Tables & Figures


Conference


Figure 2 - GDT in ERAS.png
Figure 2. Suggested, risk-based algorithm for implementation of perioperative goal-directed in patients undergoing colorectal surgical procedures in the context of an Enhanced Recovery Protocol.
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Figure 3 - Risk Stratification.png
Figure 3. Proposed risk stratification scheme for patients undergoing colorectal surgical procedures in the context of an Enhanced Recovery Protocol.
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Figure 1 - Hemodynamic Framework.png
Figure 1. Suggested clinical framework for managing perioperative hemodynamics in patients undergoing colorectal surgical procedures
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Anaglesia Part 1 - Figure 1 - optimalanalgesia.png
Figure 1: This figure illustrates the core components of providing optimal analgesia. Pain after surgery can have profound effects on patient recovery. However, the complete elimination of pain may also have untoward effects, as listed in the figure. Optimal analgesia after surgery is an approach to pain control that facilitates a positive patient experience through optimized patient comfort that facilitates functional recovery while minimizing adverse drug events. © reproduced with permission from POQI
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Anaglesia Part 1 - Figure 2 analgesia timeline.png
Figure 2: This figure illustrates suggested components of a multimodal approach to pain management in an ERP for colorectal surgery. Of note, the plan should be comprehensive, encompassing all phases of perioperative care from preoperative to post-discharge.
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Analgesia Part 2 - Figure 2 - rescue analgesia plan.png
Figure 1: This figure illustrates a structured approach as a rescue plan for a patient experiencing suboptimal pain control. Except in extreme cases, this step-by-step process should lead to appropriate management that continues the principles being employed with the goal of delivering optimal analgesia.
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Figure 3 - PONS Assessment Tool
Figure 3. PONS assessment tool. BMI indicates body mass index; PONS, preoperative nutrition score.
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Figure 1 - Perioperative Nutrition Screening and Terapy
Figure 1. Facts and data for perioperative nutrition screening and therapy. Data drawn from Awad and Lobo6, Williams and Wischmeyer19, and Philipson et al.20 R.I.P. indicates rest in peace.
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Figure 2 - POQI Nutrition 6
Figure 2. Summary of key recommendations for perioperative nutri- tion care. POQI indicates Perioperative Quality Initiative.
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Figure 4A - Pre-Operative Nutrition Care Pathway Low Nutrition Risk
Figure 4. Example of preoperative nutritional care pathways. A, Nutrition pathway for low nutrition risk patients. B, Nutrition pathway for high nutri- tion risk patients, as defined by any positive response on the PONS score (currently utilized by Duke University Peri-Operative Optimization Team [POET] Nutrition Clinic). Alb indicates Albumin; IMN, immunonutrition; PAT, pre-anesthesia testing clinic; POET, perioperative enhancement team; PONS, preoperative nutrition score.
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Figure 1 - I-FEED Scoring System
Figure 1. The I-FEED scoring system was created out of the need for a con- sistent objective definition of impaired postoperative GI function. The scoring system attributes 0–2 points for each of the 5 components based on the clinical presentation of the patient and categorizes patients into normal (0–2), postoperative GI intolerance (3–5), and postoperative GI dysfunction (≥ 6). GI indicates gastrointestinal; I-FEED, Intake, Feeling nauseated, Emesis, physical Exam, and Duration of symp- toms; POGD, postoperative gastrointes- tinal dysfunction; POGI, postoperative gastrointestinal intolerance.
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Figure 2 - Postoperative GI Function: Go, Slow, Stop
Figure 2. A treatment algorithm was developed based on the I-FEED scoring system for the management of patients with impaired postoperative GI function according to the clinical presentation of the patient in real time. ERP indi- cates enhanced recovery protocol; GI, gastrointestinal; I-FEED, Intake, Feeling nauseated, Emesis, physical Exam, and Duration of symptoms; IVF, intravenous fluids; NGT, nasogastric tube; POGD, postoperative gastrointestinal dysfunc- tion; POGI, postoperative gastrointes- tinal intolerance; PONV, postoperative nausea and vomiting.
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Figure 1 - Proposed Timeline
Figure 1. Proposed timeline for patient- reported outcome measures (PROMs) for incorporation in an enhanced recov- ery pathways (ERPs) using the Quality of Recovery score (QoR)-15, World Health Organization Disability Assessment Schedule (WHODAS) 2.0, or Patient- Reported Outcomes Measurement Information System (PROMIS) measures.
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Figure 2 - Recovery after Surgery
Figure 2. Recovery after surgery. Inpatient and postdischarge domains of patient-reported outcomes. Examples of patient- reported outcome measures (PROMs) that can be used during their respective time periods. EQ-5D indicates EuroQol 5 dimension ques- tionnaire; GU, genitourinary; PROMIS, Patient-Reported Outcomes Measurement Information System; QoR, Quality of Recovery (score); SF-36, Short-Form 36; WHODAS, World Health Organization Disability Assessment Schedule.
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Figure 3 - Simplified Wilson-Cleary Classification
Figure 3. A simplified Wilson-Cleary classification of patient outcomes. Adapted from Neville et al.
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Figure 4B - Pre-Operative Nutrition Care Pathway High Nutrition Risk
Figure 4. Example of preoperative nutritional care pathways. A, Nutrition pathway for low nutrition risk patients. B, Nutrition pathway for high nutri- tion risk patients, as defined by any positive response on the PONS score (currently utilized by Duke University Peri-Operative Optimization Team [POET] Nutrition Clinic). Alb indicates Albumin; IMN, immunonutrition; PAT, pre-anesthesia testing clinic; POET, perioperative enhancement team; PONS, preoperative nutrition score.
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Figure 1 - Risk of Harm and Postop BP.png
Figure 1. This figure demonstrates the association of perioperative hypotension with myocardial infarction (MI) and death, showing that each 10-minute episode of hypotension of postoperative day (POD) 0 is associated with a 3% increase and is associated with a 3% increase in risk, and any episodes of hypotension on POD 1-4 are associated with almost a doubling or risk. [Adapted from Sessler DI, et al. Period-dependent Associations between Hypotension during and for Four Days after Noncardiac Surgery and a Composite of Myocardial Infarction and Death: A Substudy of the POISE-2 Trial. Anesthesiology, 2018 128:317-327.]
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Figure 2 - Bedside Assessment .png
Figure 2. This figure illustrates our recommendations for a structured bedside assessment due to perturbations in postoperative blood pressure readings. *An unstable patient would be any patient who is displaying signs and symptoms of end organ dysfunction related to blood pressure (e.g. altered mental status, chest pain). [BP = blood pressure; PLR = passive leg raise; SV = stroke volume; TTE – transthoracic echocardiography; SVR = systemic vascular resistance; ECG = electrocardiogram; PACU = post-anesthesia care unit; HDU = high-dependency unit; ICU = intensive care unit]
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Figure 3 - Criteria for moving the level of care.png
Figure 3. This figure represents structured criteria for moving patients between levels of care based upon postoperative blood pressure. If the patient meets all criteria in the green box, then they would be cleared to move from PACU or the ICU/HDU to the ward based upon blood pressure (other vital signs or care issues may prevent such change in level of care). If the patient meets criteria in the red box, then they should move from the ward to a higher level of care, such as ICU/HDU. *Of note, this algorithm assumes that the bedside assessment and initial management shown in Figure 2 has occurred and the patient remains hypotensive or hypertensive after appropriate initial therapies have been undertaken that are possible on the postoperative ward. [OR = operating room/theater; PACU = post-anesthesia care unit; ICU = intensive care unit; HDU = high-dependency unit; IV = intravenous; SBP = systolic blood pressure; HR = heart rate; S/Sx = signs and symptoms]
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Figure 4 - Relationship monitoring_level of care .png
Figure 4. This figure illustrates the current standard of care for monitoring blood pressure in the perioperative period and also depicts how that may change in the near future based on available technologies and evolving evidence. Finally, we propose what may be present optimally in the future concerning the level of postoperative monitoring, anticipating that improved continuous monitoring in the first 48 hours after surgery may improve patient safety and reduce adverse events related to hypotension.
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