomiting (PONV) prophylaxis, the antiemetics used for PONV prophylaxis, and the incidence of PONV in patients who were underwent general anesthesia before and after 5-HT3 receptor antagonists became available. METHODS Patients (≥ 20 years old) who were extubated after scheduled surgery and returned to general wards between January 2021 and February 2022 and between June 2022 and July 2023 were included. Risk factors included age < 50, female, motion sickness, nonsmoker, surgical factors, and postoperative opioid use. Two and three or more prophylaxis were recommended for patients with one or two and three or more risk factors, respectively. The primary outcome was the number of patients who received adequate prophylaxis, and the secondary outcomes were antiemetic agents used during anesthesia and the incidence of PONV on postoperative days 0 and 1. PONV was defined as documented PONV or rescue antiemetic administration. RESULTS From January 2021 to February 2022 and from June 2022 to July 2023, 2342 and 2682 patients were included, respectively. Before ondansetron became available, more D2 receptor antagonists were used (p < 0.001), and after ondansetron became available, both ondansetron (p < 0.001) and propofol (p < 0.001) were given more frequently. Before and after ondansetron became available, the number of patients with adequate prophylaxis was 3.7% and 9.2%, respectively (p < 0.001), and the incidence of PONV on postoperative days 0 and 1 was 44.6% and 44.0%, respectively (p = 0.67). CONCLUSION The availability of ondansetron increased the number of patients with adequate PONV prophylaxis, but did not decrease the incidence of PONV.
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Affiliation(s)
- Sayaka Hirai
- Department of Perioperative Management Center, Nara Medical University Hospital, Nara, Japan
| | - Mitsuru Ida
- Department of Anaesthesiology, Nara Medical University, 840 Nara, Kashihara, Shijo, 634-8522, Japan.
| | - Masahiko Kawaguchi
- Department of Perioperative Management Center, Nara Medical University Hospital, Nara, Japan
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2
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Backmund T, Bohlender T, Gaik C, Koch T, Kranke P, Nardi-Hiebl S, Vojnar B, Eberhart LHJ. [Comparison of different prediction models for the occurrence of nausea and vomiting in the postoperative phase : A systematic qualitative comparison based on prospectively defined quality indicators]. DIE ANAESTHESIOLOGIE 2024; 73:251-262. [PMID: 38319326 DOI: 10.1007/s00101-024-01386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Various prognostic prediction models exist for evaluating the risk of nausea and vomiting in the postoperative period (PONV). So far, no systematic comparison of these prognostic scores is available. METHOD A systematic literature search was carried out in seven medical databases to find publications on prognostic PONV models. Identified scores were assessed against prospectively defined quality criteria, including generalizability, validation and clinical relevance of the models. RESULTS The literature search revealed 62 relevant publications with a total of 81,834 patients which could be assigned to 8 prognostic models. The simplified Apfel score performed best, primarily because it was extensively validated. The Van den Bosch score and Sinclair score tied for second place. The simplified Koivuranta score was in third place. CONCLUSION The qualitative analysis highlights the strengths and weaknesses of each prediction system based on predetermined standardized quality criteria.
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Affiliation(s)
- T Backmund
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland.
| | - T Bohlender
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland
| | - C Gaik
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland
| | - T Koch
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland
| | - P Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080 Würzburg, Deutschland
| | - S Nardi-Hiebl
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland
| | - B Vojnar
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland
| | - L H J Eberhart
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Baldinger Straße, 35043 Marburg, Deutschland
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Zhang S, Li H, Jing Q, Shen W, Luo W, Dai R. Anesthesia decision analysis using a cloud-based big data platform. Eur J Med Res 2024; 29:201. [PMID: 38528564 DOI: 10.1186/s40001-024-01764-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 03/01/2024] [Indexed: 03/27/2024] Open
Abstract
Big data technologies have proliferated since the dawn of the cloud-computing era. Traditional data storage, extraction, transformation, and analysis technologies have thus become unsuitable for the large volume, diversity, high processing speed, and low value density of big data in medical strategies, which require the development of novel big data application technologies. In this regard, we investigated the most recent big data platform breakthroughs in anesthesiology and designed an anesthesia decision model based on a cloud system for storing and analyzing massive amounts of data from anesthetic records. The presented Anesthesia Decision Analysis Platform performs distributed computing on medical records via several programming tools, and provides services such as keyword search, data filtering, and basic statistics to reduce inaccurate and subjective judgments by decision-makers. Importantly, it can potentially to improve anesthetic strategy and create individualized anesthesia decisions, lowering the likelihood of perioperative complications.
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Affiliation(s)
- Shuiting Zhang
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Anesthesia Medical Research, Center Central, South University, Changsha, 410008, Hunan, China
| | - Hui Li
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Anesthesia Medical Research, Center Central, South University, Changsha, 410008, Hunan, China
| | - Qiancheng Jing
- Department of Otolaryngology Head and Neck Surgery, Hengyang Medical School, The Affiliated Changsha Central Hospital, University of South China, Changsha, 410000, Hunan, China
| | - Weiyun Shen
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Anesthesia Medical Research, Center Central, South University, Changsha, 410008, Hunan, China
| | - Wei Luo
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
- Anesthesia Medical Research, Center Central, South University, Changsha, 410008, Hunan, China
| | - Ruping Dai
- Department of Anesthesiology, The Second Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
- Anesthesia Medical Research, Center Central, South University, Changsha, 410008, Hunan, China.
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Philteos J, McCluskey SA, Emerson S, Djaiani G, Goldstein D, Soussi S. Impact of goal-directed hemodynamic therapy on perioperative outcomes in head and neck free flap surgery: A before-and-after pilot study. Health Sci Rep 2024; 7:e1943. [PMID: 38524770 PMCID: PMC10959725 DOI: 10.1002/hsr2.1943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/29/2023] [Accepted: 02/07/2024] [Indexed: 03/26/2024] Open
Abstract
Background Free flap reconstruction for head and neck cancer is associated with a high risk of perioperative complications. One of the modifiable risk factors associated with perioperative morbidity is intraoperative hypotension (IOH). The main aim of this pilot study is to determine if the intraoperative use of goal-directed hemodynamic therapy (GDHT) is associated with a reduction in the number of IOH events in this population. Methods A before-and-after study design. The patients who had intraoperative GDHT were compared to patients from a previous period before the implementation of GDHT. The primary outcome was the number of IOH episodes defined as five or more successive minutes with a mean arterial pressure <65 mmHg. The secondary outcomes included major postoperative morbidity and 30-day mortality. Results A total of 414 patients were included. These were divided into two groups. The control group (n = 346; January 1, 2018, to December 31, 2019), and the monitored group (n = 68; January 1, 2020, to May 1, 2021). The median intraoperative administered fluid volume was similar between the control and monitored groups (2250 interquartile range [IQR] [1607-3050] vs. 2210 IQR [1700-2807] mL). The monitored group was found to have an increased use of norepinephrine and dobutamine (respectively, 1.2% vs. 5.9% and 2.4% vs. 30.9%; p < 0.05). When adjusting for confounders (comorbidities, estimated blood loss, and duration of anesthesia) the incidence rate ratio (95% confidence interval) of number of IOH events was 0.94 (0.86-1.03), p = 0.24. The rate of postoperative flap and medical complications did not differ between the two groups. Conclusions Even though the use of vasopressors/inotropes was higher in the monitored group, the number of IOH episodes and postoperative morbidity and mortality were similar between the two groups. Further change in hemodynamic management will require the use of specific blood pressure targets in the GDHT fluid algorithm.
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Affiliation(s)
- Justine Philteos
- Department of Otolaryngology—Head and Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Stuart A. McCluskey
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoOntarioCanada
| | - Sophia Emerson
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoOntarioCanada
| | - George Djaiani
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoOntarioCanada
| | - David Goldstein
- Department of Otolaryngology—Head and Neck SurgeryUniversity Health Network, University of TorontoTorontoOntarioCanada
| | - Sabri Soussi
- Department of Anesthesiology and Pain MedicineUniversity of TorontoTorontoOntarioCanada
- Department of Anesthesia and Pain ManagementToronto Western Hospital, University Health NetworkTorontoOntarioCanada
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Mizuguchi T, Sawamura S. Machine learning-based causal models for predicting the response of individual patients to dexamethasone treatment as prophylactic antiemetic. Sci Rep 2023; 13:7549. [PMID: 37161041 PMCID: PMC10169123 DOI: 10.1038/s41598-023-34505-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
Risk-based strategies are widely used for decision making in the prophylaxis of postoperative nausea and vomiting (PONV), a major complication of general anesthesia. However, whether risk is associated with individual treatment effect remains uncertain. Here, we used machine learning-based algorithms for estimating the conditional average treatment effect (CATE) (double machine learning [DML], doubly robust [DR] learner, forest DML, and generalized random forest) to predict the treatment response heterogeneity of dexamethasone, the first choice for prophylactic antiemetics. Electronic health record data of 2026 adult patients who underwent general anesthesia from January to June 2020 were analyzed. The results indicated that only a small subset of patients respond to dexamethasone treatment, and many patients may be non-responders. Estimated CATE did not correlate with predicted risk, suggesting that risk may not be associated with individual treatment responses. The current study suggests that predicting treatment responders by CATE models may be more appropriate for clinical decision making than conventional risk-based strategy.
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Affiliation(s)
- Taisuke Mizuguchi
- Department of Anesthesia, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan.
| | - Shigehito Sawamura
- Department of Anesthesia, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
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6
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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7
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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8
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Use of Apfel Simplified Risk Score to Guide Postoperative Nausea and Vomiting Prophylaxis in Adult Patients Undergoing Same-day Surgery. J Perianesth Nurs 2022; 37:445-451. [DOI: 10.1016/j.jopan.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
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9
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Rajan N, Joshi GP. Management of postoperative nausea and vomiting in adults: current controversies. Curr Opin Anaesthesiol 2021; 34:695-702. [PMID: 34560688 DOI: 10.1097/aco.0000000000001063] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Postoperative nausea and vomiting (PONV) continue to plague the surgical patient population with an adverse impact on postoperative outcomes. The aim of this review is to critically assess current evidence for PONV management, including studies evaluating baseline risk reduction and antiemetic prophylaxis, to provide a pragmatic approach to prevention and treatment of PONV in routine clinical practice. RECENT FINDINGS Multiple recent reviews and guidelines have been published on this topic with some limitations. In the current ERAS era, all patients irrespective of their PONV risk should receive two to three antiemetics for prophylaxis. Patients at a high risk of PONV [i.e. prior history of PONV, history of motion sickness, high opioid requirements after surgery (e.g. inability to use nonopioid analgesic techniques)] should receive three to four antiemetics for prophylaxis. SUMMARY This review provides a practical approach to PONV prevention based on recent literature.
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Affiliation(s)
- Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, Pennsylvania
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas, USA
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10
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The electronic health record: marching anesthesiology toward value-added processes and digital patient experiences. Int Anesthesiol Clin 2021; 59:12-21. [PMID: 34369398 DOI: 10.1097/aia.0000000000000331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Andreae MH, Maman SR, Behnam AJ. An Electronic Medical Record-Derived Individualized Performance Metric to Measure Risk-Adjusted Adherence with Perioperative Prophylactic Bundles for Health Care Disparity Research and Implementation Science. Appl Clin Inform 2020; 11:497-514. [PMID: 32726836 PMCID: PMC7390620 DOI: 10.1055/s-0040-1714692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/01/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Health care disparity persists despite vigorous countermeasures. Clinician performance is paramount for equitable care processes and outcomes. However, precise and valid individual performance measures remain elusive. OBJECTIVES We sought to develop a generalizable, rigorous, risk-adjusted metric for individual clinician performance (MIP) derived directly from the electronic medical record (EMR) to provide visual, personalized feedback. METHODS We conceptualized MIP as risk responsiveness, i.e., administering an increasing number of interventions contingent on patient risk. We embedded MIP in a hierarchical statistical model, reflecting contemporary nested health care delivery. We tested MIP by investigating the adherence with prophylactic bundles to reduce the risk of postoperative nausea and vomiting (PONV), retrieving PONV risk factors and prophylactic antiemetic interventions from the EMR. We explored the impact of social determinants of health on MIP. RESULTS We extracted data from the EMR on 25,980 elective anesthesia cases performed at Penn State Milton S. Hershey Medical Center between June 3, 2018 and March 31, 2019. Limiting the data by anesthesia Current Procedural Terminology code and to complete cases with PONV risk and antiemetic interventions, we evaluated the performance of 83 anesthesia clinicians on 2,211 anesthesia cases. Our metric demonstrated considerable variance between clinicians in the adherence to risk-adjusted utilization of antiemetic interventions. Risk seemed to drive utilization only in few clinicians. We demonstrated the impact of social determinants of health on MIP, illustrating its utility for health science and disparity research. CONCLUSION The strength of our novel measure of individual clinician performance is its generalizability, as well as its intuitive graphical representation of risk-adjusted individual performance. However, accuracy, precision and validity, stability over time, sensitivity to system perturbations, and acceptance among clinicians remain to be evaluated.
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Affiliation(s)
- Michael H. Andreae
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
| | - Stephan R. Maman
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
- Penn State College of Medicine, Hershey, Pennsylvania, United States
| | - Abrahm J. Behnam
- Department of Anesthesiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States
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12
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Wang R, Dong X, Zhang X, Gan S, Kong L, Lu X, Rao Y. Pharmacist-driven multidisciplinary initiative continuously improves postoperative nausea and vomiting in female patients undergoing abdominal surgery. J Clin Pharm Ther 2020; 45:959-967. [PMID: 32022296 DOI: 10.1111/jcpt.13110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 11/12/2019] [Accepted: 01/03/2020] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE The incorrect or insufficient prophylaxis of postoperative nausea and vomiting (PONV) is common in practice. A clinical pharmacist-led guidance team (CPGT) was established and included in general surgery teams. OBJECTIVE This study aimed to evaluate the effects of the CPGT on the improvement of PONV and prophylaxis administration. METHODS A prospective before-after study was conducted on 156 female patients undergoing abdominal surgery at a Chinese tertiary teaching hospital from December 2016 to December 2017. A total of 82 patients were enrolled in the preintervention period, and 74 patients were included in the post-intervention period. The CPGT established the evidence-based criteria for prophylactic anti-emetic administration and conducted interventions, including a review of medical records, provision of feedback, educational outreach, and dedicated support. Primary outcomes included the incidence of PONV within 24 hours of surgery, administered number of prophylactic anti-emetics, and accuracy of the timing for prophylactic anti-emetics. Outcomes were analysed by logistic regression or multivariable linear regression. RESULTS AND DISCUSSION After intervention, patients reported significantly less PONV (33.78% vs 56.10%; odds ratio [OR]: 0.29; numbers needed to treat [NNT]: 3.47), vomiting (29.73% vs 45.12%; OR: 0.42; NNT: 5.16) and nausea (31.08% vs 56.10%; OR: 0.24; NNT: 3.19) within 24 hours of surgery. The accuracy of the timing for prophylactic anti-emetics significantly increased (OR: 3.66; P: .003). Anaesthesiologists administered increased numbers of prophylactic anti-emetics (OR: 5.82; P < .001). The improvement of PONV did not decrease during the four-month period after intervention (P: .639). WHAT IS NEW AND CONCLUSION The CPGT is a valuable service model to continuously improve PONV and optimize prophylaxis administration.
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Affiliation(s)
- Rongrong Wang
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xihao Dong
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xuan Zhang
- Northern Jiangsu People's Hospital, Yangzhou, China
| | - Shuyuan Gan
- Department of Anesthesiology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Limin Kong
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoyang Lu
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yuefeng Rao
- Department of Pharmacy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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13
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Roumeliotis N, Sniderman J, Adams-Webber T, Addo N, Anand V, Rochon P, Taddio A, Parshuram C. Effect of Electronic Prescribing Strategies on Medication Error and Harm in Hospital: a Systematic Review and Meta-analysis. J Gen Intern Med 2019; 34:2210-2223. [PMID: 31396810 PMCID: PMC6816608 DOI: 10.1007/s11606-019-05236-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/02/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Computerized physician order entry and clinical decision support systems are electronic prescribing strategies that are increasingly used to improve patient safety. Previous reviews show limited effect on patient outcomes. Our objective was to assess the impact of electronic prescribing strategies on medication errors and patient harm in hospitalized patients. METHODS MEDLINE, EMBASE, CENTRAL, and CINAHL were searched from January 2007 to January 2018. We included prospective studies that compared hospital-based electronic prescribing strategies with control, and reported on medication error or patient harm. Data were abstracted by two reviewers and pooled using random effects model. Study quality was assessed using the Effective Practice and Organisation of Care and evidence quality was assessed using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS Thirty-eight studies were included; comprised of 11 randomized control trials and 27 non-randomized interventional studies. Electronic prescribing strategies reduced medication errors (RR 0.24 (95% CI 0.13, 0.46), I2 98%, n = 11) and dosing errors (RR 0.17 (95% CI 0.08, 0.38), I2 96%, n = 9), with both risk ratios significantly affected by advancing year of publication. There was a significant effect of electronic prescribing strategies on adverse drug events (ADEs) (RR 0.52 (95% CI 0.40, 0.68), I2 0%, n = 2), but not on preventable ADEs (RR 0.55 (95% CI 0.30, 1.01), I2 78%, n = 3), hypoglycemia (RR 1.03 (95% CI 0.62-1.70), I2 28%, n = 7), length of stay (MD - 0.18 (95% - 1.42, 1.05), I2 94%, n = 7), or mortality (RR 0.97 (95% CI 0.79, 1.19), I2 74%, n = 9). The quality of evidence was rated very low. DISCUSSION Electronic prescribing strategies decrease medication errors and adverse drug events, but had no effect on other patient outcomes. Conservative interpretations of these findings are supported by significant heterogeneity and the preponderance of low-quality studies.
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Affiliation(s)
- Nadia Roumeliotis
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada. .,Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, Canada.
| | - Jonathan Sniderman
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Newton Addo
- Division of Clinical Pharmacology, Department of Medicine, UCSF, San Francisco, CA, USA
| | - Vijay Anand
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Paula Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Anna Taddio
- Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, Canada
| | - Christopher Parshuram
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences, and Center for Safety Research, SickKids Research Institute, Toronto, ON, Canada
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Chae D, Kim SY, Song Y, Baek W, Shin H, Park K, Han DW. Dynamic predictive model for postoperative nausea and vomiting for intravenous fentanyl patient-controlled analgesia. Anaesthesia 2019; 75:218-226. [PMID: 31531854 DOI: 10.1111/anae.14849] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 02/07/2023]
Abstract
Postoperative nausea and vomiting is the most common side-effect of opioid-based intravenous patient-controlled analgesia. Apfel's simplified risk score is popular but it has some limitations. We developed and validated a dynamic predictive model for nausea or vomiting up to 48 postoperative hours, available as an online web application. Fentanyl was used by 22,144 adult patients for analgesia after non-cardiac surgery under general anaesthesia: we randomly divided them into development (80%) and validation (20%) cohorts, repeated 100 times. We used linear discriminant analysis to select variables for multivariate logistic regression. The incidences of postoperative nausea or vomiting were: 0-48 h, 5691/22,144 (26%); 0-6 h, 2749/22,144 (12%); 6-12 h, 2687/22,144 (12%); 12-18 h, 2624/22,144 (12%); 18-24 h, 1884/22,144 (9%); and 24-48 h, 1082/22,144 (5%). The median (95%CI) area under the receiver operating characteristic curve was 0.72 (0.71-0.73) up to 48 postoperative hours compared with 0.65 (0.64-0.66) for the Apfel model, p < 0.001. The equivalent areas for 0-6 h, 6-12 h, 12-18 h, 18-24 h and 24-48 h were: 0.70 (0.69-0.72); 0.71 (0.69-0.73); 0.69 (0.68-0.71); 0.70 (0.67-0.72); and 0.69 (0.66-0.71), respectively. Our web application allows clinicians to calculate incidences of nausea and vomiting in patients receiving intravenous fentanyl for patient-controlled analgesia.
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Affiliation(s)
- D Chae
- Department of Pharmacology, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - S Y Kim
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Y Song
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - W Baek
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - H Shin
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - K Park
- Department of Pharmacology, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - D W Han
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
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Cowley LE, Farewell DM, Maguire S, Kemp AM. Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature. Diagn Progn Res 2019; 3:16. [PMID: 31463368 PMCID: PMC6704664 DOI: 10.1186/s41512-019-0060-y] [Citation(s) in RCA: 113] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 05/12/2019] [Indexed: 12/20/2022] Open
Abstract
Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.
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Affiliation(s)
- Laura E. Cowley
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Daniel M. Farewell
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Sabine Maguire
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
| | - Alison M. Kemp
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Heath Park, Cardiff University, Wales, CF14 4YS UK
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Tabrizi S, Malhotra V, Turnbull ZA, Goode V. Implementation of Postoperative Nausea and Vomiting Guidelines for Female Adult Patients Undergoing Anesthesia During Gynecologic and Breast Surgery in an Ambulatory Setting. J Perianesth Nurs 2019; 34:851-860. [DOI: 10.1016/j.jopan.2018.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/25/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
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Perioperative outcomes: easier to predict but harder to change. Can J Anaesth 2019; 66:1014-1017. [DOI: 10.1007/s12630-019-01434-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 05/10/2019] [Accepted: 06/17/2019] [Indexed: 11/25/2022] Open
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Gabel E, Shin J, Hofer I, Grogan T, Ziv K, Hong J, Dhillon A, Moore J, Mahajan A, Cannesson M. Digital Quality Improvement Approach Reduces the Need for Rescue Antiemetics in High-Risk Patients. Anesth Analg 2019; 128:867-876. [DOI: 10.1213/ane.0000000000003828] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gustafsson UO, Scott MJ, Hubner M, Nygren J, Demartines N, Francis N, Rockall TA, Young-Fadok TM, Hill AG, Soop M, de Boer HD, Urman RD, Chang GJ, Fichera A, Kessler H, Grass F, Whang EE, Fawcett WJ, Carli F, Lobo DN, Rollins KE, Balfour A, Baldini G, Riedel B, Ljungqvist O. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS ®) Society Recommendations: 2018. World J Surg 2019; 43:659-695. [PMID: 30426190 DOI: 10.1007/s00268-018-4844-y] [Citation(s) in RCA: 961] [Impact Index Per Article: 192.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. METHODS A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. CONCLUSIONS The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Danderyd Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - M J Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, VA, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - M Hubner
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - J Nygren
- Department of Surgery, Ersta Hospital and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - N Demartines
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - N Francis
- Colorectal Unit, Yeovil District Hospital, Higher Kingston, Yeovil, BA21 4AT, UK
- University of Bath, Wessex House Bath, BA2 7JU, UK
| | - T A Rockall
- Department of Surgery, Royal Surrey County Hospital NHS Trust, and Minimal Access Therapy Training Unit (MATTU), Guildford, UK
| | - T M Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland Middlemore Hospital, Auckland, New Zealand
| | - M Soop
- Irving National Intestinal Failure Unit, The University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - H D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands
| | - R D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - G J Chang
- Department of Surgical Oncology and Department of Health Services Research, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - A Fichera
- Division of Gastrointestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - H Kessler
- Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, USA
| | - F Grass
- Department of Visceral Surgery, CHUV, Lausanne, Switzerland
| | - E E Whang
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - W J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital NHS Foundation Trust and University of Surrey, Guildford, UK
| | - F Carli
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - D N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - K E Rollins
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - A Balfour
- Department of Colorectal Surgery, Surgical Services, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - G Baldini
- Department of Anesthesia, McGill University Health Centre, Montreal General Hospital, Montreal, QC, Canada
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | - O Ljungqvist
- Department of Surgery, Örebro University and University Hospital, Örebro & Institute of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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What we can learn from Big Data about factors influencing perioperative outcome. Curr Opin Anaesthesiol 2019; 31:723-731. [PMID: 30169341 DOI: 10.1097/aco.0000000000000659] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW This narrative review will discuss what value Big Data has to offer anesthesiology and aims to highlight recently published articles of large databases exploring factors influencing perioperative outcome. Additionally, the future perspectives of Big Data and its major pitfalls will be discussed. RECENT FINDINGS The potential of Big Data has given an incentive to create nationwide and anesthesia-initiated registries like the MPOG and NACOR. These large databases have contributed in elucidating some of the rare perioperative complications, such as declined cognition after exposure to general anesthesia and epidural hematomas in parturients. Additionally, they are useful in finding patterns such as similar outcome in subtypes of beta-blockers and lower incidence of pneumonia in preoperative influenza vaccinations in the elderly. SUMMARY Big Data is becoming increasingly popular with the collaborative collection of registries offering anesthesia a way to explore rare perioperative complications and outcome to encourage further hypotheses testing. Although Big Data has its flaws in security, lack of expertise and methodological concerns, the future potential of analytics combined with genomics, machine learning and real-time decision support looks promising.
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Preoperative Risk Assessment to Guide Prophylaxis and Reduce the Incidence of Postoperative Nausea and Vomiting. J Perianesth Nurs 2018; 34:74-85. [PMID: 29945846 DOI: 10.1016/j.jopan.2018.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE This article describes the implementation of a postoperative nausea and vomiting (PONV) risk prediction and prophylaxis protocol. DESIGN This is a retrospective pre/post implementation quality improvement project. METHODS This project used chart reviews to assess the impact of the implemented PONV assessment and prophylaxis in a sample population of adult females undergoing gynecologic surgical procedures. FINDINGS The mean number of prophylactic antiemetics administered significantly increased during the postimplementation period from 3.64 (SD, 0.878) in the preimplementation period to 4.07 (SD, 1.021) in the postimplementation period (P < .001). The greatest increase in antiemetic administration occurred in the moderate-risk (risk score, 4) and the high-risk (risk score, 5 to 6) groups. The incidence of PONV decreased from 32.3% in the preimplementation period to 28.9% in the postimplementation period; however, this reduction did not meet statistical significance. Antiemetic administration compliance increased from 37% in the preimplementation group to 61% in the postimplementation group (P < .001). CONCLUSIONS The results of this project suggest that a risk-tailored approach to PONV prophylaxis using a risk assessment tool along with treatment recommendations is effective at reducing the incidence of PONV. The effectiveness of this approach is limited by the involvement of the anesthesia providers responsible for completing the assessments and administering PONV prophylaxis.
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Simplified algorithm for the prevention of postoperative nausea and vomiting: a before-and-after study. Br J Anaesth 2018; 120:156-163. [DOI: 10.1016/j.bja.2017.08.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/17/2017] [Accepted: 09/02/2017] [Indexed: 11/23/2022] Open
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Kappen TH, van Klei WA, van Wolfswinkel L, Kalkman CJ, Vergouwe Y, Moons KGM. Evaluating the impact of prediction models: lessons learned, challenges, and recommendations. Diagn Progn Res 2018; 2:11. [PMID: 31093561 PMCID: PMC6460651 DOI: 10.1186/s41512-018-0033-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 05/18/2018] [Indexed: 01/30/2023] Open
Abstract
An important aim of clinical prediction models is to positively impact clinical decision making and subsequent patient outcomes. The impact on clinical decision making and patient outcome can be quantified in prospective comparative-ideally cluster-randomized-studies, known as 'impact studies'. However, such impact studies often require a lot of time and resources, especially when they are (cluster-)randomized studies. Before envisioning such large-scale randomized impact study, it is important to ensure a reasonable chance that the use of the prediction model by the targeted healthcare professionals and patients will indeed have a positive effect on both decision making and subsequent outcomes. We recently performed two differently designed, prospective impact studies on a clinical prediction model to be used in surgical patients. Both studies taught us new valuable lessons on several aspects of prediction model impact studies, and which considerations may guide researchers in their decision to conduct a prospective comparative impact study. We provide considerations on how to prepare a prediction model for implementation in practice, how to present the model predictions, and how to choose the proper design for a prediction model impact study.
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Affiliation(s)
- Teus H. Kappen
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, Mail stop F.06.149, 3508 GA Utrecht, The Netherlands
| | - Wilton A. van Klei
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, Mail stop F.06.149, 3508 GA Utrecht, The Netherlands
| | - Leo van Wolfswinkel
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, Mail stop F.06.149, 3508 GA Utrecht, The Netherlands
| | - Cor J. Kalkman
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, Mail stop F.06.149, 3508 GA Utrecht, The Netherlands
| | - Yvonne Vergouwe
- 000000040459992Xgrid.5645.2Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karel G. M. Moons
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht University, P.O. Box 85500, Mail stop F.06.149, 3508 GA Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Risk-tailored prophylaxis for postoperative nausea and vomiting: has the big little problem gotten any smaller? Br J Anaesth 2018; 120:9-13. [DOI: 10.1016/j.bja.2017.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 10/31/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022] Open
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Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Steele SR, Feldman LS. Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2017; 31:3412-3436. [DOI: 10.1007/s00464-017-5722-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
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Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017; 60:761-784. [PMID: 28682962 DOI: 10.1097/dcr.0000000000000883] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Halliday TA, Sundqvist J, Hultin M, Walldén J. Post-operative nausea and vomiting in bariatric surgery patients: an observational study. Acta Anaesthesiol Scand 2017; 61:471-479. [PMID: 28374473 DOI: 10.1111/aas.12884] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The risk of post-operative nausea and vomiting (PONV) in patients undergoing bariatric surgery is unclear. The aim of the study was to investigate the risk of PONV and the use and effectiveness of PONV prophylaxis. METHODS This prospective observational study included 74 patients undergoing bariatric surgery with total intravenous anaesthesia. Patients were given PONV prophylaxis based on published guidelines and a simplified PONV risk score. Perioperative data were collected and a questionnaire was used at 2, 4, 6, 24, 48 and 72 h after the operation to evaluate PONV. Data are presented as risk (%) with the 95% confidence interval. RESULTS Sixty five per cent (54-75) of the patients experienced PONV in the first 24 post-operative hours and the risk increased with the number of risk factors for PONV. PONV occurred in 78% (66-87) of women and 26% (12-49) of men during the first 24 h. In relation to the guidelines, one patient received suboptimal PONV prophylaxis, 23% received optimal prophylaxis and 76% supra-optimal prophylaxis. The risk of PONV was 82% (59-94) with optimal prophylaxis and 59% (46-71) with supra-optimal prophylaxis. Of all patients, 34% (24-45) experienced severe PONV in the first 24 h that limited their activity. CONCLUSIONS The incidence of PONV in bariatric surgery patients was high despite a PONV prophylaxis regime following current guidelines. These results cast doubt as to the effectiveness of the usual PONV prophylaxis in this patient group and point to the need for further investigation of PONV prophylaxis and treatment in bariatric surgery patients.
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Affiliation(s)
- T. A. Halliday
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sundsvall Umeå University Sundsvall Sweden
| | - J. Sundqvist
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sundsvall Umeå University Sundsvall Sweden
| | - M. Hultin
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sunderbyn Umeå University Luleå Sweden
| | - J. Walldén
- Department of Surgical and Perioperative Sciences Anesthesiology and Intensive Care Sundsvall Umeå University Sundsvall Sweden
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Abstract
PURPOSE OF REVIEW Perioperative prediction models can help to improve personalized patient care by providing individual risk predictions to both patients and providers. However, the scientific literature on prediction model development and validation can be quite technical and challenging to understand. This article aims to provide the necessary insight for clinicians to assess the value of a prediction model that they intend to use in their clinical practice. RECENT FINDINGS Recent developments in prediction model research include the continuous development of new performance characteristics for prediction models, increasing insight into the limitations of old characteristics, as well as an improved understanding of the generalizability of prediction models to new populations and practices. SUMMARY Clinicians can assess the value of a prediction model for their practice by first identifying what the usage of the model will be. Second, they can recognize which performance characteristics are relevant to their assessment of the model. Finally, they need to decide whether the available scientific evidence sufficiently matches their clinical practice to proceed with implementation.
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31
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Affiliation(s)
- Kyung-Hwa Kwak
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Daegu, Korea
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Validation of a prediction model for post-discharge nausea and vomiting after general anaesthesia in a cohort of Swedish ambulatory surgery patients. Eur J Anaesthesiol 2016; 33:743-9. [DOI: 10.1097/eja.0000000000000473] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Smith CA, Haas RE, Zepp JC, Klein M. Improving the quality of post-anesthesia care: An evidence based initiative to decrease the incidence of postoperative nausea and vomiting in the post-anesthesia care unit. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.pcorm.2016.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Simpao AF, Tan JM, Lingappan AM, Gálvez JA, Morgan SE, Krall MA. A systematic review of near real-time and point-of-care clinical decision support in anesthesia information management systems. J Clin Monit Comput 2016; 31:885-894. [PMID: 27530457 DOI: 10.1007/s10877-016-9921-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/09/2016] [Indexed: 12/19/2022]
Abstract
Anesthesia information management systems (AIMS) are sophisticated hardware and software technology solutions that can provide electronic feedback to anesthesia providers. This feedback can be tailored to provide clinical decision support (CDS) to aid clinicians with patient care processes, documentation compliance, and resource utilization. We conducted a systematic review of peer-reviewed articles on near real-time and point-of-care CDS within AIMS using the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Studies were identified by searches of the electronic databases Medline and EMBASE. Two reviewers screened studies based on title, abstract, and full text. Studies that were similar in intervention and desired outcome were grouped into CDS categories. Three reviewers graded the evidence within each category. The final analysis included 25 articles on CDS as implemented within AIMS. CDS categories included perioperative antibiotic prophylaxis, post-operative nausea and vomiting prophylaxis, vital sign monitors and alarms, glucose management, blood pressure management, ventilator management, clinical documentation, and resource utilization. Of these categories, the reviewers graded perioperative antibiotic prophylaxis and clinical documentation as having strong evidence per the peer reviewed literature. There is strong evidence for the inclusion of near real-time and point-of-care CDS in AIMS to enhance compliance with perioperative antibiotic prophylaxis and clinical documentation. Additional research is needed in many other areas of AIMS-based CDS.
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Affiliation(s)
- Allan F Simpao
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA.
| | - Jonathan M Tan
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Arul M Lingappan
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd., Philadelphia, PA, 19104-4399, USA
| | - Sherry E Morgan
- University of Pennsylvania Biomedical Library, Perelman School of Medicine, University of Pennsylvania, 3610 Hamilton Walk, Philadelphia, PA, 19104-6060, USA
| | - Michael A Krall
- The Permanente Federation and the Oregon Health and Science University, 10040 SW Balmer Circle, Portland, OR, 97219, USA
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Kappen TH, van Loon K, Kappen MAM, van Wolfswinkel L, Vergouwe Y, van Klei WA, Moons KGM, Kalkman CJ. Barriers and facilitators perceived by physicians when using prediction models in practice. J Clin Epidemiol 2015; 70:136-45. [PMID: 26399905 DOI: 10.1016/j.jclinepi.2015.09.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 07/01/2015] [Accepted: 09/08/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Prediction models may facilitate risk-based management of health care conditions. In a large cluster-randomized trial, presenting calculated risks of postoperative nausea and vomiting (PONV) to physicians (assistive approach) increased risk-based management of PONV. This increase did not improve patient outcome-that is, PONV incidence. This prompted us to explore how prediction tools guide the decision-making process of physicians. STUDY DESIGN AND SETTING Using mixed methods, we interviewed eight physicians to understand how predicted risks were perceived by the physicians and how they influenced decision making. Subsequently, all 57 physicians of the trial were surveyed for how the presented risks influenced their perceptions. RESULTS Although the prediction tool made physicians more aware of PONV prevention, the physicians reported three barriers to use predicted risks in their decision making. PONV was not considered an outcome of utmost importance; decision making on PONV prophylaxis was mostly intuitive rather than risk based; prediction models do not weigh benefits and risks of prophylactic drugs. CONCLUSION Combining probabilistic output of the model with their clinical experience may be difficult for physicians, especially when their decision-making process is mostly intuitive. Adding recommendations to predicted risks (directive approach) was considered an important step to facilitate the uptake of a prediction tool.
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Affiliation(s)
- Teus H Kappen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands.
| | - Kim van Loon
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands
| | - Martinus A M Kappen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands
| | - Leo van Wolfswinkel
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands
| | - Yvonne Vergouwe
- Julius Center for Health Sciences and Primary Care, Department of Epidemiology, University Medical Center Utrecht, P.O. Box 85500, Mail Stop STR.6.131, Utrecht 3508 GA, The Netherlands; Department of Public Health, Erasmus Medical Center, P.O. Box 1738, Rotterdam 3000 DR, South Holland, The Netherlands
| | - Wilton A van Klei
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands
| | - Karel G M Moons
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands; Julius Center for Health Sciences and Primary Care, Department of Epidemiology, University Medical Center Utrecht, P.O. Box 85500, Mail Stop STR.6.131, Utrecht 3508 GA, The Netherlands
| | - Cor J Kalkman
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, Mail Stop F.06.149, Utrecht 3508 GA, The Netherlands
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Wiesmann T, Kranke P, Eberhart L. Postoperative nausea and vomiting – a narrative review of pathophysiology, pharmacotherapy and clinical management strategies. Expert Opin Pharmacother 2015; 16:1069-77. [DOI: 10.1517/14656566.2015.1033398] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kranke P. General multimodal or scheduled risk-adopted postoperative nausea and vomiting prevention: just splitting hairs? Br J Anaesth 2014; 114:190-3. [PMID: 25303990 DOI: 10.1093/bja/aeu344] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- P Kranke
- Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Oberdürrbacher Str 6, 97080 Würzburg, Germany
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