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Background: Perioperative music can have beneficial effects on postoperative pain and perioperative opioid requirement. This study aims to assess the implementation feasibility of music in day care surgery through adherence to implementation, as well as its effects. Methods: This implementation study employed a prospective single-center study design. Perioperative music was implemented as part of standard surgical care during day care surgery procedures. The music intervention consisted of preselected playlists. Primary outcome was adherence to implementation. Barriers and attitudes towards music of patients and perioperative care providers were evaluated. Furthermore, the effects of music were assessed through a matched cohort analysis. This study was registered with the Netherlands Trial Register (NL8213). Results: From January to April 2020, a total of 109 patients received the music intervention and 97 were analyzed after matching to retrospective controls. Adherence rate to the music intervention was 92% preoperatively, 81% intraoperatively, and 86% postoperatively, with 83% of patients satisfied with the preselected music, and 93% finding music to be beneficial to surgical care. All health care providers believed perioperative music to be beneficial (63%) or were neutral (37%) towards its use. Postoperative pain was not significantly different (mean numeric rating scale 0.74; the music intervention group versus 0.68; control group, p =.363). Although not statistically significant, postoperative opioid requirement in the music group was lower (30% versus 40%, p =.132). Conclusion: Perioperative music implementation in day care surgery is feasible with high adherence rates, patient satisfaction levels, and positive attitudes of health care providers towards its use.

Resumen Introduccion Los programas de recuperacion precoz (rapid recovery, RP) en artroplastia total de rodilla pueden mejorar la funcionalidad a la vez que se reducen los costes. El objetivo del estudio es comparar los resultados de un programa de rehabilitacion precoz con nuestro protocolo habitual. Pacientes y metodos Se realizo un ensayo clinico aleatorizado (NCT03823573) en pacientes operados de artroplastia total de rodilla. El grupo intervencion (RP) recibio infiltracion periarticular con levobupivacaina e inicio deambulacion supervisada a las 4-6 h tras la intervencion. El grupo control (C) empleo drenaje y recibio un bloqueo femoral e inicio la deambulacion al retirar el drenaje. Los pacientes completaron un cuestionario Oxford Knee Score preoperatorio y a los 6 meses. La incidencia de trombosis venosa profunda asintomatica se analizo mediante ecodoppler. El seguimiento minimo fue de 6 meses. Resultados Fueron incluidos 175 pacientes (92 pacientes en el grupo C y 83 en el RP). No hubo diferencias en sexo, edad, tipo de protesis, descenso de hemoglobina, necesidad de transfusiones, balance articular activo al alta (C: 82,6°; RP: 85°) ni al finalizar el seguimiento (C: 105,1°; RP: 106,6°), mejoria del cuestionario (C: 17,5 puntos; RP: 19,3 puntos), satisfaccion del paciente o reatenciones hospitalarias (C: 7,6%; RP: 10,8%). Se observo significacion en el tiempo de isquemia (C: 81,29 min; RP: 85,35 min; p = 0,03), necesidad de rescate con opioides (C: 19,7%; RP: 38,6%; p = 0,007), estancia media (C: 3,84 dias; RP: 2,54 dias; p Conclusion El protocolo RP puede reducir la estancia hospitalaria sin aumentar las complicaciones ni las reatenciones.

In this study, ultrasonic-assisted root extracts (methanolic and aqueous) of 16 Crinum genotypes were investigated for their antioxidants, phytochemicals and alkaloids (lycorine and galanthamine). The maximum TPC was recorded in methanolic extract of CAF1 (10.871 ± 0.2 mg TAE/g DW) and the least in CA (5.291 ± 0.1 mg TAE/g DW). TFC ranged from 0.446 ± 0.03 (CA) to 1.051 ± 0.07 mg CE/g DW (CMOR) for methanolic extracts whereas for aqueous extracts the range was 0.258 ± 0.01 (CAF2) to 1.312 ± 0.05 mg CE/g DW (COME). TTC values were recorded higher from aqueous extracts whereas TAC was on the higher side in methanolic extracts. TTC was the highest in COME (6.960 ± 0.16 mg CE/g DW) and TAC in CMOR (2.510 ± 0.21 mg BE/g DW). The highest DPPH and ABTS radical scavenging were noted in CMOR (1.886 ± 0.07 mg AAE/g DW) and CP (18.251 ± 1.32 mg TE/g DW), respectively. Similarly, the highest FRAP and PMA activities were found from methanolic extracts of CAF1 (6.751 ± 0.06 mg Fe(II)E/g DW) and CAF2 (6.093 ± 0.16 mg AAE/g DW). Water extract of CM (4.788 ± 0.03 mg EDTA/g DW) had the highest metal chelation potential. Maximum inhibition of α-amylase and α-glucosidase was noticed in the methanolic extracts of CV (43.51%) and CM (85.58%), respectively. Similarly, the maximum inhibition (95.99%) of acetylcholinesterase activity was noted in the methanolic extract of CA. RP-HPLC revealed that GA and COA were the most common phenolics in the roots. The alkaloid, lycorine was detected in all the genotypes and galanthamine in only 14 genotypes. The highest lycorine content was detected in CW (6.28 ± 0.54 mg/g DW) and the lowest in CXA (0.45 ± 0.01 mg/g DW). Galanthamine content ranged from 0.10 ± 0.00 μg/g DW (CP) to 348.98 ± 0.01 μg/g DW (CXA). Ultrasonic-assisted extraction can be one of the sustainable approaches for the enhanced recovery of phytochemicals from Crinum species. Present study inferred that Crinum is a magnificent source of antioxidants, natural inhibitors of α-glucosidase as well as anti-Alzheimer and anticancer drugs.

Multimodal rehabilitation brings together the experience from health professionals from de fields of surgery, anesthesia, nursery and nutrition with the main objective of becoming the standard management necessary to improve the healthcare quality of surgical patients. According to statistics from our country, in the last 5 years the 70% of the surgery of the head and neck were performed by ENT specialists. Because of this, our special interest in the perioperative management of the nutritional state, pain, stress, immune modulation. We present the protocol of our Unit of Head and Neck Surgery in pharyngolaryngeal surgery.&nbsp

Few series have reported the utility of fast-track protocols (FTP) in minimally invasive liver surgery.To report the applicability of FTP in minimally invasive liver surgery and to correlate with difficulty scores.The series of patients undergoing minimally invasive liver surgery from 2014 was analyzed. Iwate, Southampton and Gayet's scores were compared as predictors of FTP adherence. Accomplishment of FTP was considered within 24-h, 48-h and 72-h. Multivariate models were performed to define discharge24 h,72 h, complications and readmissions.From 160 cases, 78 were candidates for FTP, of which 22 (28.2%), 19 (24.4%) and 14 (17.9%) were discharged in24-h, 48-h and 72-h, respectively (total = 71.5%). Iwate, Southampton and Gayet's scores achieved area under the receiver operating characteristic values for24-h stay of 0.780, 0.687 and 0.698, respectively. Sensitivity and specificity values for the best score (Iwate) were 87.7% and 66.7%, respectively (cutoff = 5.5). In multivariate models,72 h stay and complications revealed body mass index as a risk factor independent from difficulty scores.The development of aggressive FTP is feasible and24-h stay can be achieved even in moderate and advanced complexity cases. Difficulty scores, including body mass index value, may be useful to predict which cases may adhere to these protocols

Summary This paper focuses on the results of water shutoff operations using polymer gel in the Kelebija oil field. The methodology of candidate wells’ selection and the manner of performing the operation will also be included. The Kelebija oil field is characterized by a complex reservoir system with heterogeneous layers of different permeability and dual porosity with a strong waterdrive aquifer, which led to the early breakthrough of water. For the last 25 years, the average water cut was above 90%. Implementation of water shutoff operations began in 2019 and was performed on seven wells with an 85.7% success rate. It proved to be very effective with a water-cut reduction from 23% to as much as 72%. The average water cut for the entire Kelebija oil field has dropped by 12% and oil production increased by 210%.

Background Presently, data on the impact of enhanced recovery protocols on the outcomes of laparoscopic liver resection remain limited. We performed propensity matched analysis comparing the outcomes between patients undergoing laparoscopic liver resection before and after the introduction of an enhanced recovery protocol. Methods Between 2013 and 2019, 462 consecutive patients underwent laparoscopic liver resection by 3 surgeons of which 360 met the study inclusion criteria. There were 89 patients who underwent surgery under an enhanced recovery protocol and 271 without an enhanced recovery protocol. One-to-one propensity matched analysis was performed for 84 enhanced recovery protocol patients and 84 nonenhanced recovery protocol patients. Results Comparisons between propensity matched cohorts revealed that patients who received laparoscopic liver resection with enhanced recovery protocol had reduced median blood loss (200 vs 300 mL, P = .013), postoperative stay (3 vs 4 days, P = .003), and lower open conversion rates (0% vs 8.3%, P = .008). There was no difference in other key perioperative outcomes such as operation time, postoperative morbidity, postoperative major morbidity, and 30-day readmission rates. Conclusion A combined approach of enhanced recovery protocol and laparoscopic liver resection was associated with improved perioperative outcomes as opposed to laparoscopic liver resection alone.

Background: The Enhanced Recovery After Surgery (ERAS) care pathways include evidence-based items designed to accelerate recovery after surgery. Interdisciplinarity is one of the key points of ERAS programs. Objective: To prepare a consensus document among the members of the Nutrition Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Group for Multimodal Rehabilitation (GERM), in which the goal is to homogenize the nutritional and metabolic management of patients included in an ERAS program. Methods: 69 specialists in Endocrinology and Nutrition and 85 members of the GERM participated in the project. After a literature review, 79 statements were proposed, divided into 5 sections: 17 of general characteristics, 28 referring to the preoperative period, 4 to the intraoperative, 13 to the perioperative and 17 to the postoperative period. The degree of consensus was determined through a Delphi process of 2 circulations that was ratified by a consistency analysis. Results: Overall, in 61 of the 79 statements there was a consistent agreement, with the degree of consensus being greater among members of the SEEN (64/79) than members of the GERM (59/79). Within the 18 statements where a consistent agreement was not reached, we should highlight some important nutritional strategies such as muscle mass assessment, the start of early oral feeding or pharmaconutrition. Conclusion: Consensus was reached on the vast majority of the nutritional measures and care included in ERAS programs. Due to the lack of agreement on certain key points, it is necessary to continue working closely with both societies to improve the recovery of the surgical patients.

Day surgery has been expanding since the year 2000 when the NHS set a target to perform 75% of surgeries as day procedures. Initially only elective cases were eligible, but nowadays there is a pathway for emergency surgeries as well. There are many advantages for ambulatory surgery, but for a good outcome and a low risk of complications, it is important to have a clear selection criteria, follow enhanced recovery protocols and to optimize the patient's medical conditions preoperatively.

INTRODUCTION: There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. METHODS: Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. RESULTS: 494 patients underwent open pancreaticoduodenectomy – 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p=0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p

BACKGROUND: Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain.METHODS: An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions.RESULTS: A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1-2) and 5.3% (CI:4.6-6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2-43.3) of TKA and 2.7% (CI:2.0-3.5) of THA, but with considerable interdepartmental variation (0.0-89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82-1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68-2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63-1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2-3.6) with and 1 (0.1% CI:0.02-0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4-2.0) versus 4 (0.5% CI:0.2-1.2) who fell. Correspondingly, 2 (3.7% CI:1.0-12.6) and 11 (0.6% CI:0.3-1.0) of THA patients had these complications, while 0 (0.0% CI:0.0-6.6) and 17 (0.8% CI:0.5-1.3) fell.CONCLUSION: Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.

ZnO films were fabricated by pulsed laser deposition using two different background atmospheres (argon/vacuum). The gas-sensing properties of these materials against reducing and oxidizing gases were examined. The microstructure and crystal symmetry of the deposited films were studied with X-ray diffraction (XRD), Scanning electron microscopy (SEM), X-ray photoelectron spectroscopy (XPS), Raman, and Photoluminescence (PL) spectroscopy. The XRD studies revealed that the ZnO films grown in an argon environment are highly textured in the c-axis with a hexagonal crystalline structure. The c-axis is perpendicular to the substrate plane orientation (002) compared to (100) plane orientation, which is developed in a vacuum environment. Usually, this orientation (100) is difficult to obtain. Raman scattering spectra for both types of ZnO films revealed the characteristic E2 (high) mode that is related to the vibration of oxygen atoms in wurtzite ZnO. Moreover, PL spectra showed that a high number of defects appear in both the vacuum and argon-grown ZnO films. XPS data indicated that the O1s peak consists of several components identified as lattice oxygen, oxygen close to defects, and chemisorbed species. Furthermore, gas-sensing properties were investigated for nitrogen dioxide (NO2) at different operating temperatures and concentrations. Although both types of ZnO films have shown a good response towards NO2 at ppb levels, the films prepared under vacuum conditions showed higher responses. This was attributed to differences in crystallinity, microstructure, and the type of defects present in these materials.

Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. Objective The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy. Methods An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL). Results Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores. Conclusion This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Enhanced recovery after surgery is a standardized, multidisciplinary approach for caring patients with a goal of decreasing length of hospital stay and care without negatively affecting patient outcomes. Aim: to investigate the impact of enhanced recovery pathway application outcomes on nurses and women undergoing cesarean section. Design: A quasi experimental (pre-posttest for maternity nurses and study/control groups for women undergoing cesarean section) design was utilized in this study. Settings: This study was conducted at the obstetrics departments affiliated to University Hospital and Shebin El-Kom teaching hospital, Menoufia Governorate, Egypt. Sample: A convenient sample of 50 maternity nurses worked in the previous settings and a purposive sample of 250 cesarean delivery women were recruited in this study. Instruments: for collecting data; a structured interviewing questionnaire, knowledge assessment & an observational checklist for the nurses, knowledge assessment instrument, an observational checklist and numeric pain intensity scale for the mothers were used. Results: There was an increase in total knowledge and practice scores of the maternity nurses regarding the enhanced recovery pathway application. Also, its application following CS had an effect on relieving the women’s postoperative problems especially pain than those who received the routine hospitals nursing care only.Conclusion: application of enhanced recovery pathway significantly reduces the postoperative complications especially pain, length of hospital stay, and improves the maternity nurses' knowledge and practice scores post caesarean . Recommendation: Enhanced recovery pathway should be applied during cesarean section operations to improve the patients' outcomes and reduce the postoperative complications

Background Value-based healthcare focuses on improving outcomes relative to cost. We aimed to study the impact of an enhanced recovery pathway for liver transplant recipients on providing value. Methods In total, 379 liver recipients were identified: pre–enhanced recovery pathway (2017, n = 57) and post–enhanced recovery pathway (2018–2020, n = 322). The enhanced recovery pathway bundle was defined through multidisciplinary efforts and included optimal fluid management, end-of-case extubation, multimodal analgesia, and a standardized care pathway. Pre– and post–enhanced recovery pathway patients were compared with regard to extubation rates, lengths of stay, complications, readmissions, survival, and costs. Results Pre– and post–enhanced recovery pathway recipient model for end-stage liver disease score and balance of risk scores were similar, although post–enhanced recovery pathway recipients had a higher median donor risk index (1.55 vs 1.39, P = .003). End-of-case extubation rates were 78% post–enhanced recovery pathway (including 91% in 2020) versus 5% pre–enhanced recovery pathway, with post–enhanced recovery pathway patients having decreased median intraoperative transfusion requirements (1,500 vs 3,000 mL, P Conclusion Implementation of an enhanced recovery pathway in liver transplantation is feasible, safe, and effective in delivering value, even in the setting of complex surgical care.

Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery.This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared.Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019).ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

The results of numerous studies prove the high efficiency of regulating the flow of formation water into productive reservoirs by injecting non-hydrocarbon gases near the initial gas contour. In order to improve the existing technologies for the development of fields in a water drive, a study of the effectiveness of cyclic injection of carbon dioxide into a gas condensate reservoir was carried out. The study was conducted for varying carbon dioxide injection cycle times using Schlumberger’s Eclipse and Petrel simulation tools. According to the results of calculations, it was found that an increase in the duration of the injection cycle of carbon dioxide leads to a decrease in the duration of the development period of the reservoir until the moment of breakthrough of carbon dioxide. Rapid breakthrough of non-hydrocarbon gases into production wells results in shutdowns in order to maintain production gas condition to industry standards. This, in turn, leads to a decrease in the technological indicators of the development of a productive reservoir. However, analyzing the research results, it should be noted that the injection of carbon dioxide into the reservoir at the initial gas-water contact leads to a slowdown in the flow of formation water into the gas-saturated horizons. Based on the results of processing the calculated data, the optimal value of the duration of the cycle of injecting carbon dioxide into the reservoir was established, which is 7,89 months. The final gas recovery factor for the optimal value of the injection cycle time is 64,14 %, and in the case of depletion development – 54,31 %. The results of the studies carried out indicate the technological efficiency of injecting carbon dioxide into the productive reservoir on the vboundary of the initial gas-­water contact in order to regulate the process of inflow of edge waters into gas-saturated horizons and increase the final gas recovery factor.

BACKGROUND Enhanced recovery after surgery (ERAS) includes multiple interventions that have yielded positive outcomes in a number of surgical fields. The authors evaluated whether an ERAS protocol and the subsequent addition of liposomal bupivacaine affect patient outcomes specifically in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS All patients treated with DIEP flaps from January of 2016 to December of 2019 were reviewed retrospectively. The ERAS protocol was implemented midway through 2017; halfway through 2018, intraoperative transversus abdominis plane blocks with liposomal bupivacaine were added to the protocol. Such interventions allowed for comparison of three patient groups: before ERAS, during ERAS, and after ERAS plus liposomal bupivacaine. Primary outcomes observed were postoperative opioid consumption and length of stay. The p values were obtained using the Wilcoxon test for pairwise comparisons. RESULTS After adjusting for ERAS group compliance, 216 patients were analyzed. The pre-ERAS group was composed of 67 patients, the ERAS group was composed of 69 patients, and the ERAS plus liposomal bupivacaine group was composed of 80 patients. Postoperative opioid consumption was reduced when comparing the pre-ERAS and ERAS groups (from 275.7 oral morphine equivalents to 146.7 oral morphine equivalents; p < 0.0001), and also reduced with the addition of liposomal bupivacaine (115.3 oral morphine equivalents; p = 0.016). Furthermore, hospital length of stay was decreased from 3.6 days in the pre-ERAS group to 3.2 days (p = 0.0029) in the ERAS group, and to 2.6 days (p < 0.0001) in the ERAS group plus liposomal bupivacaine groups. CONCLUSIONS Enhanced recovery after surgery protocols decrease postoperative opioid consumption and hospital length of stay in DIEP flap breast reconstruction. The addition of liposomal bupivacaine further strengthens the impact of the protocol. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Aims The aim of this study is to assess the impact of a pilot enhanced recovery after surgery (ERAS) programme on length of stay (LOS) and post-discharge resource usage via service evaluation and cost analysis. Methods Between May and December 2019, 100 patients requiring hip or knee arthroplasty were enrolled with the intention that each would have a preadmission discharge plan, a preoperative education class with nominated helper, a day of surgery admission and mobilization, a day one discharge, and access to a 24/7 dedicated helpline. Each was matched with a patient under the pre-existing pathway from the previous year. Results Mean LOS for ERAS patients was 1.59 days (95% confidence interval (CI) 1.14 to 2.04), significantly less than that of the matched cohort (3.01 days; 95% CI 2.56 to 3.46). There were no significant differences in readmission rates for ERAS patients at both 30 and 90 days (six vs four readmissions at 30 days, and nine vs four at 90 days). Despite matching, there were significantly more American Society of Anesthesiologists (ASA) grade 3 patients in the ERAS cohort. There was a mean cost saving of £757.26 (95% CI £-1,200.96 to £-313.56) per patient. This is despite small increases in postoperative resource usage in the ERAS patients. Conclusion ERAS represents a safe and effective means of reducing LOS in primary joint arthroplasty patients. Implementation of ERAS principles has potential financial savings and could increase patient throughput without compromising care. In elective care, a preadmission discharge plan is key. Cite this article: Bone Jt Open 2021;2(11):966–973.

Background The Enhanced Recovery Program after surgery is a multimodal, evidence-based protocol of care developed to minimize the response to surgical stress. Data on the influence of ERP on outcomes, particularly according to the complexity of liver surgery, are lacking. Methods A prospective multicenter cohort of patients undergoing liver surgery and exposed to Enhanced Recovery Program from 2016 to 2020 in France was analyzed. High Enhanced Recovery Program compliance was defined as more than 70% of items (15 out of 21). The outcomes were the rate of complications, length of stay, and functional recovery according to Enhanced Recovery Program compliance. Results A total of 297 patients were included in the study, and they had 61.9% overall compliance (median = 13 items, interquartile range 11–15). Complications were observed in 32.2% (n = 95) of cases, and the mean length of hospital stay was 7.28 (±7.15) days overall. A longer duration of liver surgery was associated with an increase in the complication rate, while high compliance was independently associated with a reduced risk of complications in the multivariable analysis. Conclusion High Enhanced Recovery Program compliance was associated with a lower rate of postoperative complications.

Enhanced Recovery After Surgery (ERAS) protocols are widely used in oesophageal cancer surgery. Multiple studies have demonstrated that ERAS protocols are associated with a shorter length of stay and a reduction in the incidence of post-operative complications after oesophagectomy. However, there is substantial heterogeneity in the content of ERAS protocols and the delivery of these pathways can be challenging. This paper discusses the key recommendations for ERAS protocols in oesophageal cancer surgery and the barriers and facilitating factors for their successful implementation.

Introduction. Enhanced recovery after surgery and the early initiation of chemotherapy is a significant advantage of laparoscopic surgeries for malignant tumors of abdominal cavity in children. Despite the extensive experience in using caudal block in pediatric patients, it has not yet been determined whether the use of ultrasound navigation provides any clinical advantage in post-operative recovery after laparoscopic surgeries in pediatric oncology. Materials and methods. The study included 40 patients of Pediatric Oncology and Hematology, Federal Blokhin National Medical Research Center, ASA II–III, who underwent laparoscopic surgeries for malignant tumors of the abdominal cavity during 2017–2019. Patients were divided randomly into 2 groups. The CB (caudal blockade) group included 23 children. In CB group caudal epidural block as a regional component of combined anesthesia was used (CB group n = 23). GA (general anesthesia) group included 17 children who underwent general anesthesia (GA group, n = 17). Results. The median of the total dose of fentanyl in the CB group was 7.29 (6; 9.25) μg/kg, in the GA group — 10.7 (7.6; 12.5) μg/kg (р ≤ 0.012). In the postoperative period, patients in CB group didn’t require additional analgesia for 24 hours after caudal-epidural administration of morphine. After caudal-epidural administration of trimeperidin, 12 hours later. Enteral nutrition in children in the CB group was started in 4.7 ± 0.5 hours. In the GA group, enteral nutrition in 10 (59 %) patients was started in 20 hours after the end of the surgery. 5 children developed Conclusions. This study demonstrates that caudal epidural block for laparoscopic surgeries performed under ultrasound navigation provides effective analgesia in both perioperative and postoperative periods, promotes early start of enteral nutrition, minimizing the frequency of postoperative nausea and vomiting. Ultrasound navigation increases the likelihood of success and safety of the caudal epidural block.

Целью данного исследования было сравнение анальгетических эффектов налбуфина гидрохлорида и фентанила как основных компонентов в схеме интраоперационной мультимодальной анальгезии у пациентов с морбидным ожирением во время лапароскопических бариатрических вмешательств. Материалы и методы. В исследовании приняли участие 18 пациентов с морбидным ожирением, разделенные на две равнозначные группы (n = 9). В первой группе пациенты в качестве основного анальгетического компонента во время анестезии получали фентанил, во второй группе — налбуфина гидрохлорид. Уровень послеоперационной боли оценивался по визуально-аналоговой шкале (ВАШ) в течение первых послеоперационных суток. Результаты. Уровень послеоперационной боли по ВАШ в первые послеоперационные сутки статистически не отличался между пациентами обеих групп. Выводы. В соответствии с полученными данными налбуфина гидрохлорид является эффективной альтернативой фентанилу в качестве основного анальгетического компонента в схеме мультимодальной интраоперационной анальгезии у пациентов с морбидным ожирением при лапароскопических бариатрических вмешательствах.

Enhanced recovery protocols (ERAS) aim to decrease physiological stress response to surgery and maintain postoperative physiological function. Proponents of ERAS state these protocols decrease lengths of stay (LOS) and complication rates. Our aim was to assess whether elderly patients receive the same benefit as younger patients using ERAS protocols.We queried patients from 2015 to 2017 at our institution with Enhanced Recovery in Surgery (ERIN) variables from the targeted colectomy NSQIP database. The patients were divided into sextiles and analyzed for readmission, LOS, return of bowel function, tolerating diet, mobilization, and multimodal pain management comparing the youngest sextile to the oldest sextile.Two hundred sixty-two patients (73% colectomies) were enrolled in ERAS. When compared with the youngest sextile (age 19-43.8), the oldest sextile (age 71.4-92.5) had similar readmission rates at 9.8% versus 9.5% (P-value = 0.87), quicker return of bowel function, average 1.9 d versus 3.7 d (P-value0.01), and tolerated diet quicker, average POD 2.4 d versus 5.1 d (P-value0.01). There was a slight decrease in the use of multimodal pain management 88% versus 100% (P-value = 0.07), but mobilization on POD1 was slightly better in the elderly at 80% versus 78% (P-value = 0.76). Elderly patients enrolled in ERAS had an average LOS of 4.9 days versus 7.8 in the younger patients (P-value = 0.08). Among elderly non-ERAS patients average LOS was 14.6 days.Overall, elderly patients fared better or the same on the ERIN variables analyzed than the younger cohort. ERAS protocols are beneficial and applicable to elderly patients undergoing colorectal surgery.

BACKGROUND: 60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described. METHODS: We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis. RESULTS: A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2-39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9-46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863). CONCLUSIONS: Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance. ispartof: JOURNAL OF THORACIC DISEASE vol:13 issue:10 pages:5835-5842 ispartof: location:China status: published

Aims This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events. Methods A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits. Results The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively. Conclusion Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a ‘silver lining’ to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871–878.

Introduction. Spine fusion surgery is an increasingly popular procedure, but the patient experience is variable and the cost is high. Enhanced recovery after surgery (ERAS) pathways can provide a standardized plan for spine fusion cases, improving quality of care and reducing costs. We report an early attempt at the implementation of such a pathway and compare it to a historical cohort. Methods. All adult patients undergoing elective posterior thoracolumbar spine fusion in 2019 and 2020 were included in the study. The ERAS protocol implementation started in January 2020. The study cohort was all cases performed in 2020—after implementation of ERAS—while the historical cohort was cases from 2019. Demographic and clinical data were collected and compared between the groups. Results. Ninety-three patients were included in the study. The study cohort (ERAS) included 42 patients, while the comparison group (pre-ERAS) included 51 patients. Demographic and preoperative clinical data were similar between the two groups. However, postoperative clinical data showed that ERAS resulted in less reliance on analgesics, earlier mobilization, and a reduced length of stay. Complication and readmission rates were unchanged. Conclusion. ERAS can reduce costs while maintaining or improving clinical outcomes for spinal fusion surgery.

Background Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). Methods A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients’ chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. Results 1321 patient’s files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items’ application when data collected in 2015 and 2017 were analysed together. Conclusion ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.

BACKGROUND In this study, we describe our experience regarding the implementation of early enhanced recovery after lung surgery. We achieved early ambulation within 1 hour after extubation mainly by minimally invasive surgery combined with fast-track thoracic anesthesia. METHODS We retrospectively analyzed the clinical outcomes of early enhanced recovery in 211 patients who underwent lung resection using miniport video-assisted thoracic surgery (VATS) by a multidisciplinary team in a single institution in the period from August 2018 to August 2019. RESULTS Out of the 211 patients, 178 achieved early ambulation 1 hour after extubation. The mean age of patients in the early ambulation group was 58.6±10.8 years, and 69 men and 109 women were included. The anesthesia time (100.8±26.6 minutes), extubation time (10±2.1 minutes), and operating time (71.1±25.3 minutes) were lower in the early ambulation group (P=0.001, P

ERATS decreased length of stay, postoperative complications, and readmission.

Background Minimally invasive surgery combined with enhanced recovery programmes has improved outcomes after lung cancer surgery and where early mobilisation may be an important factor. However, little is known about pulmonary function and oxygenation during mobilisation after video-assisted pulmonary lobectomy. The aim of this prospective pilot cohort study was to explore the effect of postural changes (from supine to sitting to standing) on pulmonary function and oxygen saturation in a well-defined enhanced recovery programmes setting after video-assisted thoracoscopic surgery lobectomy. Methods A total of 24 patients were evaluated daily for postoperative pain score, pulmonary function (forced expiratory volume 1 s) and oxygen saturation in supine, sitting and standing position from 6 h after surgery to 6 h after chest drain removal. Results Mobilisation from supine to standing position showed a significant 7.9% increase (p = 0.04) in forced expiratory volume in 1 s percentage and oxygen saturation about 1.8% (pp = 0.809). Conclusions Early mobilisation should be encouraged to enhance recovery after video-assisted thoracoscopic surgery lobectomy by increasing lung function and oxygen delivery. Trial registration • Name of the registry: clinicaltrials.gov • Trial registration number: NCT04508270 • Date of registration: August 11, 2020

Early postoperative low compliance to enhanced recovery protocols has been associated with morbidity following colon surgery. The purpose of this study is to evaluate the possible causes of early postoperative low compliance to the enhanced recovery pathway and its relationship with morbidity following rectal surgery for cancer. A total of 439 consecutive patients who underwent elective surgery for rectal cancer have been included in the study. Compliance to enhanced recovery protocol on postoperative day (POD) 2 was evaluated in all patients. Indicators of compliance were naso-gastric tube and urinary catheter removal, recovery of both oral feeding and mobilization, and the stopping of intravenous fluids. Low compliance on POD 2 was defined as non- adherence to two or more items. One-third of patients had low compliance on POD 2. Removal of urinary catheter, intravenous fluids stop, and mobilization were the items with lowest adherence. Advanced age, duration of surgery, open surgery and diverting stoma were predictive factors of low compliance at multivariate analysis. Overall morbidity and major complications were significantly higher (p < 0.001) in patients with low compliance on POD 2. At multivariate analysis, failure to remove urinary catheter on POD 2 (OR = 1.83) was significantly correlated with postoperative complications. Low compliance to enhanced recovery protocol on POD 2 was significantly associated with morbidity. Failure to remove the urinary catheter was the most predictive indicator. Advanced age, long procedure, open surgery and diverting stoma were independent predictive factors of low compliance.

Fragestellung: Ziel der Studie war es, das funktionelle Ergebnis und die Lebensqualität 4 Wochen und 12 Monate nach zementfreier Hüftendoprothetik in Kombination mit einem Enhanced Recovery Protokoll zu untersuchen. Methodik: 109 Patienten wurden nach zementfreier Primär-Hüftendoprothese [zum vollständigen Text gelangen Sie über die oben angegebene URL]

PurposeThe safety and feasibility of enhanced recovery after surgery (ERAS) for laparoscopic pancreaticoduodenectomy (LPD) are unclear. The aim of this retrospective clinical study was to evaluate the impact of ERAS protocols for LPD.Patients and methodsBetween March 2016 and December 2018, a total of 34 consecutive patients with ERAS for LPD were prospectively enrolled and compared with 68 consecutive patients previously treated for non-ERAS after LPD during an equal time frame. The intraoperative and postoperative data were collected and comparatively analyzed.ResultsThe mean length of postoperative hospital stay (15.8 ± 3.4 and 23.1 ± 5.1 days, P P = 0.627) and intraoperative blood loss (523.5 ± 270.0 vs. 537.5 ± 241.8 ml, P = 0.800) were similar in the two groups. The complications (ER: 32.4% vs. non-ER: 35.3%, P > 0.05) and their severities (Clavien–Dindo grade ≥3 complications, 2 vs. 5 patients; P = 0.783) of patients with ERAS protocols were not increased. No difference in mortality and readmission rates was found. Finally, the total medical costs ($2.1 ± 0.7 × 104 and $2.3 ± 0.7 × 104, P = 0.017) in ER group were lower than those in non-ER group.Conclusionthe ERAS is safe and effective in the perioperative period of LPD. It could effectively reduce the length of postoperative stay and medical costs, and does not increase the incidence of postoperative complications.

Background: Prevalence of diabetes in surgical patients is 10–40%. They have higher incidence of complications, and longer stay in hospital compared to non-diabetic. Radical cystectomy with urinary diversion is considered one of the high-risk surgeries associated with morbidity and mortality. Enhanced recovery after surgery (ERAS) is an evidence-based multimodal surgical care protocol that improves post-operative outcomes and length of stay (LOS) in patients without diabetes. This study evaluates the evidence on whether diabetic patientswould benefit from ERAS pathway.The aim of the study: was to evaluate the efficacy of ERAS protocol from anesthesia in diabetic patients undergoing radical cystectomy.Patients and methods: This study was carried out in Alexandria main University Hospital on fifty-four adult ASA physical status I, II and III participants of either sex. Participants were scheduled for radical cystectomy surgeries under the effect of general anesthesia, following ERAS protocol, divided into two group diabetic and non-diabetic27 participants each. The ICON device was used to measure the stroke volume variation (SVV) to apply goal-directed fluid therapy (GDFT) for all patients.Measurements: Demographic data, hemodynamic parameters (stoke volume, cardiac index), intra-operative fluid requirement, blood loss, postoperative pain intensity, time of first bowel movement, PH, Bicarbonate level, serum lactate level, heamatocrit and LOS were measured and recorded.Main results: No statistical significant difference was detected between both groups as regard age, sex, weight, vital signs, serum lactate, first bowel movement and VAS. There was statistical significant difference between both groups as regard fluid requirement, and the days of hospital stay.Conclusion: ERAS is a beneficial protocol to improve postoperative outcome in radical cystectomy surgeries, it can be used in diabetic patients to decrease postoperative morbidity and mortality.

INTRODUCTION The aim of study was to assess the impact of an enhanced recovery after surgery (ERAS) protocol and minimally invasive approaches on short-term outcomes in rectal surgery. PATIENTS AND METHODS A consecutive series of patients that underwent open or minimally invasive rectal resections in a single institution between January 2015 and April 2020 were included in the study. An ERAS program was introduced in April 2016. The study cohort was divided into three groups: open surgery without ERAS, open surgery with ERAS, and minimally invasive surgery with ERAS. Outcome measures compared were recovery parameters, surgical stress parameters, 30-day morbidity and mortality, oncological radicality and length of hospital stay. RESULTS A total of 202 patients were included: 43 in the open non-ERAS group, 92 in the open ERAS group and 67 in the minimally invasive ERAS group. All recovery parameters apart from postoperative nausea and vomiting were significantly improved in both ERAS groups. Surgical stress parameters, prolonged postoperative ileus, and hospital stay were significantly reduced in the minimally invasive ERAS group. The overall 30-day morbidity and mortality and oncological radicality did not significantly differ among the three groups. CONCLUSIONS Minimally invasive approaches and enhanced recovery care in rectal surgery improve short-term outcomes. Their combination leads to an improvement in recovery parameters and a reduction of prolonged postoperative ileus and hospital stay.

Crude oil deposits as light/heavy form all over the world. With the continued depletion of the conventional crude and reserves trending heavier, the interest to maximise heavy oil recovery continues to emerge in importance. Ordinarily, the traditional oil recovery stages leave behind a large amount of heavy oil trapped in porous reservoir structure, making the imperative of additional or enhanced oil recovery (EOR) technologies. Besides, the integration of downhole in-situ upgrading along with oil recovery techniques not only improves the efficiency of production but also the quality of the produced oil, avoiding several surface handling costs and processing challenges. In this review, we present an outline of chemical agents underpinning these enabling technologies with a focus on the current approaches, new formulations and future directions.

Enhanced Recovery After Surgery (ERAS) protocols have shown significant success in improving pain scores and postoperative recovery and reducing hospital length of stay. Since the initial application in the colorectal patient population in the late 1990s, ERAS pathways have expanded to include many surgical subspecialties. This review explores the applicability of ERAS and its components in the field of cranial and spinal surgery. Only recently have researchers begun to study how to apply ERAS principles to intracranial or spine procedures. To date, robust evidence is lacking. Spine surgery patients benefit from preoperative education and early physical therapy, but how anesthetic or analgesic choice impacts recovery remains unclear. Additionally, there is a dearth of high-quality evidence to support the specific use of ERAS in cranial surgery. One randomized controlled trial, however, indicates that there is value in further study of ERAS care standardization in cranial neurosurgery and that concerns about increased complications may be unfounded. Regardless of adherence to ERAS components, the nature of intracranial surgery carries a high risk for morbidity and neurologic deficit. Patients across multiple surgical specialties benefit from ERAS protocols. Early studies suggest many of the components in these protocols can be advantageous in neurosurgery. However, how to tailor them to the neurosurgical patient is still evolving.

Background Decreasing the length of stay after thoracic surgery provides both clinical and financial benefits to both the patient and the clinical system. Since 2017, our institution has seen advancements in the care of patients undergoing thoracic surgery after utilising our protocol Enhanced Recovery After Thoracic Surgery (ERATS). Methods The protocol we implemented is comprehensive, including the patient’s pain management, thoracostomy tube drainage, physical therapy and rehabilitation, ventilator support and pulmonary care, as well as other features of preoperative, intraoperative, and postoperative care. In a retrospective review, we compared the overall length of stay prior to the protocol implementation to the length of stay after initiating the changes. Results We identified a median decrease of 2 days (from 6 days to 4 days) following the implementation of this protocol for all types of thoracic surgical procedures (p Conclusions Upon implementation of the ERATS protocol, we appreciated a decrease in the length of stay of thoracic surgery patients at our institution.

AIM The aim was to describe risk factors for hospital readmission in patients undergoing laparoscopic colorectal procedures and being discharged in ≤24 h. METHOD All consecutive patients undergoing minimally invasive colorectal surgery between 2010 and 2019 from a single institution were retrospectively reviewed. All patients were included in an enhanced recovery programme. Patients who met criteria for hospital discharge were compared according to the need for readmission in a 45-day follow-up. RESULTS In all, 664 patients underwent minimally invasive colorectal surgery during the study period and 237 (35.7%) were discharged in ≤24 h. Readmission was required in 16 (6.8%) patients discharged in ≤24 h and no postoperative mortality was observed in this group. Patients discharged in ≤24 h were more likely to have benign disease (P

BACKGROUND: Enhanced recovery after surgery protocols incorporate evidence-based practices of pre-, intra- and post-operative care to achieve the most optimal surgical outcome, safe on-time discharge, and surgical cost efficiency. Such protocols have been adapted for specialty-specific needs and are implemented by a variety of surgical disciplines including general thoracic surgery. This study aims to evaluate the impact of our enhanced recovery after thoracic surgery (ERATS) protocol on postoperative outcomes, pain, and opioid utilization following thoracotomy. METHODS: This is a retrospective analysis of patients undergoing elective resection of intrathoracic neoplasms via posterolateral thoracotomy between 1/1/2016 and 3/1/2020. Our enhanced recovery protocol, with a focus on multimodal pain management (opioid-sparing analgesics, infiltration of local anesthetics into intercostal spaces and surgical wounds, and elimination of thoracic epidural analgesia) was initiated on 2/1/2018. Demographics, clinicopathology data, subjective pain levels, peri-operative outcomes, in-hospital and post-discharge opioid utilization were obtained from the electronic medical record. RESULTS: A total of 98 patients (43 pre- and 55 post-protocol implementation) were included in this study. There was no difference in perioperative outcomes or percentage of opioid utilization between the two cohorts. The enhanced recovery group had significantly less acute pain. A significant reduction of in-hospital potent schedule II opioid use was noted following ERATS implementation [average MME: 10.5 (3.5–16.5) (ERATS) vs. 19.5 (12.6–36.0) (pre-ERATS), P

Pain control is challenging after minimally invasive repair of pectus excavatum (MIRPE). Cryoanalgesia, which temporarily ablates peripheral nerves, improves pain control and may accelerate post-operative recovery. We hypothesized that cryoanalgesia would be associated with shorter length of stay (LOS) in children undergoing MIRPE.A matched cohort study was conducted of children (18 years) who underwent MIRPE 2016-2018, using the National Surgical Quality Improvement Program-Pediatric database. Each patient who received cryoanalgesia during MIRPE was matched to four controls (no cryoanalgesia). Univariate and multilevel regression analyses were performed.Thirty-five patients who received cryoanalgesia during MIRPE were matched to 140 controls. Patients who received cryoanalgesia had a LOS reduction with similar secondary outcomes (operative time, rates of complication, reoperation, and readmission). On multilevel regression adjusted for matched groups, cryoanalgesia was associated with a 1.3-day reduction in LOS (95% CI -1.8 to -0.8, p 0.001). On sensitivity analysis excluding patients with complications, cryoanalgesia remained associated with a LOS reduction.Cryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE. Utilization is associated with a shorter LOS without an increase in operative time or complications. Cryoanalgesia should be considered for inclusion in enhanced recovery strategies for patients undergoing MIRPE.

This is a summary document that provides an Australian perspective on the Fourth Consensus Guidelines for the management of postoperative nausea and vomiting. The Australian Society of Anaesthetists has endorsed the Fourth Consensus Guidelines for the management of postoperative nausea and vomiting and has written this document with permission from the authors and the American Society for Enhanced Recovery to provide an Australia-specific summary.