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Reducing Postoperative Pulmonary Complications

Reducing Postoperative Pulmonary Complications

Pulmonary complications after surgery are relatively common, occurring in roughly 3% of patients who undergo non-cardiac operations. When compared with other adverse postoperative outcomes, pulmonary complications are also among the most costly. Some analyses have shown that these complications can increase hospital length of stay by as many as 14 days when compared with a lack of these complications. “Clinicians have little guidance on how to prevent pulmonary complications after operations,” says David McAneny, MD. “Efforts to standardize care may reduce the incidence of adverse pulmonary outcomes.” Testing an Intervention In a study published in JAMA Surgery, Dr. McAneny and colleagues tested an intervention designed to reduce the incidence of postoperative pulmonary complications. “Our goal was to create a simple, inexpensive pulmonary care program that was easily understood and remembered by patients, their families, and our staff,” says Dr. McAneny. “We included lung expansion exercises, early and frequent patient mobilization, oral hygiene, and education as key components of our strategy.” In order to facilitate recall of the intervention, the acronym “I COUGH” was developed. I COUGH components included: Incentive spirometry. Coughing and deep breathing. Oral care (brushing teeth and using mouthwash twice daily). Understanding (patient and family education). Getting out of bed frequently (at least three times daily). Head-of-bed elevation. “A critical component of I COUGH is patient education, a process that begins in clinics and continues during preoperative assessments,” explains Dr. McAneny. “Brochures, a video in various languages, and posters with instructions that describe the importance of postoperative pulmonary care were developed.” The multidisciplinary program taught and reinforced principles of the I COUGH interventions. Elements of I COUGH...
Guidelines for Managing Fever & Neutropenia in Cancer Patients

Guidelines for Managing Fever & Neutropenia in Cancer Patients

Neutropenia, a common condition among cancer patients that is caused by low levels of neutrophils, can be caused by cancer itself or by the types of chemotherapy used. People with neutropenia are much more likely to develop infections when compared with those who have normal blood counts. Febrile neutropenia occurs when patients with neutropenia develop fevers, which are a sign of possible infection. Typically, febrile neutropenia is treated by immediately hospitalizing patients and providing them with intravenous antibiotics to prevent life-threatening complications, such as sepsis. Recent studies, however, suggest that select patients who are at low risk of complications related to febrile neutropenia may be eligible for outpatient treatment. The American Society of Clinical Oncology (ASCO) has issued a clinical practice guideline update on the management of neutropenia with fever and for the prevention of related infections in cancer patients. ASCO also endorsed a related guideline for children with cancer. To develop these guidelines, an expert panel systematically reviewed evidence from relevant medical literature, including 47 seminal articles. “These guidelines are intended to help physicians identify patients at high risk of medical complications related to neutropenia with fever,” says Christopher R. Flowers, MD, MS, who co-chaired the ASCO expert panel that drafted the guideline for adults. “They also provide clarity on when preventive treatment for infection is needed.” Additionally, guidance is offered on managing select patients who can be managed safely at home during febrile neutropenia episodes. Hospitalizations & Assessing Risks According to Dr. Flowers, a priority of ASCO’s guidelines was to help clinicians identify patients with febrile neutropenia who do not require hospitalization. “The guideline will help spare...
Innovative Techniques to Address Bariatric Surgery Complications

Innovative Techniques to Address Bariatric Surgery Complications

Millions of patients find it extremely difficult to achieve durable weight loss without medical intervention. Many opt for bariatric surgery to achieve a healthier weight, but up to 30% of patients who undergo these procedures regain weight. There are a variety of reasons for regaining weight after bariatric surgery. In some cases, there may be dysfunction of the stomach pouch that was surgically created. Others may experience dangerous and painful complications, such as fistulas and leaks. Patients who experience these types of post-bariatric surgical problems are reluctant to undergo another invasive procedure to correct the issues. Alternatives to Bariatric Surgery Complications In recent years, an important treatment alternative has emerged for this patient population thanks to advanced endoscopy. Using this approach, we can address post-bariatric surgery problems like fistulas, ulcers, and lap band erosion with less invasive endoscopic surgery techniques. Advanced endoscopy enables clinicians to: Locate and repair defects. Close leaks and fistulas with endoscopic sutures. Reduce patient discomfort. Reduce postoperative recovery time. Help re-establish proper pouch dimensions. Help stop weight gain and aid in weight loss. With advanced endoscopy, we’re able to perform endoscopic pouch reduction surgery to restore the stomach pouch to its original post-surgery dimensions and halt weight gain. These procedures help patients experience less postoperative discomfort, as there is minimal to no blood loss, no external cuts, and no need to re-route the existing anatomy. This results in shorter hospital recovery times, with most patients going home the same day. Advanced endoscopic techniques can be beneficial to manage complications after bariatric surgery. These include repairing and/or addressing gastric pouch dysfunction/defects, esophageal and gastric fistulas, sleeve...
Decreasing 30-Day Morbidity Rates in Surgery Patients

Decreasing 30-Day Morbidity Rates in Surgery Patients

Numerous studies have demonstrated that 30-day postoperative complications resulting from unintended harm adversely affect patients and their families and increase institutional healthcare costs. Several medical societies and associations have developed simple, inexpensive surgical checklists to help reduce postoperative morbidity and mortality. These readily available checklists are capable of shifting the hierarchical culture of the operating room (OR). Although there is evidence that these tools enhance communication and reduce postoperative complications and death, studies suggest they are not used universally. In April 2010, the Association of Perioperative Registered Nurses (AORN) unveiled a comprehensive surgical checklist that incorporates mandated clinical practices required by the World Health Organization, the Joint Commission, and CMS. The one-page document compartmentalizes information to make documentation during the perioperative process easier. It also includes a debriefing component that encourages the OR team to acknowledge concerns and the plan of care for patients to ensure they are safely transitioned to recovery room staff. Taking a Closer Look In the Journal of the American College of Surgeons, Lindsay A. Bliss, MD, and colleagues had a study published that sought to determine if combining a structured, team communications training curriculum with a comprehensive, standardized surgical checklist could reduce 30-day morbidity for patients. The communications training included three 60-minute sessions, with topics such as differences between introverts and extroverts, effective dialogue among all OR personnel, and how to use the AORN’s surgical checklist. High-risk procedures included in the National Surgical Quality Improvement Program database were analyzed for postoperative morbidity. These operations served as the baseline group because the teams carrying out these procedures did not participate in communications training or use...

Making the Case for Early Palliative Care

Throughout the United States, palliative care (PC) is becoming a more established and integral component of comprehensive cancer care for patients with advanced disease. “Published research has shown that PC is associated with better quality of life and mood, improved symptom control, and more appropriate health resource use,” explains Jennifer S. Temel, MD. “It has also been linked to increased patient and caregiver satisfaction, healthcare savings, and survival.” Clinical guidelines recommend that all patients with metastatic cancer be offered PC services early in the course of the disease. Currently, many cancer centers have some form of PC services, such as inpatient consultative services and acute inpatient units. PC clinics, on the other hand, are scarcer entities. Recent analyses have suggested that integrating PC early in the ambulatory care setting is feasible and can improve patient-reported outcomes as well as several key measures of quality end-of-life care and resource use. Early integration of PC with cancer care improves patients’ understanding of their disease and prognosis, leads to more timely transitions to hospice care, and decreases chemotherapy use near the end of life. Looking Closer at Early Palliative Care According to Dr. Temel, more information about the nature and elements of early PC in ambulatory care is needed. “The integration of PC with standard oncologic care may have a different emphasis and focus than traditional inpatient or consultative PC,” she says. Earlier and longer collaborative relationships between PC clinicians and patients may allow the time and opportunity to face complex issues like treatment decisions and advanced care planning rather than focus mostly on acute symptom management and imminent death. A study...
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