Cardiac arrest, intubation and survival.  Journal of the American Medical Association 2017 doi:10.1001/jama.2016.20165

Since 2010, the importance of tracheal intubation during cardiac arrest in adults has become less important. The optimal approach for airway management during arrest is not clear. This was an observational cohort study of 86,628 adult patients who had an in-patient cardiac arrest between January 2000 to December 2014. Intubation within the first 15 minutes was associated with a lower chance of ROSC, lower survival to hospital discharge with reduced functional outcome. The authors of this study admit that it does not totally eliminate the potential for confounding. However, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.

 

Intraoperative monitoring of analgesia using nociceptive reflexes correlates with delayed extubation and immediate postoperative pain. European Journal of Anaesthesiology 2017;34:1-9 doi:10.1097/EJA.0000000000000597

Up to 50% of patient have moderate to severe pain immediately after surgery. Does it matter? Not only is it is unpleasant, it can cause hamemodynamic instability, impair wound healing and risk development of chronic pain with reduced mobility. Easy to avoid with long-acting analgesics at the end of surgery……but how to avoid overdosing, prolonged sedation and respiratory depression?

This study looked at the pupillary dilation reflex (PDR) and the nociceptive flexion reflex (NFR) of the biceps femoris. The PDR threshold (PDRT) and the NFR threshold (NFRT) were measured 1 week pre-operatively, then repeated  at the end of surgery. The PDRT and NFRT both correlate with immediate postoperative pain and the time to extubation.

How clinically relevant this is remains questionable. The authors admit the reflexes are of limited use except in clinical studies where clinical variability is reduced. Possibly something for the future?

 

Start2quit:a RCT. Effectiveness of personalised smoking cessation advice. Lancet 2017 doi:10.1016/S0140-6736(16)32379-0

The number of adults smoking in the UK has fallen by more than 50% since 1974, but this has slowed since 2007. The total direct cost to the NHS of smoking-related disease was estimated at £5.2 billion (2005-6). NHS Stop Smoking Services (SSS), established in 2000, effectively help and support smokers to quit with quit rates of about 35%. Despite this fewer than 5% of smokers attend each year – maybe due to the increasing popularity of e-cigarettes?

This study aimed to look at whether showing how smoking related to their individual risk of bad things happening works as motivation. Smokers aged 16 or over were randomly assigned to receive either an individually tailored risk letter and invitation to attend a non-commitment introductory SSS session (intervention group) or a standard generic letter advertising the local SSS group (control group).

Attendance at the SSS group was significantly higher in the intervention group (17.4% vs 9%) although still at the low rate expected for smoking cessation trials. (NB this was just the attendance at the initial SSS meeting and not the quit rate). Possibly a more proactive approach may reduce patient barriers to access treatment and increase uptake of cessation session?

 

Surgical Decision Making: Sharing Decisions……… Journal of the American Medical Association 2017;317(4):357-358 doi:10.1001/jama.2016.18719

Shared decision-making (SDM) is an approach in which clinicians and patients communicate together using the best available evidence when faced with the task of making decisions. It should be a collaboration in which the physician (in this case the surgeon) explains treatment options, elicits values from the patient and importantly guides the conversation towards a decision consistent with the patient’s values and current evidence. Three recent RCTs looked at surgical management in appendicitis, diverticulitis and knee osteoarthritis. The common factor in these studies is that they compared commonly used operations with significantly less aggressive than non-operative alternatives – importantly neither treatment option was superior. However, all studies showed that surgical treatment may be required later on.

Surgical dogma is being challenged – accepted treatment is shifting away from long-established surgical gold-standard treatments. But who and how should the decision be made? The patient-centred framework challenges the ‘one-size fits all’ model. One treatment option is rarely shown to improve outcomes for all important end-points. There are barriers: ‘Surgeons often lack the time or training to talk patients through these complicated trade-offs. They may have concerns about liability for untoward outcomes from unconventional treatments.’ What is clear is that SDM is here to stay and we must find a way to embrace this.

 

Editorial: The never-ending story of the elderly with fractured neck of femur. European Journal of Anaesthesiology 2017;34:115-117

What the literature tell us so far……..

  • In the UK, 30-day mortality is 8.5% – decreasing but still unacceptably high.
  • Hospital stays of <10 days are associated with increased survival 30 days after discharge.
  • 95% of hip-fracture patients have at least one major co-morbidity
  • Unsurprisingly the number of co-morbidities negatively influences the physical and psychological outcomes of patients.
  • Anaesthetic for hip-fracture surgery varies greatly – Regional techniques are associated with a shorter hospital stay but 30-day mortality is no different whether GA or regional anaesthesia is used.
  • Perioperative pain management with a multi-modal approach is vital – implementing fast-track care pathways and early surgery improves 30-day mortality rate.
  • Intraoperative haemodynamic stability seems to improve outcome
  • Anaemia is an independent risk factor for long-term mortality
  • Dedicated geriatric care leads to improved mobility at 4 months compared to standard orthopaedic care.

 

A couple obs related studies…………

Number of pregnancies and atrial fibrillation risk: the Women’s health study. Circulation 2017 doi:10.1161/CIRCULATIONAHA.116.026629

  • This study followed 34,639 women for a median of 20.5 years
  • Having four or more pregnancies means you are 30-50% more likely to develop AF than nulligravida women
  • Possibly thought to be due to repeated exposure to physiological, metabolic or hormonal factors during pregnancy
  • Mainly European women in the study so may not be generalisable to all races or ethnicities

Preterm delivery and maternal cardiovascular disease in young and middle aged adult women. Circulation 2017 doi:10.1161/CIRCULATIONAHA.116.025954

  • Women who deliver their first child before 37 weeks gestation have a 40% greater risk of developing cardiovascular disease later in life.
  • If the baby was delivered before 32 weeks this doubled thee risk of later cardiovascular disease – even when adjusted for pre-eclampsia or gestational diabetes
  • In less than 25% of cases this increased risk was explained by hypertension, hypercholesterolaemia, type 2 diabetes and changes in body mass developing after the first birth.
  • Delivering a preterm infant could be an early warning signal of a high risk for cardiovascular disease

It’s never too early to adopt a heart healthy lifestyle……should we be warning women??