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Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working groupBackground: Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups. Methods: The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion. Recommendations: Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are nil per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO. Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention. Discussion: This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited. Copyright 2018 The Author(s).
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Recommendations for patient engagement in guideline development panels: A qualitative focus group study of guideline-naïve patientsBackground Patient and consumer engagement in clinical practice guideline development is internationally advocated, but limited research explores mechanisms for successful engagement. Objective To investigate the perspectives of potential patient/consumer guideline representatives on topics pertaining to engagement including guideline development group composition and barriers to and facilitators of engagement. Setting and participants Participants were guideline-naïve volunteers for programs designed to link community members to academic research with diverse ages, gender, race, and degrees of experience interacting with health care professionals. Methods Three focus groups and one key informant interview were conducted and analyzed using a qualitative descriptive approach. Results Participants recommended small, diverse guideline development groups engaging multiple patient/consumer stakeholders with no prior relationships with each other or professional panel members. No consensus was achieved on the ideal balance of patient/consumer and professional stakeholders. Pre-meeting reading/training and an identified contact person were described as keys to successful early engagement; skilled facilitators, understandable speech and language, and established mechanisms for soliciting patient opinions were suggested to enhance engagement at meetings. Conclusions Most suggestions for effective patient/consumer engagement in guidelines require forethought and planning but little additional expense, making these strategies easily accessible to guideline developers desiring to achieve more meaningful patient and consumer engagement. Copyright 2017 Armstrong et al.
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Clinical Practice Guideline for Utilizing Sugammadex in Reversal of Neuromuscular Blocking AgentsBackground: Residual paralysis is ongoing presence of muscle weakness postoperatively following the administration of a neuromuscular blocker and subsequent reversal agent during the intraoperative period. Presence of residual neuromuscular blockade postoperatively has been associated with increased mortality and morbidity, low oxygenation, and respiratory complications. Recent studies have shown incidences of residual neuromuscular blockade ranging from 16 to 60 percent. Local Problem: A medium sized hospital in Maryland reported postoperative complications associated with residual paralysis. Increased side effects such as muscle weakness, increased length of stay in Post Anesthesia Care Unit, and delay in discharge may be due to the lack of guidelines for reversal of non-depolarizing neuromuscular blockers. A meeting with institutional key stakeholders identified the need for a guideline for the use of sugammadex in prevention of residual paralysis. Development of CPG: The focus of this project was to develop a Clinical Practice Guideline for the use of sugammadex in the prevention of residual paralysis for high risk patients and in emergent situations such as cannot intubate, cannot ventilate scenarios. A literature review was conducted to support evidence for the Clinical Practice Guideline, gathered data was presented to the key stakeholders. The project proposal was then submitted to the University of Maryland, Institutional Review Board and granted a Non-Human Subjects determination. The quality of the Clinical Practice Guideline was assessed by institutional key stakeholder and analyzed using the AGREE II tool and then presented to the entire anesthesia department for further evaluation. Adjustments to the Clinical Practice Guideline were made following departmental feedback and a final Clinical Practice Guideline along with algorithms were developed for this project and were distributed throughout the perioperative arena. A further assessment was done by the department using Practitioner Feedback Questionnaires. All data collected from the AGREE II tool and the Practitioner Feedback Questionnaires were synthesized, analyzed, and evaluated. The final project manuscript was submitted to the University of Maryland School of Nursing Doctorate of Nursing Practice committee for review. Results: The results of the final AGREE II Tool were 100% across the 6 domains and for the overall assessment. Each appraiser had a total score of 161/161 points and an overall of 322/322 points. The anesthesia providers, the end users of the guideline, evaluated the Clinical Practice Guideline using the Practitioner Feedback Questionnaires. Majority of anesthesia providers felt the guideline should be approved for practice (95.5%) and felt if the guideline was approved, they would use it in their own practice (100%) and would apply the recommendations to their patients (100%). This analysis demonstrated buy-in and acceptance of the Clinical Practice Guideline by the department. Conclusion: Study results indicate sugammadex compared to current reversal, neostigmine, is safe and effective in the reversal of neuromuscular blocking agents and reduces adverse events and undesirable side effects. The approval of the Clinical Practice Guideline can change clinical practice and improve patient care. A standardized approach for reversal of neuromuscular blockade with the use of sugammadex will decrease the incidence of residual paralysis in this institution.
