Introduction
RECOvER development
RECOvER items
Item | Recommendation | Page | |
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Title
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Title | 1 | Indicate that this is an enhanced recovery study in the title | |
Introduction
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Background | 2 | Explain the area of uncertainty that the study seeks to address | |
Guidelines | 3 | If a published set of enhanced recovery guidelines exists for this procedure, include a reference to the guidelines | |
Outcomes | 4 | Define the primary outcome and any key prespecified secondary outcomes for the study | |
Methods
| |||
IRB approval | 5 | Give the Institutional Review Board/Ethics Committee name and approval number. If permission was not required, reasons should be stated | |
Study design | 6 | Indicate what type of study is presented (randomized controlled trial, cohort, cross-sectional, etc.) The individual guidelines for the type of study should be followed (e.g., CONSORT for randomized controlled trial, STROBE for cohort studies, etc.) | |
Setting | 7 | Describe whether this is a single or multicenter study, the type of practice (academic vs. community, tertiary vs. primary), and the providers (limited group or all providers on a service) | |
Timing | 8 | Describe periods of recruitment, time points at which outcomes assessed, and follow-up | |
Participants | 9 | Define study inclusion and exclusion criteria | |
Enhanced recovery protocol | 10 | Describe when the enhanced recovery protocol was implemented relative to the study period | |
11 | Provide a flow diagram or table through the continuum of care detailing the enhanced recovery protocol including the following elements: | ||
(a) Preadmission patient education regarding the protocol | |||
(b) Preadmission screening and optimization as indicated for nutritional deficiency, frailty, anemia, HbA1c, tobacco cessation, and ethanol use | |||
(c) Fasting and carbohydrate loading guidelines | |||
(d) Preemptive analgesia (dose, route, timing) | |||
(e) Anti-emetic prophylaxis (dose, route, timing) | |||
(f) Intraoperative fluid management strategy | |||
(g) Types, doses, and routes of anesthetics administered | |||
(h) Patient warming strategy | |||
(i) Management of postoperative fluids | |||
(j) Postoperative analgesia and anti-emetic plans | |||
(k) Plan for opioid minimization | |||
(l) Drain and line management | |||
(m) Early mobilization strategy | |||
(n) Postoperative diet and bowel regimen management | |||
(o) Criteria for discharge | |||
(p) Tracking of post-discharge outcomes | |||
Enhanced recovery auditing | 12 | Describe the audit system for compliance with the enhanced recovery protocol and how compliance data are measured | |
Outcomes | 13 | (a) Explain the criteria for assessing primary and secondary outcomes | |
(b) Distinguish among clinical, functional, administrative, and quality of life outcome measures | |||
PROs | 14 | If patient questionnaires are used, provide references to validation of these study instruments | |
Results
| |||
Patient population | 15 | Use a flow diagram to explain the derivation of the study population | |
(a) Provide a Table I with the key demographic and clinical features of the study population | |||
(b) Indicate number of participants with missing data for each variable of interest | |||
Enhanced recovery compliance | 16 | Provide a Table II with average compliance for each enhanced recovery protocol element and present a comparison of the variation in enhanced recovery compliance among the study groups | |
Correlations | 17 | Perform logistic regression to correlate the change in primary outcome with the study intervention | |
Discussion
| |||
Context | 18 | Explain what the study adds to the body of knowledge regarding the study intervention within the context of enhanced recovery after surgery care | |
Limitations | 19 | Discuss the limitations of the study and how these might temper the findings | |
Other information
| |||
Funding | 20 | Document all sources of funding and potential conflicts of interest for the study authors |
RECOvER scope
Item | Recommendation | Page | |
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Title
| |||
Title | 1 | Gum chewing improves recovery of gut function within an enhanced recovery protocol for hepatic resection | 1 |
Introduction
| |||
Background | 2 | Whether gum chewing offers additional benefit for functional gut recovery after liver resection beyond other enhanced recovery elements is uncertain | 3 |
Guidelines | 3 | Melloul E, et al. World J Surg 2016 Oct;40(10):2425–2440 | 3 |
Outcomes | 4 | Primary outcome Time to first bowel movement after surgery Secondary outcomes Incidence of postoperative ileus, length of stay, incidence of postoperative emesis | 3 |
Methods
| |||
IRB approval | 5 | General Hospital IRB #123456 | 4 |
Study design | 6 | Retrospective cohort study | 4 |
Setting | 7 | Single institution, community-based academic hospital with stable group of surgeons during the study period | 5 |
Timing | 8 | Patients included from March 2013–May 2015, events assessed daily from surgery to discharge, all patients followed until 2-week postoperative visit | 5 |
Participants | 9 | Inclusion criteria 18+ years old, participating in the enhanced recovery protocol, undergoing hepatic resection, not admitted to ICU postoperatively Exclusion criteria Age <18, unable or unwilling to participate in enhanced recovery protocol, other surgical procedures, ICU admission | 5 |
Enhanced recovery protocol | 10 | enhanced recovery protocol was initiated in March 2012 | 6 |
11 | Provide a flow diagram or table through the continuum of care detailing the enhanced recovery protocol including the following elements: | 7 | |
(a) Preadmission patient education regarding the protocol All patients receive an informational packet, watch a 10-minute video, and attend a 1-h preoperative educational class | |||
(b) Preadmission screening and optimization for nutritional deficiency, frailty, tobacco cessation, and ethanol use Patients are screened for nutritional deficiency using the NRS scoring system, frailty using the scoring model published by Kim et al. and referred preoperatively for tobacco and ethanol counseling | |||
(c) Fasting and carbohydrate loading guidelines Normal diet until midnight, clear liquids until 2 h before surgery, 300-ml isotonic beverage containing a total of 50 grams of maltodextrin finished 2 h before surgery | |||
(d) Preemptive analgesia (dose, route, timing) 300 mg celecoxib, 500 mg acetaminophen both oral given in pre-op | |||
(e) Anti-emetic prophylaxis (dose, route, timing) 4 mg ondansetron and 8 mg dexamethasone given intravenously prior to emergence | |||
(f) Intraoperative fluid management strategy Esophageal Doppler monitoring of stroke volume variation | |||
(g) Types, doses, and routes of anesthetics administered Continuous propofol, intravenous lidocaine, and low-dose ketamine infusion, no volatile anesthesia | |||
(h) Patient warming strategy Forced warm air and intravenous fluid warmer | |||
(i) Management of postoperative fluids 0.5 ml/kg/h × 6 h | |||
(j) Postoperative analgesia and anti-emetic plans 0.25% liposomal bupivacaine wound infiltration, 500 mg acetaminophen and 600 mg ibuprofen every 6 h orally, 4 mg ondansetron every 6 h intravenously as needed | |||
(k) Plan for opioid minimization First-line analgesic 25 mg tramadol every 6 h orally as needed, increased to 50 mg tramadol if needed, followed by addition of IV lidocaine infusion if needed, followed by pregabalin 100–300 mg every 8 h if needed, followed by 5–10 mg oral oxycodone for breakthrough pain | |||
(l) Drain and line management No routine wound drains, Foley catheter removed in OR | |||
(m) Early mobilization strategy Patients ambulate to chair in PACU, ambulate × 3 starting postoperative day 0, out of bed all meals, out of bed 8 h per day starting postoperative day 1 | |||
(n) Postoperative diet and bowel regimen management Clear liquids post-op day 0, regular diet beginning post-op day 1, standing MiraLax daily beginning post-op day 0 | |||
(o) Criteria for discharge Tolerating at least 2000 ml po daily, voiding independently, pain well controlled on oral medication, ambulating in hallways | |||
(p) Tracking of post-discharge outcomes Patients contacted by office through daily email survey | |||
Enhanced recovery auditing | 12 | All enhanced recovery elements charted by physician assistant into Enhanced Recovery Interactive Audit System (EIAS) | 8 |
Outcomes | 13 | (a) Primary outcome Bowel movement as documented by RN Secondary outcomes Per patient report as collected by physician assistant interview | 9 |
(b) Clinical outcomes | |||
PROs | 14 | European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (J Clin Epidemiol 2014) | 9 |
Results
| |||
Patient population | 15 | See Figure 1 (or similar) | 10 |
(a) See Table 1 (or similar) | 11 | ||
(b) Participants with missing data indicated in Table 1 footnotes | 11 | ||
Enhanced recovery compliance | 16 | Table II provides enhanced recovery compliance for the gum-chewing versus non-gum-chewing groups for 15 metrics from the enhanced recovery pathway | 12 |
Correlations | 17 | Table III provides logistic regression examining gum chewing with respect to primary and secondary outcomes | 13 |
Discussion
| |||
Context | 18 | Study suggests that gum chewing has additional benefits to standard bowel regimen, early feeding, and laxative guidelines for promoting early return of gut function | 15 |
Limitations | 19 | Not a prospective study, did not have sufficient power to subdivide patients by indication for hepatic resection, poor compliance among the cohort with respect to early mobilization and termination of intravenous fluids | 16 |
Other information
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Funding | 20 | Support from departmental grant | 2 |