Perioperative structure and process quality and safety indicators: a systematic review
M. Chazapis; D. Gilhooly; A.F. Smith; P.S. Myles; G. Haller; M.P.W. Grocott; S.R. Moonesinghe
Clinical indicators assess healthcare structures, processes, and outcomes. While used widely, the exact number and level of scientific evidence of these indicators remains unclear. The aim of this study was to evaluate the number, type, and evidence base of clinical process and structure indicators currently available for quality and safety measurement in perioperative care..
Congratulations to Dr Chris Ball who has contributed to this publication with a chapter on the history of airway management.
Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state
P. S. Myles, D. B. Myles, W. Galagher, D. Boyd, C. Chew, N. MacDonald, A. Dennis
Br J Anaesth (2017) 118 (3): 424-429
The 100 mm visual analog scale (VAS) score is widely used to measure pain intensity after surgery. Despite this widespread use, it is unclear what constitutes the minimal clinically important difference (MCID); that is, what minimal change in score would indicate a meaningful change in a patient’s pain status.Analgesic interventions that provide a change of 10 for the 100 mm pain VAS signify a clinically important improvement or deterioration, and a VAS of 33 or less signifies acceptable pain control (i.e. a responder), after surgery.
Duminda N Wijeysundera, Rupert M Pearse, Mark A Shulman, Tom E F Abbott, Elizabeth Torres, Bernard L Croal, John T Granton, Kevin E Thorpe, Michael P W Grocott, Catherine Farrington, Paul S Myles, Brian H Cuthbertson , on behalf of the METS Study Investigators
BMJ Open 2016;6:3 e010359 doi:10.1136/bmjopen-2015-010359
Paul S. Myles, M.P.H., M.D., Julian A. Smith, F.R.A.C.S., Andrew Forbes, Ph.D., Brendan Silbert, M.B., B.S., Mohandas Jayarajah, M.B., B.S., Thomas Painter, M.B., Ch.B., D. James Cooper, M.D., Silvana Marasco, Ph.D., John McNeil, Ph.D., Jean S. Bussières, M.D., and Sophie Wallace, M.P.H., for the ATACAS Investigators of the ANZCA Clinical Trials Network*
N Engl J Med 2016; 374:728-737February 25, 2016DOI: 10.1056/NEJMoa1507688
Limitations of body mass index as an obesity measure of perioperative risk
U. Gurunathan and P. S. Myles
Br. J. Anaesth. 2016 116: 319-321.
The prevalence of obesity is rapidly increasing around the world. It is generally believed that overweight and obese individuals are at greater risk of many complications after surgery, but most perioperative studies have found that this is not the case. In fact, mildly obese and overweight patients tend to have better survival rates than normal weight patients after many types of surgery, despite some evidence of increased surgical site and other infections.
Survival and freedom from disability are arguably the most important patient-centered outcomes after surgery, but it is unclear how postoperative disability should be measured. The authors thus evaluated the World Health Organization Disability Assessment Schedule 2.0 in a surgical population.
The authors examined the psychometric properties of World Health Organization Disability Assessment Schedule 2.0 in a diverse cohort of 510 surgical patients. The authors assessed clinical acceptability, validity, reliability, and responsiveness up to 12 months after surgery.
Criterion and convergent validity of World Health Organization Disability Assessment Schedule 2.0 were supported by good correlation with the 40-item quality of recovery scale at 30 days after surgery (r = -0.70) and at 3, 6, and 12 months after surgery with physical functioning (The Katz index of independence in Activities of Daily Living; r = -0.70, r = -0.60, and rho = -0.47); quality of life (EQ-5D; r = -0.57, -0.60, and -0.52); and pain interference scores (modified Brief Pain Inventory Short Form; r = 0.72, 0.74, and 0.81) (all P < 0.0005). Construct validity was supported by increased hospital stay (6.9 vs. 5.3 days, P = 0.008) and increased day 30 complications (20% vs. 11%, P = 0.042) in patients with new disability. There was excellent internal consistency with Cronbach's α and split-half coefficients greater than 0.90 at all time points (all P < 0.0005). Responsiveness was excellent with effect sizes of 3.4, 3.0, and 1.0 at 3, 6, and 12 months after surgery, respectively.
World Health Organization Disability Assessment Schedule 2.0 is a clinically acceptable, valid, reliable, and responsive instrument for measuring postoperative disability in a diverse surgical population. Its use as an endpoint in future perioperative studies can provide outcome data that are meaningful to clinicians and patients alike.
Patients undergoing thyroid surgery with retrosternal goitre may raise concerns for the anaesthetist, especially airway management. We reviewed a multicentre prospective thyroid surgery database and extracted data for those patients with retrosternal goitre. Additionally, we reviewed the anaesthetic charts of patients with retrosternal goitre at our institution to identify the anaesthetic induction technique and airway management. Of 4572 patients in the database, 919 (20%) had a retrosternal goitre. Two cases of early postoperative tracheomalacia were reported, one in the retrosternal group. Despite some very large goitres, no patient required tracheostomy or cardiopulmonary bypass and there were no perioperative deaths. In the subset of 133 patients managed at our institution over six years, there were no major adverse anaesthetic outcomes and no patient had a failed airway or tracheomalacia. In the latter cohort, of 32 (24%) patients identified as having a potentially difficult airway, 17 underwent awake fibreoptic tracheal intubation, but two of these were abandoned and converted to intravenous induction and general anaesthesia. Eleven had inhalational induction; two of these were also abandoned and converted to intravenous induction and general anaesthesia. Of those suspected as having a difficult airway, 28 (87.5%) subsequently had direct laryngoscopy where the laryngeal inlet was clearly visible. We found no good evidence that thyroid surgery patients with retrosternal goitre, with or without symptoms and signs of tracheal compression, present the experienced anaesthetist with an airway that cannot be managed using conventional techniques. This does not preclude the need for multidisciplinary discussion and planning.
Cervical spine immobilisation can make direct laryngoscopy difficult, which might lead to airway complications. This randomised control trial compared the time to successful intubation using either the Macintosh laryngoscope or the McGrath® Series 5 videolaryngoscope in 128 patients who had cervical immobilisation applied. Intubation difficulty score, Cormack & Lehane laryngoscopic view, intubation failures, changes in cardiovascular variables and the incidence of any complications were recorded. The mean (SD) successful intubation time with the Macintosh laryngoscope was significantly shorter compared with the McGrath laryngoscope, 50.0 (32.6) s vs 82.7 (80.0) s, respectively (p = 0.0003), despite the McGrath laryngoscope's having a lower intubation difficulty score and a superior glottic view. There were five McGrath laryngoscope intubation failures, three owing to difficulty in passing the tracheal tube and two to equipment malfunction. Equipment malfunction is a major concern as a reliable intubating device is vital when faced with an airway crisis.