TP6.2.13 A PEG insertion pathway for Motor Neurone Disease patients improves efficiency and patient outcomes

Aims Patients with Motor Neurone Disease (MND) often require a Percutaneous Endoscopic Gastrostomy (PEG) as a palliative procedure during the later stages of their illness, due to swallowing difficulties. More recently these are being inserted earlier before the inevitable decrease in nutritional intake and subsequent fall in albumin levels. This allows patients to eat food they enjoy rather than concentrating on maintaining intake. Insertion has traditionally been done with local anaesthetic and OGD, which can be difficult and traumatic. We propose a method of insertion using TIVA (Totally Intravenous Anaesthetic) in theatre with no intubation, performed by the surgical team, with a pathway including pre-operative anaesthetic assessment. Methods Data was collected from all PEG insertions performed in theatre from 1/1/2011 to 1/9/2019. MND patients following our pathway were compared to all other indications for PEG insertions. Length of stay (LOS), 30-day re-admission rates, 30-day, 90-day and 1-year mortality were analysed. Results 98 patients were identified. Median LOS was 3 days (mean 12.2) with a 3% 30-day mortality, 12.2% 90-day mortality and 34.7% 1-year mortality. In the MND group there were 27 patients. Median LOS was 2 days (mean 8.6) with a 7.4% (2 patients) 30-day mortality, which remained 7.4% at 90 days. There were 13 re-admissions (13.3%) overall compared to 0% in the MND group (p = 0.04 (Chi-squared test)). Conclusions PEG insertion under TIVA for MND patients is safe. A set pathway for admission and pre/post-insertion care increases efficiency with reduced length of stay and improves patient outcomes with no re-admissions.

PREVALENCE OF ANAEMIAAMONG PATIENTS ATTENDED PRE-ANAESTHETIC ASSESSMENT POSTED FOR OBSTETRICS & GYNAECOLOGICAL OPERATIONS AND ITS SURGICAL OUTCOME

INTRODUCTION: Anaemia is estimated to contribute to more than 115 000 maternal deaths and 591 000 perinatal deaths globally per year. In high resource settings, even mild anaemia adversely effects surgical outcome and is independently associated with increased postoperative mortality, complications, and length of hospital stay. Therefore non-treatment of perioperative anaemia is considered 'substandard practice'. This study is designed to analyse such routinely recorded data and observe prevalence of anaemia in patients posted for obstetric and gynaecological operations. MATERIALS AND METHODS: This Observational Retrospective study was conducted in MRD, ESI-PGIMSR & MC. All elective postsurgical patients who underwent surgery in between the period of January 2017 to December 2019. Total 2073 patients were present in this study. RESULT: The severe anaemia group had 8.58 [3.65, 19.49] higher odds of experiencing any surgical complication (p<0.001) compared to nonanaemic patients. Analysis of each complication showed a 33.13 [9.57, 110.39] higher odds of unexpected ICU admission (p=0.001); a 7.29 [1.98, 21.45] higher odds of surgical site infection (p<0.001); and 7.48 [1.79, 25.78] higher odds of requiring hospital readmission (p<0.001). CONCLUSION: Severe anaemia predisposes to postoperative complications but mild anaemia does not.

The effect of pre-anaesthetic assessment clinic: a systematic review of randomised and non-randomised prospective controlled studies

ABSTRACT Objectives: The aim of this systematic review was to examine the effectiveness of pre-anaesthetic assessment clinics (PACs) implemented to improve quality and patient safety in perioperative care. Design: Systematic review. Data sources: The electronic databases CINAHL Plus with Full Text (EBSCOhost), Medline, and Embase (OvidSP) were systematically searched from 1st April, 1996 to 4th February, 2021. Eligibility criteria: The main inclusion criterion was that the study, using empirical quantitative methods, addressed the effectiveness of PACs. Data extraction and synthesis: Titles, abstracts, and full texts were screened in duplicate by two authors. Risk of bias assessment, using the Joanna Briggs Institute critical appraisal checklist for quasi-experimental studies, and data extraction were performed by one author and checked by the other author. Results were synthesised narratively owing to the heterogeneity of the included studies. Results: Seven prospective controlled studies were conducted. Most studies had a high risk of bias. Three studies reported a significant reduction in the length of the hospital stay, and two studies reported a significant reduction in cancellation of surgery for medical reasons when patients were seen in the PAC. In addition, the included studies presented mixed results regarding anxiety in patients. Conclusion: This systematic review demonstrated a reduction in the length of hospital stay and cancellation of surgery when the patients had been assessed in the PAC. There is a need for high-quality prospective studies to gain a deeper understanding of the effectiveness of PACs. PROSPERO registration number: CRD42019137724

Antenatal assessment and pain management

Successive confidential enquiry reports have emphasized that planned and timely antenatal anaesthetic assessment plays a vital role in the successful management of women with complex medical problems, or in women whose delivery is considered high risk. Women who benefit from referral to a high risk obstetric anaesthetic clinic, usually at 32–34 weeks gestation, are outlined. Particular emphasis is given to antenatal assessment of the woman with cardiac disease, who should be meticulously managed in a combined multi-disciplinary clinic with a cardiologist, obstetrician, anaesthetist, echocardiography technician, and specialist midwife all present. Antenatal pain is commonly reported and can be due to a variety of causes. It may follow an acute presentation, or chronic pain which becomes difficult to manage due to restrictions in drug treatments because of concerns for the developing fetus. A generic pathway for pain management is described, with non-pharmacological and safe pharmacological options for ongoing analgesia management.

Obstetric Anaesthesia

Starting work on the labour ward is very challenging for all junior anaesthetists. This handbook is an easily navigated practical reference guide for anaesthetists new to this environment, as well as other members of the labour ward multi-disciplinary team; midwives, obstetricians, and Consultant Anaesthetists who visit labour ward less frequently or only when on-call. It covers all aspects of obstetric anaesthesia that the trainee anaesthetist will encounter during their obstetric training module, and is essential reading for FRCA exam preparation. Since the first edition, there is no doubt that the pregnant population has become more complex, with increasing maternal age and BMI, and challenging co-morbidities presenting more frequently. As well as providing updates from recent MBRRACE reports and national guidelines, new techniques, drugs, and technology, such as point of care testing have been included. New chapters covering the application of ultrasound in obstetric anaesthesia, recognition of the sick and septic patient, maternal obesity and neonatal resuscitation have been introduced. Previous chapters, e.g. haemorrhage, have been extensively updated, with the latest management protocols and algorithms based on recent published research in obstetric bleeding. We have retained our practical guides to performing, managing, and trouble-shooting regional techniques that are more problematic on labour ward, and our extensive A–Z of rarer conditions has updated references. More conventional chapters on maternal physiology and pathophysiology provide readers with essential examination material. The importance of anticipating risk in the antenatal period through high risk anaesthetic assessment clinics and postpartum management of tricky neurological complications is also well covered.