TopMedTalk

With questions from the online audience, this piece looks at the "not too much and not too litte" sweet spot regarding fuel, fluid and oxygen; where is it and how do we get there, according to our distinguished panel?

This podcast works well as a companion piece to the following talks which have already been released here on TopMedTalk:

Helen McKenna, "Fuel, can you have too much?" https://www.topmedtalk.com/ebpom-2020-london-fuel-can-you-have-too-much/

Tim Miller "Optimising fluid and hemodynamic management during major surgery" https://www.topmedtalk.com/ebpom-london-2020-optimizing-fluid-and-hemodynamic-management-during-major-surgery/

Dan Martin "Perioperative Oxygenation" https://www.topmedtalk.com/ebpom-london-2020-perioperative-oxygenation/

Presented by Mike Grocott and Dennie Levett with their panelists; Tim Miller, Associate Professor of Anesthesiology from Duke University Medical Centre, Helen McKenna, is in the final year of her PhD at University College London, investigating bioenergetic and redox function in critically ill patients and Dan Martin, OBE anaesthetist and intensivist at the Royal Free Hospital and Reader at University College London (UCL).

This piece is a continued deep dive into the subject, of 'fitness, function, or frailty' and, perhaps, "fixing". It's essential listening for anyone interested in the latest thinking on this crucial topic and was a highlight of the London conference.

How can we integrate frailty and cognitive scores in risk assessment tools to facilitate inclusion in shared decision making? How can we improve a surgical colleague's ability to identify frailty? Most patients will have an operation sometime in their life; should surgical school be renamed and moved to being a "well being" clinic and offered to all patients? What screening tools would you recommend if only minimal time or money is available? Is pre-op screening actually 'public health' and should it really be being done for everyone? What are the differences and where is the overlap between fitness functional capacity, frailty, and sarcopenia? In mild cognitive impairment, should we tell patient that it will work and postop and not be expected to fully recover? What strategies have you found most helpful in engaging surgeons with identifying their frail patients? How are we tackling the workforce shortage among geriatricians? What has your experience been in advising achieving physical fitness in patients who present to surgery with persistent pain which is a limitation?

This is part two of a two part piece. Each of the contributors comments upon talks which they gave at EBPOM 2020, all of which are now available as part of the TopMedTalk podcast. To ensure you are among the first to hear information of this kind please investigate www.ebpom.org for more details about how you can attend our online conferences.

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Presented by Scarlett McNally, Deputy Director of The Centre for Perioperative Care (CPOC) consultant Orthopaedic Surgeon, Eastbourne DGH, UK and Monty Mythen, Smiths Medical Professor of Anaesthesia and Critical Care at University College London with questions from the online audience for their guests; Denny Levett, Professor in Perioperative Medicine and Critical Care at Southampton University Hospital NHS Foundation trust and Honorary Associate Professor at the University of Southampton, Daniel Conway, Consultant in Anaesthesia and Critical Care, Group Lead for Perioperative Medicine, Manchester Royal Infirmary, UK and Chair of the Manchester Perioperative Medicine Society, Jude Partridge, consultant geriatrician POPS, honorary senior lecturer, King's College London, Chairs the British Geriatrics Society POPS SIG, Vicki Morton, Director of Clinical and Quality Outcomes at Providence Anesthesiology Associates, P.A.

Fitness, function and, or, frailty are important determinants of the quality of the life that we live. In the context of major surgery it's very important we recognize and work with individual patients improving and optimizing them and their ability to handle an operation. This piece is an essential deep dive into the subject, essential listening for anyone interested in the latest thinking on this crucial topic.

What are the limitations on your resources when considering a plan of preoperative evaluation?

This is part one of a two part piece. Each of the contributors comments upon talks which they gave at EBPOM 2020, all of which are now available as part of the TopMedTalk podcast. To ensure you are among the first to hear information of this kind please investigate www.ebpom.org for more details about how you can attend our online conferences.

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Presented by Scarlett McNally, Deputy Director of The Centre for Perioperative Care (CPOC) consultant Orthopaedic Surgeon, Eastbourne DGH, UK and Monty Mythen, Smiths Medical Professor of Anaesthesia and Critical Care at University College London with questions from the online audience for their guests; Denny Levett, Professor in Perioperative Medicine and Critical Care at Southampton University Hospital NHS Foundation trust and Honorary Associate Professor at the University of Southampton, Daniel Conway, Consultant in Anaesthesia and Critical Care, Group Lead for Perioperative Medicine, Manchester Royal Infirmary, UK and Chair of the Manchester Perioperative Medicine Society, Jude Partridge, consultant geriatrician POPS, honorary senior lecturer, King's College London, Chairs the British Geriatrics Society POPS SIG, Vicki Morton, Director of Clinical and Quality Outcomes at Providence Anesthesiology Associates, P.A.

"We have to create the culture of learning; the culture of having a safe space, the culture of wanting to do better and learning those conditions in which we do do better"

This powerful talk looks directly at how a clear approach to patient safety really can improve the standard of care where you work. What is the culture of quality and safety that you're trying to embed, can you actually do better? Learn why it's important to focus on psychological safety; "if people start being scared, everyone gets scared then it expands".

Learn how an evidence based approach can allow us to tackle these issues rather than shy away from them; "what factors are maintaining safety? How do we get to good outcomes? What are the things working well? How do we understand human variation?".

Presented by Lee Fleisher, Emeritus Professor of Anesthesiology and Critical Care, University of Pennsylvania.

This piece covers the PREP-WELL project which is a community based prehabilitation program in South Tees, in the North of England:

"We established the following guiding principles; we wanted to provide patient centered care under one roof with facilitated self management; we wanted to work as a cross sector collaborative, by that I mean primary care, secondary care and public health; all working together to try and improve on the fragmented service provision and sign work that we often see in our health care services; we wanted to provide a community based facility for patients; and I'll come to the reasons for this".

See the PREP-WELL team here: https://www.southtees.nhs.uk/services/prepwell-project/meet-the-prepwell-team/

The links mentioned in the talk are here:

Home exercises: https://www.southtees.nhs.uk/services/prepwell-project/home-exercises/

Nutrition: https://www.southtees.nhs.uk/services/prepwell-project/nutrition/

Pdf download: https://bmjopenquality.bmj.com/content/bmjqir/9/1/e000898.full.pdf

We've been following the groundbreaking success of the PREP-WELL project for some time now here on TopMedTalk, why not check out this piece here, the first part in our most recent "P.O.E.T - Perioperative Enhancement Teams" series; https://www.topmedtalk.com/poet-2-01-the-uks-prepwell-initiative/

This piece was originally part of EBPOM 2020 - Live from London, our groundbreaking virtual conference; find out more about Evidence Based Perioperative Medicine (EBPOM) here: www.ebpom.org

Presented by Gerard Danjoux, consultant in Anaesthesia and Sleep Medicine at South Tees Hospitals NHS Foundation Trust.

"We have to remember that patients have a team"

How do we involve patients in the increasingly complex conversations we have in the perioperative space? This piece is a detailed case study which shows how shared decision making works in the perioperative setting. We know this improves patient experience yet in the last 10 or so years, consistently only 50 to 60% of patients say they were involved in decision making.

How can shifting towards a value based care model help? What is "moral injury" and how do we avoid it? Can a data driven analysis actually show shared decision making reduces costs?

Perioperative medicine for older people undergoing surgery (POPS) is an award winning geriatrician led service and the first of its kind in the UK - find out more here: https://www.guysandstthomas.nhs.uk/our-services/ageing-and-health/specialties/pops/overview.aspx

The Centre for Perioperative Care is here: https://cpoc.org.uk/

Presented by Ramai Santhirapala, Consultant Anaesthetist and Perioperative Medicine Lead at Guy's and St Thomas' NHS Foundation Trust, fellow of the Royal College of Anaesthetists, Faculty of Intensive Care Medicine and Higher Education Academy, Honorary Associate Professor at University College London, Clinical Lead for the UK arm of an international programme in shared decision making, "Choosing Wisely", which is led by the Academy of Medical Royal Colleges, Shared Decision Making Lead at the Centre for Perioperative Care and sits on the Choosing Wisely International Roundtable.

This talk aims to answer four major questions: How much fluid should you give perioperatively? Does hypotension matter? Should you use advanced hemodynamic monitoring, and do colloids have any advances over crystalloids?

Using high quality studies and a data based approach in all four categories, a lot of which has come from conversations that have had happened at Evidence Based Perioperative Medicine (EBPOM) meetings, this talk draws some interesting conclusions.

The American Society of Enhanced Recovery (ASER) is here: https://www.aserhq.org/web/

The Perioperative Quality Initiative (POQI) is here: https://thepoqi.org/

Presented by Tim Miller, Associate Professor of Anesthesiology from Duke University Medical Centre.

"As Anaesthetists the ultimate goal of almost all of our interventions and monitoring is to support cell energy production to provide mitochondria with the oxygen and the fuel they need to produce enough adenosine triphosphate (ATP) to power cell function and integrity".

How human cells produce energy, how this changes in response to stress and how this may influence survival; this piece focuses what we know about how our bodies get the fuel they need to survive surgery and thrive as a result, providing a positive long term outcome. This is not a piece about nutrition, it's a provocative session exploring concepts designed to provide food for thought.

Presented by Helen McKenna, is in the final year of her PhD at University College London, investigating bioenergetic and redox function in critically ill patients.

This is a story that starts with some of the challenges faced in our world outside the operating theatre and it's about how we might address some of these problems systematically. Healthcare organizations have to deliver high quality, competitive and sustainable results and costs. Good quality perioperative surgery is absolutely critical to maintain the health and well being of our population going forwards; this talk is a step in that direction.

Presented by Guy Ludbrook Professor of Anaesthesia at the University of Adelaide and Royal Adelaide Hospital.

"I cannot sleep. It's like, I wake up at 1am and my mind's going crazy ... if you had someone come to you and say; 'I'm really struggling right now, I'm having a lot of anxiety, with work with family, with kids with whatever'; what are some of the top things that you want to share with them?"

How can a regular yoga practice bring you into a deeper union with what you do and help improve your performance? Why is it that people in the caring profession sometimes leave self care at the bottom of their priority list? What resources can professional bodies offer you?

With special thanks to the American Association of Nurse Anesthetists (AANA) for their help with this piece, their excellent website is here: www.aana.com/covidwellness

The help number mentioned is: 1-800 654 5167

The Breathing App is here: https://eddiestern.com/the-breathing-app/

The book "Why we sleep" is here: https://www.amazon.co.uk/Why-We-Sleep-Science-Dreams/dp/0141983760

"Insight Timer" is here: https://insighttimer.com/

Presented by Desiree Chappell with her guests Bridget Petrillo, CRNA at The Mayo Clinic in Phoenix Arizona, volunteer member for the AANA Peer Assistance Advisors Committee, State Peer Advisor for the Arizona Association of Nurse Anesthetists (AZANA), member of the Wellness Committee for AZANA and Jessica Switzman, CRNA, MSN, Johns Hopkins, also served on the AANA Wellness Committee and AANA Peer Advisors Committee, State Peer Advisor for MANA and has been teaching Yoga since 2007.