Protocol for the development of a multidisciplinary clinical practice guideline for the care of patients with chronic subdural haematoma

Introduction: A common neurosurgical condition, chronic subdural haematoma (cSDH) typically affects older people with other underlying health conditions. The care of this potentially vulnerable cohort is often, however, fragmented and suboptimal. In other complex conditions, multidisciplinary guidelines have transformed patient experience and outcomes, but no such framework exists for cSDH. This paper outlines a protocol to develop the first comprehensive multidisciplinary guideline from diagnosis to long-term recovery with cSDH. Methods: The project will be guided by a steering group of key stakeholders and professional organisations and will feature patient and public involvement. Multidisciplinary thematic working groups will examine key aspects of care to formulate appropriate, patient-centered research questions, targeted with evidence review using the GRADE framework. The working groups will then formulate draft clinical recommendations to be used in a modified Delphi process to build consensus on guideline contents. Conclusions: We present a protocol for the development of a multidisciplinary guideline to inform the care of patients with a cSDH, developed by cross-disciplinary working groups and arrived at through a consensus-building process, including a modified online Delphi.

Impact of perioperative direct oral anticoagulant assays: a multicenter cohort study

BACKGROUND

There is little evidence to guide the perioperative management of patients on a direct oral anticoagulant(DOAC) in the absence of a last known dose. Quantitative serum titers may be ordered but there is little evidence supporting this.

AIMS

This multi-center retrospective cohort study of consecutive surgical in-patients with a DOAC assay, performed over a five-year period, aimed to characterize preoperative DOAC assay orders and their impact on perioperative outcomes.

MATERIALS AND METHODS

Patientsprescribed regular DOAC (both prophylactic and therapeutic dosing) with apreoperative DOAC assay were included. DOAC assay titer was evaluated againstendpoints. Further, patients with an assay were compared against anticoagulatedpatients who did not receive a preoperative DOAC assay. The primary endpointwas major bleeding. Secondary endpoints included perioperative hemoglobinchange, blood transfusions, idarucizumab or prothrombin complex concentrateadministration, postoperative thrombosis, in-hospital mortality andreoperation. Adjusted and unadjusted linear regression models were used forcontinuous data. Binary logistic models were performed for dichotomous outcomes.

RESULTS

1065 patientswere included, 232 had preoperative assays. Assays were ordered most commonlyby Spinal (11.9%), Orthopedics (15.4%) and Neurosurgery (19.4%). For every10ng/ml increase in titer, the hemoglobin decreases by 0.5066g/L and the oddsof a preoperative reversal increases by 13%. Compared to those without anassay, patients with preoperative DOAC assays had odds 1.44x higher for majorbleeding, 2.98x higher for in-hospital mortality and 16.3x higher for receivinganticoagulant reversal.

CONCLUSION

A preoperativeDOAC assay order was associated with worse outcomes despite increased reversaladministration. However, the DOAC assay titer can reflect the patient'slikelihood of bleeding.

Practical strategies for the prevention and management of chronic postsurgical pain

Chronic postsurgical pain (CPSP) is a multifactorial condition that affects a significant proportion of patients undergoing surgery. The prevention and management of CPSP require the identification of preoperative risk factors to screen high-risk patients and establish appropriate perioperative pain management plans to prevent its development. Active postoperative pain management should be provided to prevent CPSP in patients with severe pain following surgery. These tasks have become important for perioperative team members in the management of CPSP. This review article provides a comprehensive overview of the latest research on the role of perioperative team members in preventing and managing CPSP. Additionally, it highlights practical strategies that can be employed in clinical practice, covering the definition and risk factors for CPSP, including preoperative, intraoperative, and postoperative factors, as well as a risk prediction model. The article also explores various treatments for CPSP, as well as preventive measures, including preemptive analgesia, regional anesthesia, pharmacological interventions, psychoeducational support, and surgical technique modification. This article emphasizes the importance of a comprehensive perioperative pain management plan that includes multidisciplinary interventions, using the transitional pain service as an example. By adopting a multidisciplinary and collaborative approach, perioperative team members can improve patient outcomes, enhance patient satisfaction, and reduce healthcare costs. However, further research is necessary to establish targeted interventions to effectively prevent and manage CPSP.

Focused cardiac ultrasound in preoperative assessment: the perioperative provider's new stethoscope?

Focused cardiac ultrasound (FoCUS)—a simplified, qualitative version of echocardiography—is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20–30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image acquisition. However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image interpretation. Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.

Randomised controlled pilot study to investigate the effectiveness of thoracic epidural and paravertebral blockade in reducing chronic post-thoracotomy pain: TOPIC feasibility study protocol

INTRODUCTION

Open chest surgery (thoracotomy) is considered the most painful of surgical procedures. Forceful wound retraction, costochondral dislocation, posterior costovertebral ligament disruption, intercostal nerve trauma and wound movement during respiration combine to produce an acute, severe postoperative pain insult and persistent chronic pain many months after surgery is common. Three recent systematic reviews conclude that unilateral continuous paravertebral blockade (PVB) provides analgesia at least equivalent to thoracic epidural blockade (TEB) in the postoperative period, has a lower failure rate, and symptom relief that lasted months. Crucially, PVB may reduce the development of subsequent chronic pain by intercostal nerve protection or decreased nociceptive input. The overall aim is to determine in patients who undergo thoracotomy whether perioperative PVB results in reducing chronic post-thoracotomy pain (CPTP) compared with TEB. This pilot study will evaluate feasibility of a substantive trial.

METHODS AND ANALYSIS

TOPIC is a randomised controlled trial comparing the effectiveness of TEB and PVB in reducing CPTP. This is a pilot study to evaluate feasibility of a substantive trial and study processes in 2 adult thoracic centres, Heart of England NHS Foundation Trust (HEFT) and University Hospital of South Manchester NHS Foundation Trust (UHSM). The primary objective is to establish the number of patients randomised as a proportion of those eligible. Secondary objectives include evaluation of study processes. Analyses of feasibility and patient-reported outcomes will primarily take the form of simple descriptive statistics and where appropriate, point estimates of effects sizes and associated 95% CIs.

ETHICS AND DISSEMINATION

The study has obtained ethical approval from NHS Research Ethics Committee (REC number 14/EM/1280). Dissemination plan includes: informing patients and health professionals; engaging multidisciplinary professionals to support a proposal of a definitive trial and submission for a full HTA application dependent on the success of the study.

TRIAL REGISTRATION NUMBER

ISRCTN45041624; Pre-results.

Use of Key Words as an Adjunctive Learning Tool Improves Learning During a Perioperative Medicine Rotation for Anesthesiology Residents

Designing a successful block rotation for anesthesiology residents requires not only an appropriate curriculum but also a set of teaching tools, which promote learning. Traditional clinical rotations in Anesthesiology residencies emphasize clinical teaching, supported by interaction with staff. Since Perioperative Medicine is a non-traditional subject for anesthesia residents, we introduced a syllabus, and didactic curriculum to support clinical teaching. We hypothesized that the use of key words would enhance learning. Alternating groups of residents were assigned to receive key words, while control residents were expected to learn without key words. The key words were delivered in writing on the first day of the rotation and the syllabus was highlighted to identify the key words in the text. Pre and post-tests were administered to residents participating in the perioperative rotation. Learning was assessed by calculating the change in test scores. There was significantly more learning in the group given the key words. We conclude that key word designation improved learning in a rotation designed to teach perioperative medicine.

Creation of a Perioperative Medicine Curriculum for an Anesthesiology Residency Program

Because of the increasing expansion of the practice of anesthesiology beyond the borders of the operating room, there is attention being paid to Perioperative Medicine (PM) within anesthesiology training programs. With the elements of PM incorporated into the newest requirements for anesthesiology residency programs by the Residency Review Committee (RRC) for Anesthesiology of the American College of Graduate Medical Education (ACGME), programs are obliged to develop PM curriculum. At the Cleveland Clinic, a PM curriculum was created from existing, diverse elements of the clinical practice. Clinical supervision of the Pre-Anesthesia testing center, the Same-Day-Surgery unit, In-House Consultation and the Post-Anesthesia Care Unit were combined into a single teaching service. A didactic curriculum was created, resident function within these units was defined, and weekly teaching sessions were created. The result has been increased clinical teaching of PM, satisfaction of RRC requirements, and improved opportunity for resident learning in these areas. Residents have rated PM within the top 10% of rotations for the first two years of existence. We conclude that a combined service is an excellent approach to the creation of a PM curriculum.