SP1.2.7Developing a fast- track pre-assessment pathway for laparoscopic cholecystectomy

Aims To develop a safe and reliable assessment process for patients undergoing laparoscopic cholecystectomy and negate the need for formal pre- assessment. Methods A system consisting of a health screening questionnaire completed by patients (previous general anaesthesia, cardiac and respiratory history, bleeding disorders and medications) along with a functional capacity assessment (Duke Activity Status Index), allied with screening blood tests was developed. Only patients who passed all 3 components were fast-tracked to surgery while the remainder proceeded to formal pre-assessment. Results Data was collected and analyzed on 90 consecutive patients. An interim analysis identified the format of some questions needed to be altered to facilitate patient completion, resulting in 59% (rather than 36%) of patients successfully fulfilling the fast-track criteria and not excluded by incomplete entries. Overall, 40 of the 90 patients (44%) successfully completed the fast-track assessment of whom 38 underwent surgery (2 waiting). Six patients incorrectly passed the assessments due to misinterpretation of the Duke Activity Status Index but proceeded to surgery. All 38 patients had an uneventful peri-operative course. 45 of the 50 patients who failed fast-track assessments subsequently passed formal nurse-led pre-assessment, as did 4 of the remaining 5 patients after anaesthetic review – all had an uneventful peri-operative course. Conclusion Pre-assessment driven by a health screening questionnaire, activity index and simple blood tests is safe, reduced formal pre-assessment by 44% and avoids delays. Such tools may have a significant resource impact in appropriate patient populations. The health screening questionnaire needs further revision.

Microvascular Assessment of Ranolazine in Non-Obstructive Atherosclerosis

Background: Microvascular dysfunction is known to play a key role in patients with angina and nonobstructive coronary artery disease. We investigated the impact of ranolazine among patients with angina and nonobstructive coronary artery disease. Methods: In this randomized, double-blinded, placebo-controlled pilot trial, 26 patients with angina once weekly or more, abnormal stress test, and nonobstructive coronary artery disease (<50% stenosis by angiography and fractional flow reserve >0.80) were randomized 1:1 to ranolazine or placebo for 12 weeks. Primary end point was ΔSeattle Angina Questionnaire (SAQ) angina frequency score. Baseline and 3 months follow-up SAQ, Duke Activity Status Index scores along with invasive fractional flow reserve, coronary flow reserve (CFR), hyperemic myocardial resistance, and cardiopulmonary exercise testing measurements were performed. Results: No significant differences in ΔSAQ angina frequency scores ( P =0.53) or Duke Activity Status Index ( P =0.76) were observed between ranolazine versus placebo, although patients on ranolazine had lesser improvement in SAQ physical limitation scores ( P =0.02) compared with placebo at 3 months. There were no significant differences in ΔCFR or Δhyperemic myocardial resistance between ranolazine and placebo groups. Patients treated with ranolazine, compared with placebo, had no significant improvement in maximum rate of oxygen consumption measured during incremental exercise (VO 2 max) and peak metabolic equivalents of task. Interestingly, in the ranolazine group, patients with baseline CFR<2.0 demonstrated greater gain in CFR compared with those with baseline CFR≥2.0 ( P =0.02). Conclusions: Ranolazine did not demonstrate improvement in SAQ angina frequency score, invasive microvascular function, or peak metabolic equivalent compared with placebo at 3 months. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02147067.