Ambulance organisations in Sweden have introduced prehospital fast track care (PFTC) for patients with suspected hip fracture. This means that the ambulance nurse starts the pre-operative procedure otherwise implemented at the accident & emergency ward (A&E) and transports the patient directly to the radiology department instead of A&E. If the diagnosis is confirmed, the patient is transported directly to the orthopaedic ward. No previous randomised, controlled studies have analysed PFTC to describe its possible advantages. The aim of this study is to examine whether PFTC has any impact on outcomes such as time to surgery, length of stay, post-operative complications and mortality. The design of this study is a prehospital randomised, controlled study, powered to include 400 patients. The patients were randomised into PFTC or the traditional care pathway (A&E group). Time from arrival to start for X-ray was faster for PFTC (mean, 28 vs. 145 min; p<0.001), but the groups did not differ with regard to time from start of X-ray to start of surgery (mean 18.40 h in both groups). No significant differences between the groups were observed with regard to: time from arrival to start of surgery (p=0.07); proportion operated within 24h (79% PFTC, 75% A&E; p=0.34); length of stay (p=0.34); post-operative complications (p=0.75); and 4 month mortality (18% PFTC, 15% A&E p=0.58). PFTC improved time to X-ray and admission to a ward, as expected, but did not significantly affect time to start of surgery, length of stay, post-operative complications or mortality. These outcomes were probably affected by other factors at the hospital. Patients with either possible life-threatening conditions or life-threatening conditions prehospital were excluded. Copyright © 2016 Elsevier Ltd. All rights reserved.

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English-language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi-institutional prospective and adequately powered randomized trials. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

A bespoke clinical pathway is increasingly often used to expedite patient's recovery after video-assisted thoracoscopic surgery (VATS). The importance and predictors of adherence to a clinical pathway have not been previously investigated. A defined clinical pathway was used for the perioperative management of 136 consecutive patients receiving major pulmonary resection surgery. The clinical pathway encompassed multiple aspects of clinical care, including chest drainage, analgesia, mobilization, physiotherapy, investigations, etc. The cohort consisted of 76 males (56%), and had a median age of 61 years (range, 14-84). A single lobectomy was performed in 66 patients (49%), with sublobar or more complex resections performed in the remainder. Although all patients were intended for a VATS approach, VATS was ultimately used to complete the procedure in 113 patients (83%). It was impossible to adhere strictly to the clinical pathway throughout the hospital stay of most patients, with 83 patients (61%) found to have adhered to the clinical pathway for 50% or more or the duration of their in-hospital stay. The rate of adherence to the clinical pathway for 50% or more of the time was lower in patients who were male (31.6% vs 48.3%, P = 0.047); had a smoking history (25.9% vs 47.6%, P = 0.011); and did not have absence of pain immediately after surgery (33.9% vs 59.3%, P = 0.016). There were trends for poorer adherence among patients who had: age older than 65 years; previous tuberculosis; body mass index greater than 25 kg/m; and longer operation times-but these failed to reach statistical significance. The approach and extent of surgery did not influence clinical pathway adherence. Adherence for 50% or more of the hospital stay was associated with reduced mean chest drain duration (3.2 ± 1.7 vs 5.1 ± 5.0 days, P = 0.002) and mean length of stay (4.6 ± 1.9 vs 7.9 ± 6.6 days, P < 0.001). Among smokers, adherence for 75% or more of the hospital stay was particularly well predicted by better pain control on the day of surgery, and was in turn associated with a significant reduction in morbidity rate (7.7% vs 39.0%, P = 0.043). Good adherence to a detailed clinical pathway may ensure faster recovery after VATS but is often difficult to maintain postoperatively. Predictors of poor adherence include male sex, smoking history, and immediate postoperative pain. Smokers are at particular risk for failure to adhere but paradoxically have the most to gain from adhering to the clinical pathway.