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Post-operative ileus: What are the associated risk factors?
Abstracts / Clinical Nutrition ESPEN 12 (2016) e30ee59
The study of T and B cells subsets showed a significant higher CD4 and CD19 levels in G2 at m2. NK cells count was significant lower in the same group at m3. There were no significant differences in the levels of immunoglobulin between groups. Conclusion: This study demonstrates that laparoscopic surgery appears to be associated with similar immune responses compared with open surgery, considering that immune parameters vary slightly between groups. Although higher CRP levels showed a high level of injury in the open surgery group, the management of perioperative care through an ERAS protocol seemed to minimise the effect of open surgery associated to more postoperative complications. Further studies are be required in order to clarify the significance of the different levels of CD4, CD19 and CD56 found among groups. Disclosure of interest: None declared. P003. POST-OPERATIVE ILEUS: WHAT ARE THE ASSOCIATED RISK FACTORS? Ana M.D.V. Martins*, Gonçalo Almeida, Joana Marques, Maria L. Castro, Susana Cadilha. Anaesthesiology, Centro Hospitalar Lisboa Central, Lisboa, Portugal Objectives: This study aimed at identifying the perioperative risk factors associated with POI in patients undergoing colorectal surgery (CRS). Methods: This was a retrospective observational study. Sample consisted of 57 patients undergoing CRS in general surgery unit of Hospital de Santo nio dos Capuchos. Data were extracted from intraoperative records Anto and electronic processes. Cases were stratified by the occurrence of clinician-diagnosed POI. POI was defined by the absence of cramps, passage of flatus or stool on or after 72 hours post-surgery. Results were analyzed using SPSS 17.0. Frequencies (Chi-square), univariate (Mann-Whitney test) and regression analysis were done to identify significant associations and risk factors. Results: From a total of 57 patients (28.1%) developed POI. The associated variables were: time (t) of nasogastric tube decompression (p<0.001, OR 1.07; IC 95%: 1.03-1.12), t of bowel rest (p<0,001, OR 1.05; IC 95%: 1.021.08), t to ambulation (p<0.001, OR 1.06; IC 95%: 1.02-1.10), and opioids (OP) administration route (p¼0.024). Development of POI was higher after epidural OP (OR 5.06; IC 95%: 1.24-20.60). POI developed in 3 (17.6%) patients receiving intravenous (IV) tramadol, 10 (30.30%) receiving epidural morphine and 3 (50%) receiving epidural sufentanil. In patients receiving IV morphine by PCA (7) none developed POI. The retrospective character and the reduced sample size limited the capacity to identify other potentially associated variables and to determine the weight of each factor in the development of POI. Conclusion: Prospective studies which allow the stratification of POI risk in the pre-operative period and the adoption of effective measures that enable POI prevention are needed. Development of POI is related to many variables. Early ambulation and oral feeding, and reduced time of nasogastric decompression should be encouraged. Regarding the anesthetic technique, the opioid type and administration route have to be considered. Of IV opioids, tramadol and IV PCA morphine showed a trend towards lower incidence of POI. For the epidural route, morphine showed the best results. IV tramadol and IV PCA morphine should be considered for patients undertaking CRS. Disclosure of interest: None declared. P004. ENHANCED RECOVERY AFTER SURGERY PROTOCOLS IN A PORTUGUESE HOSPITAL: COMPLIANCE INTO DAILY PRACTICE IN COLORECTAL SURGERY Marcos Costa 1, Ana Margarida Silva Santos 2, *, Bruna Manuel Gonçalves 2, Paula Camilo 1, Ana Paula Silva 2. 1 Surgery, Unidade Local de Saúde de Matosinhos e Hospital Pedro Hispano, Matosinhos, Portugal; 2 Anaesthesiology, Unidade Local de Saúde de Matosinhos e Hospital Pedro Hispano, Matosinhos, Portugal Objectives: Enhanced Recovery After Surgery (ERAS) protocols have become the standard in elective colorectal surgery, but despite existing clear guidelines and conclusive evidence of the success of its full
e35
implementation, putting them into practice meets certain difficulties. The aim of this study was to analyse the compliance with our ERAS protocol in patients undergoing elective colorectal surgery in our hospital. Methods: The protocol based on the ERAS Society guidelines was introduced in 2010 and includes 20 items. A retrospective evaluation of compliance with the protocol was done to patients who undergone surgery in the first semester of 2015. Results: During this audit we analysed compliance with the protocol in 40 patients, conducted by a multidisciplinary team. Twenty-two (55%) were men. ASA II e 62.5% and ASA III e 37.5%. 53.9% were aged >65 years. The compliance with the items of ERAS protocol was: Preoperative multidisciplinary consultation e 54.6%; Admission on the surgery day - 0%; No bowel preparation - 100%; Preoperative fasting of 2h - 59%. No premedication - 0%; Antibiotic and antithrombotic prophylaxis - 100%; Laparoscopic surgery e 62.5%; Thoracic epidural in open surgery - 100%; No nasogastric tubes - 95%; No drains e 82.1%; Balanced intravenous fluid therapy - 0%; Hypothermia prevention e 46.2%; Postoperative pain control with multimodal analgesia - 100%; Postoperative ileus prevention - 100%; Postoperative nausea and vomiting prophylaxis - 100%; Urinary catheter removal first day e 23.1%; Oral feeding first day e 57.5%; Full mobilisation first day e 56.4%. Conclusion: The ERAS programme represents a considerable change and the introduction of a protocol is a gradual process. Implementing a standardised and feasible protocol into an organisation is vital to improve its full compliance, sustaining its beneficial effects. In our institution we face some difficulties: human, material and administrative. This first audit, a tool for quality improvement, helped us to understand the facilitators and the barriers. Having an optimal adherence remains an ongoing challenge that requires training, dedicated personnel and continuous evaluation of results, in order to support a sustainable change. Disclosure of interest: None declared. P005. ENHANCED RECOVERY AFTER TOTAL KNEE REPLACEMENT SURGERY e A CASE-CONTROL STUDY Bruna Manuel Gonçalves, Ana Margarida Silva Santos*, Carolina nio Vaz, Carla Pinto. Anaesthesiology, ULSM e Hospital Pedro Santos, Se Hispano, Matosinhos, Portugal Objectives: Recently, our institution has been working with Enhanced Recovery After Surgery (ERAS) protocol in total knee replacement. So far, only seven patients were enrolled in this programme. Our objective was to evaluate its impact on functional capacity and postoperative rehabilitation, in order to apply ERAS in total knee replacement in our daily routine. Methods: A case-control study, 1:1 pair-matched. A total of 7 pairs of cases, matched by sex, age and ASA functional status classification were purposed to total knee replacement. The case group consisted of patients that enrolled ERAS programme. Descriptive statistics are presented as percentage for categorical variables and average ± standard deviation for continuous variables. Results: In both groups six (85.7%) patients were female and the average age was 72±5.03 years. All operations were performed under subarachnoid block. The average tourniquet time was 91.71±16.42 and 102±16.03 minutes in the case and control group, respectively. Post-surgical pain was managed in the ERAS group with ropivacaine 0.2% through a knee joint catheter while in the control group was used ropivacaíne 0.2% and morphine by use of an epidural catheter. Numeric pain rating scale was 3 in 71.43% in the case group versus 28.57% in the control group. None of the 14 patients were transfused or had thrombotic complications. The average length of hospital stay (LOS) was 5.1±1.9 and 6.0±0.6 days in the case and control group, respectively. At discharge 13 patients were walking independently with crutches assistance and one patient from the control group was dependent on wheelchair. Conclusion: The ERAS programme seems to be associated with better outcomes in pain management, LOS and postoperative rehabilitation, without more complications. This was the starting point for the implementation, fitting and standardisation of the ERAS programme in orthopaedic surgery at our institution, however further studies are needed to validate our results. Disclosure of interest: None declared.
The study of T and B cells subsets showed a significant higher CD4 and CD19 levels in G2 at m2. NK cells count was significant lower in the same group at m3. There were no significant differences in the levels of immunoglobulin between groups. Conclusion: This study demonstrates that laparoscopic surgery appears to be associated with similar immune responses compared with open surgery, considering that immune parameters vary slightly between groups. Although higher CRP levels showed a high level of injury in the open surgery group, the management of perioperative care through an ERAS protocol seemed to minimise the effect of open surgery associated to more postoperative complications. Further studies are be required in order to clarify the significance of the different levels of CD4, CD19 and CD56 found among groups. Disclosure of interest: None declared. P003. POST-OPERATIVE ILEUS: WHAT ARE THE ASSOCIATED RISK FACTORS? Ana M.D.V. Martins*, Gonçalo Almeida, Joana Marques, Maria L. Castro, Susana Cadilha. Anaesthesiology, Centro Hospitalar Lisboa Central, Lisboa, Portugal Objectives: This study aimed at identifying the perioperative risk factors associated with POI in patients undergoing colorectal surgery (CRS). Methods: This was a retrospective observational study. Sample consisted of 57 patients undergoing CRS in general surgery unit of Hospital de Santo nio dos Capuchos. Data were extracted from intraoperative records Anto and electronic processes. Cases were stratified by the occurrence of clinician-diagnosed POI. POI was defined by the absence of cramps, passage of flatus or stool on or after 72 hours post-surgery. Results were analyzed using SPSS 17.0. Frequencies (Chi-square), univariate (Mann-Whitney test) and regression analysis were done to identify significant associations and risk factors. Results: From a total of 57 patients (28.1%) developed POI. The associated variables were: time (t) of nasogastric tube decompression (p<0.001, OR 1.07; IC 95%: 1.03-1.12), t of bowel rest (p<0,001, OR 1.05; IC 95%: 1.021.08), t to ambulation (p<0.001, OR 1.06; IC 95%: 1.02-1.10), and opioids (OP) administration route (p¼0.024). Development of POI was higher after epidural OP (OR 5.06; IC 95%: 1.24-20.60). POI developed in 3 (17.6%) patients receiving intravenous (IV) tramadol, 10 (30.30%) receiving epidural morphine and 3 (50%) receiving epidural sufentanil. In patients receiving IV morphine by PCA (7) none developed POI. The retrospective character and the reduced sample size limited the capacity to identify other potentially associated variables and to determine the weight of each factor in the development of POI. Conclusion: Prospective studies which allow the stratification of POI risk in the pre-operative period and the adoption of effective measures that enable POI prevention are needed. Development of POI is related to many variables. Early ambulation and oral feeding, and reduced time of nasogastric decompression should be encouraged. Regarding the anesthetic technique, the opioid type and administration route have to be considered. Of IV opioids, tramadol and IV PCA morphine showed a trend towards lower incidence of POI. For the epidural route, morphine showed the best results. IV tramadol and IV PCA morphine should be considered for patients undertaking CRS. Disclosure of interest: None declared. P004. ENHANCED RECOVERY AFTER SURGERY PROTOCOLS IN A PORTUGUESE HOSPITAL: COMPLIANCE INTO DAILY PRACTICE IN COLORECTAL SURGERY Marcos Costa 1, Ana Margarida Silva Santos 2, *, Bruna Manuel Gonçalves 2, Paula Camilo 1, Ana Paula Silva 2. 1 Surgery, Unidade Local de Saúde de Matosinhos e Hospital Pedro Hispano, Matosinhos, Portugal; 2 Anaesthesiology, Unidade Local de Saúde de Matosinhos e Hospital Pedro Hispano, Matosinhos, Portugal Objectives: Enhanced Recovery After Surgery (ERAS) protocols have become the standard in elective colorectal surgery, but despite existing clear guidelines and conclusive evidence of the success of its full
e35
implementation, putting them into practice meets certain difficulties. The aim of this study was to analyse the compliance with our ERAS protocol in patients undergoing elective colorectal surgery in our hospital. Methods: The protocol based on the ERAS Society guidelines was introduced in 2010 and includes 20 items. A retrospective evaluation of compliance with the protocol was done to patients who undergone surgery in the first semester of 2015. Results: During this audit we analysed compliance with the protocol in 40 patients, conducted by a multidisciplinary team. Twenty-two (55%) were men. ASA II e 62.5% and ASA III e 37.5%. 53.9% were aged >65 years. The compliance with the items of ERAS protocol was: Preoperative multidisciplinary consultation e 54.6%; Admission on the surgery day - 0%; No bowel preparation - 100%; Preoperative fasting of 2h - 59%. No premedication - 0%; Antibiotic and antithrombotic prophylaxis - 100%; Laparoscopic surgery e 62.5%; Thoracic epidural in open surgery - 100%; No nasogastric tubes - 95%; No drains e 82.1%; Balanced intravenous fluid therapy - 0%; Hypothermia prevention e 46.2%; Postoperative pain control with multimodal analgesia - 100%; Postoperative ileus prevention - 100%; Postoperative nausea and vomiting prophylaxis - 100%; Urinary catheter removal first day e 23.1%; Oral feeding first day e 57.5%; Full mobilisation first day e 56.4%. Conclusion: The ERAS programme represents a considerable change and the introduction of a protocol is a gradual process. Implementing a standardised and feasible protocol into an organisation is vital to improve its full compliance, sustaining its beneficial effects. In our institution we face some difficulties: human, material and administrative. This first audit, a tool for quality improvement, helped us to understand the facilitators and the barriers. Having an optimal adherence remains an ongoing challenge that requires training, dedicated personnel and continuous evaluation of results, in order to support a sustainable change. Disclosure of interest: None declared. P005. ENHANCED RECOVERY AFTER TOTAL KNEE REPLACEMENT SURGERY e A CASE-CONTROL STUDY Bruna Manuel Gonçalves, Ana Margarida Silva Santos*, Carolina nio Vaz, Carla Pinto. Anaesthesiology, ULSM e Hospital Pedro Santos, Se Hispano, Matosinhos, Portugal Objectives: Recently, our institution has been working with Enhanced Recovery After Surgery (ERAS) protocol in total knee replacement. So far, only seven patients were enrolled in this programme. Our objective was to evaluate its impact on functional capacity and postoperative rehabilitation, in order to apply ERAS in total knee replacement in our daily routine. Methods: A case-control study, 1:1 pair-matched. A total of 7 pairs of cases, matched by sex, age and ASA functional status classification were purposed to total knee replacement. The case group consisted of patients that enrolled ERAS programme. Descriptive statistics are presented as percentage for categorical variables and average ± standard deviation for continuous variables. Results: In both groups six (85.7%) patients were female and the average age was 72±5.03 years. All operations were performed under subarachnoid block. The average tourniquet time was 91.71±16.42 and 102±16.03 minutes in the case and control group, respectively. Post-surgical pain was managed in the ERAS group with ropivacaine 0.2% through a knee joint catheter while in the control group was used ropivacaíne 0.2% and morphine by use of an epidural catheter. Numeric pain rating scale was 3 in 71.43% in the case group versus 28.57% in the control group. None of the 14 patients were transfused or had thrombotic complications. The average length of hospital stay (LOS) was 5.1±1.9 and 6.0±0.6 days in the case and control group, respectively. At discharge 13 patients were walking independently with crutches assistance and one patient from the control group was dependent on wheelchair. Conclusion: The ERAS programme seems to be associated with better outcomes in pain management, LOS and postoperative rehabilitation, without more complications. This was the starting point for the implementation, fitting and standardisation of the ERAS programme in orthopaedic surgery at our institution, however further studies are needed to validate our results. Disclosure of interest: None declared.