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Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients. Obes Surg 2020; 29:2843-2853. [PMID: 31183785 DOI: 10.1007/s11695-019-03943-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes. METHODS ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates. RESULTS During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group. CONCLUSIONS This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.
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Dogan K, Kraaij L, Aarts EO, Koehestanie P, Hammink E, van Laarhoven CJHM, Aufenacker TJ, Janssen IMC, Berends FJ. Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care. Obes Surg 2015; 25:28-35. [PMID: 24993524 DOI: 10.1007/s11695-014-1355-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC). METHODS This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates. RESULTS Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively. CONCLUSIONS The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.
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Affiliation(s)
- Kemal Dogan
- Department of Surgery, Rijnstate Hospital Arnhem, Intern post number 1190, Post Box 9555, 6800 TA, Arnhem, The Netherlands,
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Hollis IB, Jennings DL, Oliphant CS, Baker WL, Davis EM, Allender JE, Zemrak WR, Ensor C. Key articles and guidelines in the management of patients undergoing cardiac surgery. J Pharm Pract 2015; 28:67-85. [PMID: 25715085 DOI: 10.1177/0897190015570566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Significant numbers of patients undergo cardiac surgery worldwide each year. A large evidence base exists regarding the optimal pre-, intra-, and postoperative mediation management for patients undergoing coronary artery bypass grafting (CABG) surgery, valve replacements or repairs, and mechanical circulatory support (MCS). Prevention and treatment of perioperative arrhythmias, perioperative antimicrobial prophylaxis, prevention of thrombosis, and bleeding through proper management of perioperative antiplatelet and anticoagulant therapies, and the use of pharmacotherapy to optimize both short- and long-term patient outcomes after cardiac surgery are the focus of this first compilation of guidelines and key articles in this patient population to be published in the Journal of Pharmacy Practice.
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Affiliation(s)
- Ian B Hollis
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, NC, USA UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Douglas L Jennings
- Heart Transplant and Mechanical Circulatory Support, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Carrie S Oliphant
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA Department of Clinical Pharmacy, The University of Tennessee College of Pharmacy, Memphis, TN, USA
| | - William L Baker
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Estella M Davis
- Creighton University School of Pharmacy and Health Professions, Omaha, NE, USA
| | - J Erin Allender
- Department of Pharmacy, WakeMed Health & Hospitals, Raleigh, NC, USA
| | - Wesley R Zemrak
- Department of Pharmacy, Maine Medical Center, Portland, ME, USA
| | - Christopher Ensor
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Baker WL, Marrs JC, Davis LE, Nutescu EA, Rowe AS, Ryan M, Splinter MY, Vardeny O, Fagan SC. Key Articles and Guidelines in the Acute Management and Secondary Prevention of Ischemic Stroke. Pharmacotherapy 2013; 33:e115-42. [DOI: 10.1002/phar.1252] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- William L. Baker
- Department of Pharmacy Practice; University of Connecticut School of Pharmacy; Storrs; Connecticut
| | - Joel C. Marrs
- Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora; Colorado
| | - Lindsay E. Davis
- Department of Pharmacy Practice; Midwestern University College of Pharmacy; Glendale; Arizona
| | - Edith A. Nutescu
- Departments of Pharmacy Practice and Administration; University of Illinois at Chicago College of Pharmacy; Chicago; Illinois
| | - A. Shaun Rowe
- Department of Pharmacy Practice; University of Tennessee College of Pharmacy; Knoxville; Tennessee
| | - Melody Ryan
- Department of Pharmacy Practice and Science; University of Kentucky College of Pharmacy; Lexington; Kentucky
| | - Michele Y. Splinter
- Department of Pharmacy Clinical and Administrative Services; University of Oklahoma College of Pharmacy; Oklahoma City; Oklahoma
| | - Orly Vardeny
- Division of Pharmacy Practice; University of Wisconsin School of Pharmacy; Madison; Wisconsin
| | - Susan C. Fagan
- Department of Pharmacy Practice; University of Georgia College of Pharmacy; Augusta; Georgia
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Baker WL, Marrs JC, Davis LE, Nutescu EA, Shaun Rowe A, Ryan M, Splinter MY, Vardeny O, Fagan SC. Key Articles and Guidelines in the Primary Prevention of Ischemic Stroke. Pharmacotherapy 2013; 33:e101-14. [DOI: 10.1002/phar.1255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- William L. Baker
- Department of Pharmacy Practice; University of Connecticut School of Pharmacy; Storrs; Connecticut
| | - Joel C. Marrs
- Skaggs School of Pharmacy and Pharmaceutical Sciences; Aurora; Colorado
| | - Lindsay E. Davis
- Department of Pharmacy Practice; Midwestern University College of Pharmacy; Glendale; Arizona
| | - Edith A. Nutescu
- Departments of Pharmacy Practice and Administration; University of Illinois at Chicago College of Pharmacy; Chicago; Illinois
| | - A. Shaun Rowe
- Department of Pharmacy Practice; University of Tennessee College of Pharmacy; Knoxville; Texas
| | - Melody Ryan
- Department of Pharmacy Practice and Science; University of Kentucky College of Pharmacy; Lexington; Kentucky
| | - Michele Y. Splinter
- Department of Pharmacy: Clinical and Administrative Services; University of Oklahoma College of Pharmacy; Oklahoma City; Oklahoma
| | - Orly Vardeny
- Division of Pharmacy Practice; University of Wisconsin School of Pharmacy; Madison; Wisconsin
| | - Susan C. Fagan
- Department of Pharmacy Practice; University of Georgia College of Pharmacy; Augusta; Georgia
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Dobesh PP, Beavers CJ, Herring HR, Spinler SA, Stacy ZA, Trujillo TC. Key articles and guidelines in the management of acute coronary syndrome and in percutaneous coronary intervention: 2012 update. Pharmacotherapy 2012; 32:e348-86. [PMID: 23165917 DOI: 10.1002/phar.1225] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
More than 1 million people in the United States experience an acute coronary syndrome (ACS) every year, and almost 600,000 undergo percutaneous coronary intervention (PCI) for treatment of cardiovascular disease. There is a large amount of evidence-based literature to guide appropriate management of these patients. There have been a number of advances in the treatment of these patients over the last several years. Due to the large amount of rapidly available literature concerning the care of patients with ACS or undergoing PCI, clinicians can often find it difficult to keep up with the information needed for optimizing care of these patients. Therefore, we provide the second update to the first compiled bibliography of key articles and guidelines relative to patients with ACS published in Pharmacotherapy in 2004. The initial update was published in Pharmacotherapy in 2007 and also included bibliographies concerning management of patients undergoing PCI. A number of guidelines and practice-changing literature have been published since the update in 2007. Specific areas included in this review are updated summaries of clinical practice guidelines and clinical trials of anticoagulants, antiplatelets, platelet aggregation testing, pharmacogenomics testing in patients taking clopidogrel, clopidogrel loading dose comparisons, clopidogrel and proton pump inhibitor drug interactions, the impact of bleeding in ACS, and statins. As with previous versions of this document, we hope that this compilation will serve as a resource for pharmacists, physicians, nurses, residents, and students responsible for the care of patients with coronary heart disease.
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Affiliation(s)
- Paul P Dobesh
- Pharmacy Practice, College of Pharmacy, University of Nebraska Medical Center, Omaha, NE 68198-6045, USA.
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Venous thromboembolism after surgery for inflammatory bowel disease: are there modifiable risk factors? Data from ACS NSQIP. Dis Colon Rectum 2012; 55:1138-44. [PMID: 23044674 PMCID: PMC3767395 DOI: 10.1097/dcr.0b013e3182698f60] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although it is commonly reported that IBD patients are at increased risk for venous thromboembolic events, little real-world data exist regarding their postoperative incidence and related outcomes in everyday practice. OBJECTIVE We aimed to identify the rate of venous thromboembolism and modifiable risk factors within a large cohort of surgical IBD patients. DESIGN We performed a retrospective review of IBD patients who underwent colorectal procedures. PATIENTS Patient data were obtained from the American College of Surgeons National Surgical Quality Improvement Program 2004 to 2010 Participant Use Data Files. MAIN OUTCOME MEASURES The primary outcomes measured were short-term (30-day) postoperative venous thromboembolism (deep vein thrombosis and pulmonary embolism). Clinical variables were analyzed by univariate and multivariate analyses to identify modifiable risk factors for these events. RESULTS A total of 10,431 operations were for Crohn's disease (52.1%) or ulcerative colitis (47.9%), and 242 (2.3%) venous thromboembolic events occurred (178 deep vein thromboses, 46 pulmonary embolisms, 18 both) for a combined rate of 1.4% in Crohn's disease and 3.3% in ulcerative colitis. Deep vein thrombosis and pulmonary embolism each occurred at a mean of 10.8 days postoperatively (range for each, 0-30 days). A multivariate model found that bleeding disorder, steroid use, anesthesia time, emergency surgery, hematocrit <37%,malnutrition, and functional status were potentially modifiable risk factors that remained associated (p < 0.05) with venous thromboembolism on regression analysis. Patients with thromboembolism had longer length of stay (18.8 vs 8.9 days), more complications (41% vs 18%), and a higher risk of death (4% vs 0.9%). LIMITATIONS This study was limited by its retrospective design and its limited generalizability to nonparticipating hospitals. CONCLUSIONS Inflammatory bowel disease patients are at increased risk for postoperative venous thromboembolism. Reducing preoperative anemia, steroid use, malnutrition, and anesthesia time may also reduce venous thromboembolism in this at-risk population. Risk-reducing, preventative strategies are needed in this at-risk population.
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Abstract
Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.
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Polich AL, Etherton GM, Knezevich JT, Rousek JB, Masek CM, Hallbeck MS. Can eliminating risk stratification improve medical residents' adherence to venous thromboembolism prophylaxis? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2011; 86:1518-1524. [PMID: 22030760 DOI: 10.1097/acm.0b013e318235c3f6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE Hospital-acquired venous thromboembolism (VTE) is a common and preventable adverse event that most patients are at risk of developing during their hospital stay. VTE prophylactic anticoagulation (chemoprophylaxis) is the preferred pharmacological assignment for reducing risk of VTE, but it is underused in current practices involving risk stratification (RS) for VTE prevention. The purpose of this study was to determine whether a protocol that eliminates the RS step (non-RS protocol) is more likely to lead residents to evidence-based VTE assignment than the currently used RS protocol. The non-RS protocol follows a methodology that reduces complexity by assuming that the risk of VTE is present and uses contraindications to determine appropriate VTE assignment. METHOD In 2009, 41 medicine residents at the Nebraska Western Iowa Veterans Affairs clinic participated in an online comparison of two different protocols (RS and non-RS) for assigning chemoprophylaxis for VTE. Six validated, hypothetical patient scenarios were used to compare appropriate (evidence-based) VTE assignments for VTE and completion times for each protocol. RESULTS Statistical analyses found that the non-RS protocol produced significantly faster (P < .001) scenario completion times and significantly more (P < .001) appropriate VTE assignments than the RS protocol for four of the six patient scenarios. CONCLUSIONS This study used a new, streamlined protocol (non-RS), which improved VTE assignment and the use of chemoprophylaxis and simplified the process when compared with the use of a traditional RS protocol.
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Affiliation(s)
- Ann L Polich
- Nebraska Western Iowa Veterans Affairs Health Care System and Division of General Internal Medicine, Creighton University School of Medicine, Omaha, Nebraska, USA
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Amin AN, Deitelzweig SB. Optimizing the prevention of venous thromboembolism: recent quality initiatives and strategies to drive improvement. Jt Comm J Qual Patient Saf 2010; 35:558-64. [PMID: 19947332 DOI: 10.1016/s1553-7250(09)35076-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is associated with a substantial health care and economic burden, yet many VTE events are preventable. Despite the availability of evidence-based guidelines derailing effective thromboprophylaxis strategies, the underuse and inappropriate prescribing of VTE prophylaxis are common. Current national quality initiatives were reviewed to identify strategies that may help hospitals and health care professionals optimize current VTE prophylaxis practices. METHODS A computerized literature search was performed using PubMed and MEDLINE, and this was complemented by hand searches of relevant journals and Web sites to identify additional literature related to VTE prevention and quality improvement. FINDINGS Many organizations, including the Centers for Medicare & Medicaid Services, the National Quality Forum, the Joint Commission, and the Agency for Healthcare Research and Quality have developed performance measures, quality indicators, public reporting initiatives, incentive programs, and "negative reimbursement" that are designed to help improve VTE prevention. CONCLUSIONS It remains the responsibility of individual hospitals to identify specific areas in which they can improve their VTE prophylaxis rates to obtain positive results from the reporting initiatives and incentive programs. If performance measures are to be met, all hospital departments will need to implement effective VTE prevention policies, including early risk assessment, appropriate prophylaxis prescribing, monitoring, and follow-up. Multifaceted, integrated initiatives involving risk assessment tools, decision support, electronic alert systems, and hospitalwide education, with a mechanism for audit and feedback, may help ensure that all health care professionals comply with VTE-prevention policies and initiatives.
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Affiliation(s)
- Alpesh N Amin
- Department of Medicine, University of California, Irvine, USA.
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