TopMedTalk

Names, titles and definitions were sliced, diced and discussed at the Perioperative Quality Initiative (POQI). This conversation, recorded on the morning of the second day of the meeting and featuring some of the participants, reflects that.

"Stress volumes" and "Pre-load" are a couple of examples given in this piece. Everyone involved knew what these words described but once discussions got into detail it became clear multiple definitions were at play. Part of the point of an initiative like POQI is to bring terms like this, used by different people in different ways, to a concensus. This conversation explores some of the dillemmas which emerged as a result.

'Starling pressures' are discussed as is the role of lymph in the fluid balance of our patient's bodies. Furthermore the topic of fluid responsiveness comes up as does passive leg raising. Also, how does the fact that a patient's blood pressure can be normal, even if they've lost upto 25% of blood volume, impact on our understanding of these things?

Finally, how does this relate to the practitioners at the bedside? How do we translate these debates into practical advice which will make a real difference to patients, this piece goes some way towards answering those questions.

Send us your thoughts and contribute ot the debate: [email protected]

Coming from this summer's Peroperative Quality Initiative (POQI) hosted at Washington Duke University in Durham this podcast is presented by Desiree Chappell with Professor Monty Mythen, Henry Howe and their guest Tim Miller, anaesthsiologist from Duke University Medical Centre and organiser of the POQI meeting.

We begin with a question from the audience; 'how do we drive change in our institutions towards enhanced recovery after surgery?'

The GIRFT (Getting It Right First Time) project is explained. The Health Foundation is also mentioned.

This conversation is taken from a longer piece to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-2/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features questioner Paul Hutchings, Consultant Anaesthetist at Norfolk and Norwich University Hospital, alongside Professor Monty Mythen and his two guests; Dr Simeon West, consultant anaethetist at (University College London Hospitals) UCLH who sits on the board at Regional Anaesthesia UK (RAUK) and Mark Harper Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for thearaputic purposes.

We begin with a question from the audience; 'how do we drive change in our institutions towards enhanced recovery after surgery?'

The GIRFT (Getting It Right First Time) project is explained. The Health Foundation is also mentioned.

This conversation is taken from a longer piece to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-2/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features questioner Paul Hutchings, Consultant Anaesthetist at Norfolk and Norwich University Hospital, alongside Professor Monty Mythen and his two guests; Dr Simeon West, consultant anaethetist at (University College London Hospitals) UCLH who sits on the board at Regional Anaesthesia UK (RAUK) and Mark Harper Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for thearaputic purposes.

Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study.

Memtsoudis SG1, Poeran J, Zubizarreta N, Cozowicz C, Mörwald EE, Mariano ER, Mazumdar M.

BACKGROUND: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.

METHODS: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.

RESULTS: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P

CONCLUSIONS: While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

DOI: 10.1097/ALN.0000000000002132

Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study.

Memtsoudis SG1, Poeran J, Zubizarreta N, Cozowicz C, Mörwald EE, Mariano ER, Mazumdar M.

BACKGROUND:
Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.

METHODS:
Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.

RESULTS:
Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.

CONCLUSIONS:
While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

DOI: 10.1097/ALN.0000000000002132

The debate 'Direct laryngoscopes should be consigned to history' was hosted by The Royal College Of Anaesthetists and carried out by the two guests on this piece.

The conversation explores the fact that this skill is a key part of the job of practitioners, are we "de-skilling" the profession in an overly enthusiastic race toward new technology, or are some resisting it simply because it's not what they are used to?

This piece is taken from a longer conversation, to be found here: https://www.topmedtalk.com/rcoa-12-should-direct-laryngoscopes-be-consigned-to-the-history-books/

Where do you stand on the debate? Send us your thoughts: [email protected]

Presented by Joff Lacey and Monty Mythen with their two guests; Professor Tim Cook, Consultant in Anaesthesia and ICM, Royal United Hospitals, Bath and Dr William Harrop-Griffiths, St Mary's Hospital, Imperial College Healthcare NHS Trust.

The debate 'Direct laryngoscopes should be consigned to history' was hosted by The Royal College Of Anaesthetists and carried out by the two guests on this piece.

The conversation explores the fact that this skill is a key part of the job of practitioners, are we "de-skilling" the profession in an overly enthusiastic race toward new technology, or are some resisting it simply because it's not what they are used to?

This piece is taken from a longer conversation, to be found here: https://www.topmedtalk.com/rcoa-12-should-direct-laryngoscopes-be-consigned-to-the-history-books/

Where do you stand on the debate? Send us your thoughts: [email protected]

Presented by Joff Lacey and Monty Mythen with their two guests; Professor Tim Cook, Consultant in Anaesthesia and ICM, Royal United Hospitals, Bath and Dr William Harrop-Griffiths, St Mary's Hospital, Imperial College Healthcare NHS Trust.

The patient experience can be quite passive and, as a result, people can lose temperature quickly. The consequences can be very negative, this conversation revolves around how you can keep your patients warm.

This piece is taken from a longer conversation to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-1/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features Professor Monty Mythen and his guest Mark Harper, Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for theraputic purposes.

The patient experience can be quite passive and, as a result, people can lose temperature quickly. The consequences can be very negative, this conversation revolves around how you can keep your patients warm.

This piece is taken from a longer conversation to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-1/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features Professor Monty Mythen and his guest Mark Harper, Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for theraputic purposes.

This piece focuses on the latest print issue of 'Anesthesia and Analgesia' which is saturated with coverage of the Perioperative Quality Initiative (POQI), the most recent meeting of which was sponsored by the American Society of Enhanced Recovery (ASER).

This conversation acts as an update on where some of the latest thinking is as regards perioperative medicine. It includes a deep dive into gastrointestinal tract dysfunction and allows you to find out the best "whey" to an enhanced recovery alongside information about nutrition screening.

There's also a look at the perioperative medicine calendar, with details on how you can meet Monty and the team at one of the many events we're covering over the next few months.

Monty Mythen is interviewing Dr Tim Miller from Duke University Medical Centre.

Send us your thoughts: contact@topmedtalk

Web links:

- The ASER open source articles mentioned in the piece can be found on the POQI website.

- Also in this piece there is news about, The Morpheus Consortium, there's more information here: http://morpheusconsortium.org

- And finally, the website Dr Tim Miller mentions, is here: https://anesthesiology.duke.edu