Perioperative outcomes afterlaparoscopic cholecystectomy in the elderly patients: Asystematic review and meta-analysis (2020)

Type of publication:
Conference abstract

Author(s):
Kew T.; Lin A.; Ekeozar C.; Bundred J.; Evans R.; Griffiths E.; Kamarajah S.; *Karri S.; Singh P.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 5-6

Abstract:
Aim: The need to perform elective and emergency cholecystectomy in an ever ageing population increases yet these risks are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of cholecystectomy in the elderly population.
Method(s): A systematic literature search of PubMed, EMBASE and the Cochrane Library databases were conducted and a meta-analysis was performed in accordance with the recommendations of the Cochrane Library and PRISMA guidelines.
Result(s): This review identified 99 studies incorporating 333,041 patients. Increasing age was significantly associated with increased rates of overall complications (OR 2.33, CI95%: 2.00-2.71, p<0.001), major complication (OR 2.32, CI95%: 1.52-3.54, p<0.001), risk of conversion to open cholecystectomy (OR 2.32, CI95%: 1.95-2.76, p<0.001), risk of bile leaks (OR 2.05, CI95%: 1.18-3.55, p<0.001), risk of postoperative mortality (OR 5.99, CI95%: 3.77-9.52, p<0.001) and was significantly associated with increased length of stay (MD 2.12 days, CI95%: 1.01-3.24, p<0.001).
Conclusion(s): Post-operative outcomes such as overall and major complications are significantly higher in all age cut-offs. There is six-fold increase in perioperative mortality which increases by nine-fold in patients >80 years old. This study confirms preconceived suspicions of risk in elderly patients undergoing cholecystectomy and will aid treatment planning and informed consent.

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Is pain properly managed in children presenting with fractures? A retrospective audit of children presenting to the emergency department (2020)

Type of publication:
Conference abstract

Author(s):
*Rafie A

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 68

Abstract:
Aim: Pain is a common problem in the surgical field, especially when treating children – but how well is it managed, and documented? In this audit we aim to answer a few key questions. Is analgesia administered prehospital? Are pain scores recorded, and re-evaluated? And is analgesia offered and/or administered in the Emergency Department(ED)? Method: A retrospective audit was carried out between two hospitals on 100 patients aged between 5-15 presenting to the ED. A search was carried out using SNOMEDand ICD10 codes, to find patients presenting with fractures – and the ED CAS cards reviewed.
Result(s): The data showed poor compliance between both hospitals – pain scores were seldom recorded, or reevaluated; and in 58% of cases analgesia was not offered and no reason was documented. 28% of patients were given pre-hospital analgesia and only 2% of patients had an analgesia review.
Conclusion(s): Adequate pain management is vital, especially in children – as they often don’t self-report pain. The study found that the worst compliance was in documentation of pain scores, and their re-evaluation. However, more concerningly analgesia was only administered in 19% of cases – and in many cases there was no documentation as to why it wasn’t offered.

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Impact of gastrografin in clinical practice in the management of small bowel obstruction of various etiologies (2020)

Type of publication:
Conference abstract

Author(s):
*Karim M.O.; *Jamshed M.H.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 204

Abstract:
Aim: Gastrografin has shown to accelerate the resolution of small bowel obstruction of certain etiologies. This audit aims to review the outcome of oral gastrografin (OG) in patients with the small bowel obstruction of diverse causes diagnosed on radiological investigation.
Method(s): A retrospective study of 57 patients who had oral gastrograffin for small bowel obstruction
between 1st June 2018 to 30th June 2019 was included in this study.
Result(s): After excluding 9 patients, 48 included in the study who met the inclusion criterion. 31 patients had adhesive small bowel obstruction (ASBO), of these symptoms resolved in 52% after OG, all patients with postoperative ileus (9), Crohn’s stricture (3) and constipation with small bowel dilatation (1) showed resolution of obstructive symptoms with oral gastrografin. 2 patients out of 3 with serosal/peritoneal metastasis showed response to oral gastrografin.
Conclusion(s): Gastrografin is beneficial and safe to use as a therapeutic agent in a carefully selected patient with certain GI conditions including adhesive small bowel obstruction, postoperative ileus, Crohn’s stricture, constipation, serosal metastasis (peritoneal cancer). Appropriate use of gastrografin can reduce the need for surgical intervention and hospital stay.

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Boat propeller transection of hemithorax-successful multidisciplinary surgical reconstruction (2020)

Type of publication:
Conference abstract

Author(s):
*Cheruvu S.; Oo K.T.M.; Erel E.; Satur C.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 37

Abstract:
A 69 year old man fell into canal and was drawn into the propeller of his canal boat that resulted in transection of the right thoracic cavity and the right upper arm. Emergency helicopter transfer was made to our major trauma centre for multidisciplinary surgical care. Injuries included a full thickness antero-posterior transection from the sternum to beyond the tip of the scapula, and an open right midshaft humeral fracture with wound extending obliquely into the axilla. The entire thoracic cavity was contaminated by canal water. There was severe haemodynamic and cardiorespiratory compromise requiring level 3 intensive care. Following emergency resuscitative management, multidisciplinary surgical care was provided by the cardiothoracic, plastic and orthopaedic surgery teams utilising innovative operative techniques. Multistage operative management of chest wall required initial damage control surgery with debridement and negative pressure therapy. After 4 days of intensive care physiological stabilisation, reconstruction of the thoracic defect was undertaken with specialist thoracic titanium implants and the chest wall was reconstructed. This was a major thoracic trauma case treated successfully using revolutionary surgical techniques at the Royal Stoke Hospital. The subsequent impact on practice for thoracic polytrauma has led to improved survival rates by 75%.

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Assessing the adequacy of radiographs for hip fractures (2020)

Type of publication:
Conference abstract

Author(s):
*Mulrain J.; *Omar N.; *Burston B.

Citation:
British Journal of Surgery; Jun 2020; vol. 107 ; p. 138

Abstract:
Aim: Radiographs for the assessment of femoral neck fractures are frequently inadequate for the visualisation of the proximal femur. A low centred radiograph of both hips offers enough information but is rarely achieved.We sought to determine the proportion of hip fractures where initial radiographs adequately visualised the femur to encompass the proposed surgical management.We also sought to find the proportion of patients who required repeat radiographs and whether this was affected by time of presentation. Method(s): A retrospective review of the radiographs of hip fractures presenting to our institution, over a three-month period was undertaken. The timings, number and adequacy of radiographs was assessed. Result(s): Radiographs of 89 patients were reviewed. Most radiographs were taken between 8am and 5pm. Radiographs of 58 patients were centred on the pelvis rather than the hips. Patients presenting overnight were more likely to have adequate radiographs. Despite a duplicate x-ray rate of 48%, most patients (55%) had inadequate visualisation of the proximal femur. The average excess radiation exposure by duplicate radiographs was 2.31mSv per patient. Conclusion(s): The majority of patients had inadequate visualisation of the fractured proximal femur on their radiographs.Many had excessive radiographs performed. This was not improved by increased staffing levels during daylight hours.

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Acute appendicitis-can we shorten the length of hospital stay? (2020)

Type of publication:
Conference abstract

Author(s):
British Journal of Surgery; Jun 2020; vol. 107 ; p. 197

Citation:
*Jones G.; *Bura K.; *Rink J.

Abstract:
Introduction: Appendicectomy is the most commonly performed emergency general surgical operation in the UK. Hospital episode data revealed that our unit had longer than average length of stay (LOS). We designed a study to examine our length of stay and management of acute appendicitis. Method(s): We performed a retrospective study of consecutive patients undergoing appendicectomy from January to March 2019. Cases were identified from theatre logbooks. Data collection included demographics, pre and post-operative LOS, CT imaging and histology. The data was then examined to see what factors were associated with length of stay and where improvements might be realised. Result(s): 71 patients were identified. Mean LOS was 81 hours, mean time to theatre from admission was 22 hours withmean post-operative LOS at 58 hours. There was a difference between females vs males LOS 95 vs 67 hours. CT scan was obtained in 26 patients and the mean time to theatre in these patients was longer at 27 hours compared to 20 hours in the non- CT group. Patients who took longer to get to theatre had increased LOS. Conclusion(s): Rapid access to CT could shorten time to theatre. Getting patients to theatre quicker might shorten post-operative length of stay.

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Regional experiences of endotracheal intubation during the COVID-19 pandemic in The United Kingdom (2020)

Type of publication:
Conference abstract

Author(s):
Shuker B.; Smith E.; *Checketts P.; Khan Q.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: In the United Kingdom (UK), consensus guidelines for airway management were published early in the COVID-19 pandemic making recommendations to support clinicians during this potentially challenging intervention (1). Adaptions to existing guidance for airway management in critically ill adults from the Difficult Airway Society (2) included: use of personal protective equipment (PPE), preferential use of the best skilled airway manager to maximise chance of first-pass success, avoidance of aerosol-generating procedures (such as noninvasive ventilation, high flow nasal oxygenation), and use of reliable well practiced techniques (including videolaryngoscopy where appropriate). Objective(s): Areas of the West Midlands were some of the worst affected by the COVID-19 pandemic in the UK (3). We aimed to gain insight into the experiences of clinicians involved with airway management during the COVID-19 pandemic in this region. Method(s): An online survey was distributed to multiple centres within the West Midlands region of the UK. Clinicians who had experience of endotracheal intubation in patients with confirmed, suspected, or unknown COVID-19 status were asked to reflect upon their experience of one patient intubation. Result(s): 127 clinicians from 16 hospitals including 3 large university hospitals responded to the online survey, most were consultant grade (56.7%). Clinicians self-reported an average approximate number of pandemic intubations of 7.35 (range 1-30). When asked to reflect on a single intubation, clinicians reflected on intubations in ICU (42.5%), emergency departments (20.5%), wards (8.7%), and theatre (28.3%). Appropriate PPE was available in 96.1%. The most senior clinician available intubated in 65.4%. Clinicians reported first pass success in 93.7% of responses. Most intubators reported use of videolaryngoscopy (74.8%), however 26% reported not using this equipment regularly and 5.5% did not feel confident with their equipment. Despite a high success rate, difficulties were reported in 15.1%. The most common was desaturation. Other common difficulties included equipment or environment unfamiliarity, lack of skilled support. When asked what advice they would give to colleagues, frequently occurring themes included: ensuring familiarity with equipment, use of a checklist, use of videolaryngoscopy, and availability of a second intubator. Desire for simulation and equipment familiarisation was highlighted in multiple responses, and in one example a clinician attributed their success to a simulation session performed in the week prior. Conclusion(s): Experiences from clinicians in this region highlight the specific challenges encountered involved in airway management of patients with COVID-19, in particular highlighting the importance of advance preparation for intubation when faced with unfamiliar circumstances. Simulation sessions, use of checklists and standard operating procedures for emergency intubation may contribute to maintaining preparedness for intubation in this challenging patient group.

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Intensive care unit (ICU) referrals and admissions at a district general hospital (DGH) in light of the COVID-19 pandemic (2020)

Type of publication:
Conference abstract

Author(s):
*Blair J.; *Naughton E.; *Pradhan N.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: The COVID-19 pandemic has led to an increase in ICU referrals and admissions across the UK during 2020 [1]. Intensive care beds are a limited and expensive resource and decisions on patient admission are often very challenging [2]. Proformas help to standardise documentation and decision logging during patient referrals [3]. They provide easily accessible evidence in case of a future referral and allow audit of decision-making processes. A preliminary survey of doctors working in a DGH ICU was undertaken to assess the current referral and admission process in expectation of an increased volume of work.
Objective(s): As a result of the survey, three main areas for improvement were identified: 1. To maintain a record of all ICU referrals and decision-making processes 2. To reduce the time taken for documentation of referrals and admissions 3. To improve the quality and appropriateness of referrals from parent specialities Methods: A proforma was designed for dual use as a referral and admission document. All referrals were recorded on paper and staff received training on how to apply the proforma. After assessment of each referral, irrespective of admission outcome, a completed copy of the proforma was placed in both the patient’s notes and a dedicated referrals folder. After one month, a further survey was designed to assess the response postimplementation of the proforma. All referrals made over a threemonth period between April and June 2020 were audited.
Result(s): The initial survey received 12 responses. Prior to the COVID-19 pandemic, documentation of any referral or admission took on average 10-15 minutes. All survey participants felt that referring teams did not have a good understanding of the role of ICU care and estimated that up to 40% of all referrals received were inappropriate. The follow-up survey received 14 responses. Implementation of the proforma reduced the time taken to document a referral or admission on average by 5-10 minutes. Twelve participants found the proforma a useful aid, helping to provide clear documentation and ease communication between ICU team members. Less than 9% of the referrals made between April and June 2020 were admitted to ICU with over 32% of referrals deemed unsuitable for further escalation. Approximately 50% of referrals were made by registrars, with 13% discussed by consultants. The median age of patients referred was 67.5 and the most common reason was for respiratory deterioration.
Conclusion(s): This quality improvement project successfully reduced the time taken to document ICU referrals and admissions. Use of a proforma has provided many benefits, including standardisation of documentation, decision logging and improvement of intra-and inter-team communication. Only a small proportion of patients referred to ICU have been suitable for admission. A teaching session is being designed so that referral information can be fed-back to parent specialties. Referrals will be reaudited after this. Data analysis of this project has been limited by incomplete proforma documentation from participating users.

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A Tidal volume calculator to improve lung protective ventilation in COVID-19 related Acute Respiratory Distress Syndrome (ARDS) (2020)

Type of publication:
Conference abstract

Author(s):
*Blair J.; *Hester S.; Baldwin A.; Ali T.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: Routine use of lower tidal volumes (TVs) for the mechanical ventilation of patients with ARDS results in decreased mortality and increases the number of days without ventilator use [1]. Severe COVID-19 pneumonia has been associated with the development of ARDS as characterised by the Berlin definition [2]. A multi-centre preliminary audit was undertaken to identify whether ventilated COVID-19 related ARDS patients were receiving optimal TVs, as recommended by the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) ARDS management guidelines [3]. Objective(s): As a result of the audit, three main areas for improvement were identified. 1. To achieve accurate calculations for ideal body weight (IBW) and target TV 2. To improve documentation of IBW and target TV 3. To achieve TVs no greater than 6 ml/kg Methods: A ‘tidal volume calculator’ tool was developed using Microsoft Excel, which was simple, colour coded and kept on all Intensive Care Unit (ICU) computer desktops. This tool was designed to use height to calculate IBW and, if the patient’s height was unavailable, could also be utilised to calculate height from ulna length. IBW was subsequently used to calculate a target TV. Staff received training on how to apply the tool. Two snapshot audits were carried out in April and May 2020 at two ICUs. The first was conducted prior to the tool’s introduction with the second two weeks after its implementation. All patients receiving mechanical ventilation, except those spontaneously breathing, were included. Data was extracted from patient notes, charts and ventilator settings. Result(s): The initial audit included 14 patients. Six patients did not have an IBW documented. Three patients had documented IBWs that were 12 kg, 15 kg and 23 kg greater than the weight calculated using the tool, leading to increased tidal volume targets. Only three patients were achieving TVs of 4-6 ml/kg. Eleven patients were achieving a TV greater than 6 ml/kg, with two of these achieving a TV of greater than 8 ml/kg. The follow-up audit included ten patients. This revealed that all patients had an IBW clearly documented. Moreover, nine patients were achieving TVs within 4-6 ml/kg, with only one patient found to be achieving a TV greater than 6 ml/kg. Conclusion(s): This audit cycle revealed that initially adherence to lung protective ventilation and documentation of IBW was poor. In some instances, documented IBW was vastly different to the calculated IBW, suggesting that in these situations actual body weight may have been used. In a time when clinicians were being redeployed to support ICU, this simple tool was shown to support staff by clearly calculating and displaying IBW and target TV for reference. This directly led to improved adherence to lung protective ventilation and optimisation of patient care. Limitations include that no consideration was made for overall patient outcome, and only a snapshot of achieved TVs from ventilators were recorded; daily/weekly trends were not studied.

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‘Daycase parathyroidectomy: Time to change the norm?’ (2020)

Type of publication:
Conference abstract

Author(s):
Chang J.; Neophytou C.; Howard E.; Houghton A.

Citation:
British Journal of Surgery; 2020; vol. 107 ; p. 37

Abstract:
Introduction: The most recent BAETs audit report of 2017 shows a surprisingly low rate of same-day discharge following parathyroidectomy (10%). In our unit we have developed a simple and safe protocol which allows same day discharge for almost all patients (95%). The 2017 BAETS report has 11,463 patients recorded for primary hyperparathyroidism. Following this simple protocol could save over 9,500 inpatient bed days.
Method(s): Demographics, histology, biochemistry and length of stay were identified for all patients undergoing parathyroidectomy for primary hyperparathyroidism between 01/01/2010 and 31/12/2019. Following surgery all patients were discharged on Calcichew D3 one tablet tds, with arrangements for serum calcium analysis and outpatient appointment at 7 and 10 days Results: We performed 264 parathyroid procedures during the study period. The cohort had a median age of 63 (range 15 – 90). Day-case procedures were carried out in 95% (n=249). 10 patients stayed 24 hours, 4 for 48 hours and 1 patient for 4 days (urgent parathyroidectomy following acute medical admission with symptomatic hypercalcaemia). 1 patient was admitted overnight for observation of bleeding wound (no return to theatre). The remainder were admitted for a mixture of social and anaesthetic reasons. 6 patients (2%) had 30 day morbidity: 2with symptoms of relative hypocalcaemia (not admitted), 1 patient with hypocalcaemia requiring intravenous calcium, 1 seroma, 1 patient presented with an exacerbation of COPD and 1 haematoma.
Conclusion(s): We have shown that same-day discharge after parathyroid surgery is safe and ought to become the norm in other units.

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