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Evidence-based Practice and Quality Improvement

Use of a multi-modal care pathway for laparoscopic cholecystectomy: preliminary results

1AP4-10

Moore, D.; McCarthy, S.; Maloney, G.

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European Journal of Anaesthesiology (EJA): June 2013 - Volume 30 - Issue - p 18-18
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Background and Goal of Study: Laparoscopic Cholecystectomy (LC) is performed as a day-case procedure in many institutions. LC is associated with a high incidence of post-operative pain and post-operative nausea and vomiting (PONV). In our institution, LC is never performed as a day-case procedure. Our study aimed to evaluate if a care pathway bundle including many proven interventions would facilitate a transition to a day-case LC service.1

Materials and Methods: Our study was approved by the Clinical Research Ethics Committee of our hospital. Consent was sought from all patients. It was a prospective, observational study. Over 4 weeks, 17 patients underwent LC. Following exclusion criteria, 12 patients received a set “bundle” of treatments and interventions, and post-operative data was gathered. Patients received IV fluids, oral paracetamol, celecoxib, gabapentin, and IV dexamethasone pre-operatively, a bilateral-dual TAP block, intra-peritoneal local anaesthetic, and fentanyl boluses intra-operatively, and po paracetamol, celecoxib, and oxycodone post-operatively. IV morphine was avoided. Our primary end-point was suitability for discharge at 6-hours post-operatively (Post-anaesthetic discharge score (PADS) > 8).2

Results: Medain (IQR). The 5 excluded patients had contra-indications to study drugs, had drains inserted intra-operatively, or refused consent. Of the remaining 12 patients, 11 were female, age 45.5 (40.5-49.3), BMI 29.75 (26.3-32.2), ASA 2 (1-2). Eight patients (66.7%) achieved a PADS > 8 at 6-hours post-operatively. All 8 patients also had a PADS > 8 at 24 hours post-op. Intraoperative fentanyl dose was 310 mcg (300-400), and total oxycodone consumption post-op was 10 mg (5-20). Of the 12 patients, only 5 (42%) received all elements of the care-pathway bundle.

Conclusion: Our study suggests that 67% of pre-selected LC patients would be fit for discharge at 6 hours post-op, and maintain a PADS > 8 at 24 hours, facilitating a day-case service for the majority of LC patients. Further improvements may be possible with only 42% of patients receiving all elements of the bundle. We plan to use this bundle in a day-service LC pilot project and audit the results.

References:

1. Ahn Y, Woods J, Connor S. A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy. HPB (Oxford). 2011 Oct;13(10):677-86
2. Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Can J Anesth 2006; 53: 858-72
© 2013 European Society of Anaesthesiology