This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

SummaryThe number of fluctuations of skin conductance per second correlates with postoperative pain. The aim of this prospective study was to test the cut-off value for the number of fluctuations of skin conductance per second obtained from a previous study. Seventy-five patients were asked to quantify their level of pain on a numeric rating scale (0-10) in the recovery room. The number of fluctuations of skin conductance per second was recorded simultaneously. The number of fluctuations of skin conductance per second was different between patients with no (0.07), mild (0.16), moderate (0.28) and severe pain (0.33); p < 0.001. The tested cut-off value for the number of fluctuations of skin conductance per second (0.1) distinguished a numeric rating scale £ 3 from > 3 with 88.5% sensitivity and 67.7% specificity. The number of fluctuations of skin conductance per second may be a useful means of assessing postoperative pain. Postoperative complications may be prevented by a suitable choice of analgesic technique [1]. Moreover, adequate pain control is a prerequisite for the use of rehabilitation programmes to accelerate recovery from surgery [1], and existing data indicate that effective pain relief may lead to an improved overall postoperative outcome [2].Accurate assessment of postoperative pain is a key factor for successful pain management. Though various scoring systems are available for this purpose, they rely almost entirely on the co-operation of the patient. Hence these systems are bound to fail in unconscious, confused or otherwise uncooperative subjects. A more objective, subject-independent parameter for the assessment of pain is therefore highly desirable. As pain greatly modifies the surgical stress response [3], monitoring of parameters of postoperative stress, such as sympathetic tone, could be a helpful tool for assessment of analgesia. Increased sympathetic tone leads to a higher rate of firing in sympathetic, postganglionic cholinergic neurones [4,5]. The resulting change of sweat gland filling can be measured in terms of skin conductance. The number of fluctuations within the mean skin conductance per second has been reported to correlate well with intra-operative noxious stimuli, with a sensitivity and specificity of 86% for their detection [6].In a pilot study [7] we confirmed correlation between the number of fluctuations of skin conductance per second and postoperative pain in the recovery room rated on a numeric rating scale (0-10). As the number of fluctuations of skin conductance per second was highly Anaesthesia, 2007, 62, pages 989-993

The severity of postoperative pain significantly influences SC. Using cut-off values, NFSC may prove a useful tool for pain assessment in the postoperative period.

Recent breakthroughs in molecular biology have enabled a reclassification of drug metabolising enzymes based on their amino acid sequence. This has led to a better understanding of drug metabolism and drug interactions. The majority of these drug metabolising enzymes may be either induced or inhibited by drugs or by extraneous substances including foodstuffs, cigarette smoke and environmental pollutants. Virtually all drugs used in anaesthesia are metabolised by either hepatic phase 1 or phase II enzymes. This review considers the classification of drug metabolising enzymes, explains the mechanisms of enzyme induction and inhibition, and also considers how the action of drugs commonly used by anaesthetists, including opioids and neuromuscular blocking drugs, may be altered by this mechanism. Factors that affect the metabolism of foreign substances (collectively called xenobiotics) include age, sex, hereditary and genetic factors, disease states, dietary and nutritional status, hormonal changes in the body and the activity of liver enzymes. Humans are exposed to a number of environmental substances that are known to affect the activity of liver enzymes. These substances include foodstuffs, medications, recreational substances such as alcohol and tobacco, and pollutants found in the household and in the atmosphere. Recently, our improved understanding of the classification of liver enzymes has enabled us to predict with considerable precision how these substances will affect enzyme function , thus altering drug metabolism. Xenobiotics are broken down by drug metabolising enzymes (DMEs), which are found mainly in the liver and which act by making these substances more water-soluble. Traditionally, these enzymes are designated as being either Phase 1 or Phase II enzymes. Phase I enzymes consist of cytochrome P450 enzymes, previously known as mixed function oxidase enzymes and are responsible for reactions (mainly oxidation and hydroxylation) that alter the existing functional groups to increase water solubility. The cytochrome P450 (CYP) isoenzymes (the name derives from the enzymes' absorption peak at 450 nm; the p signifies pigment) are a family of haemoproteins that are the terminal oxidases of the mixed function oxidase system found on the membranes of the endoplasmic reticulum [1]. The present system of nomenclature for the various CYP isoenzymes employs a three-tiered classification based on the conventions of molecular biology: a numeral and a capital letter designate the amino-acid sequence, with a final number indicating the individual enzyme, e.g. CYP3A4 [2]. Italicised lettering signifies the gene that encodes the enzyme. At present, more than 270 different CYP families have been described across the animal kingdom, with 18 recorded in mammals [3]. In man there are 43 subfamilies and 57 individual enzymes, each of which is encoded by an individual gene. Phase II reactions involve conjugation reactions occurring primarily in the cytosolic (that part of the cytoplasm outside the organelles) fraction of cell...

Objectives To determine whether preoperative dexamethasone reduces postoperative vomiting in patients undergoing elective bowel surgery and whether it is associated with other measurable benefits during recovery from surgery, including quicker return to oral diet and reduced length of stay. Design Pragmatic two arm parallel group randomised trial with blinded postoperative care and outcome assessment. Setting 45 UK hospitals. Participants 1350 patients aged 18 or over undergoing elective open or laparoscopic bowel surgery for malignant or benign pathology. Interventions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia compared with standard care. Main outcome measures Primary outcome: reported vomiting within 24 hours reported by patient or clinician. Secondary outcomes: vomiting with 72 and 120 hours reported by patient or clinician; use of antiemetics and postoperative nausea and vomiting at 24, 72, and 120 hours rated by patient; fatigue and quality of life at 120 hours or discharge and at 30 days; time to return to fluid and food intake; length of hospital stay; adverse events. Results 1350 participants were recruited and randomly allocated to additional dexamethasone (n=674) or standard care (n=676) at induction of anaesthesia. Vomiting within 24 hours of surgery occurred in 172 (25.5%) participants in the dexamethasone arm and 223 (33.0%) allocated standard care (number needed to treat (NNT) 13, 95% confidence interval 5 to 22; P=0.003). Additional postoperative antiemetics were given (on demand) to 265 (39.3%) participants allocated dexamethasone and 351 (51.9%) allocated standard care (NNT 8, 5 to 11; P<0.001). Reduction in on demand antiemetics remained up to 72 hours. There was no increase in complications. Conclusions Addition of a single dose of 8 mg intravenous dexamethasone at induction of anaesthesia significantly reduces both the incidence of postoperative nausea and vomiting at 24 hours and the need for rescue antiemetics for up to 72 hours in patients undergoing large and small bowel surgery, with no increase in adverse events. Trial registration EudraCT (2010-022894-32) and ISRCTN (ISRCTN21973627).

In this study, BIS was found to predict arousal with a higher probability but slower response times than NFSC in patients waking after TIVA.

When a modular-based training system was combined with case selection, both clinical and histopathological outcomes following resectional laparoscopic colorectal surgery were similar between trainees and trainer. This should encourage the use of more training opportunities in laparoscopic colorectal surgery.

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