A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12851

It is becoming increasingly common to find reports or see patients who are convinced that cannabis or cannabinoid medication help with their acute pain. Recently I have spoken to several elderly patients who like to ‘smoke a joint’ every night because it helps with various aches and pains. This systematic review aimed to assess the analgesic efficacy and adverse effects of cannabinoids when used for acute pain. It looked at 7 studies. 5 studies found cannabinoids worked as well as a placebo, 1 study found them to be superior and 1 found them to be inferior.

Sadly for these patients convinced that cannabis is the answer to their pain, this systematic review concluded that cannabinoids were no better than a placebo either by themselves or combined with opioids and 5 of the studies found that adverse effects were more common than with placebo.

Calling the patient’s own name facilitates recovery from general anaesthesia: a randomised double-blind trial. Anaesthesia 2017;72:197-203

‘The cocktail party effect’ describes the effect where one can tune into one voice even in a noisy room, and also how one can immediately detect words of importance such as hearing one’s name in another conversation.

The authors of this study found that after discontinuing the anaesthetic, calling the patient by their name meant that they opened their eyes quicker and the time to i-gel removal was faster. A BIS of 60 was reached in a shorter time and patients spent less time in the post anaesthetic care unit. There are limitations to the study but either way using the patient’s name is an easy method to aid recovery.

But surely out of respect for the patient should we not be doing this anyway?

Editorial: Real-time physiologic monitoring and physician feedback: Are we ready? Canadian Journal of Anaesthesiology 2017;64:239-241

Individual and group data feedback was given to anaesthetists regarding their management of intraoperative temperature monitoring, firstly the percentage of time the patient was hypothermic and secondly the time taken from the start of the case to the first temperature measurement. Giving feedback didn’t change the amount of time the patient was hypothermic however it did reduce the delay in starting to monitor temperature.

The concept of physician feedback as a QI tool is becoming increasingly popular. The authors reason that the reduction shown in the time taken to start temperature monitoring is evidence that providing feedback may contribute to improved perioperative outcomes.

Or is it possible that giving feedback results in the Hawthorne effect – the knowledge of being measured changes behaviour? Does it matter if the goal is to modify current practice? Individualised and group feedback means we need to accept our imperfections to drive improvement. Hospitals will continue to use QI strategies to improve patient care and reduce costs.

As clinicians we need to accept feedback and undergo a cultural shift from ‘shame and blame’ to high-quality continuous improvement focusing on providing the best care for the patient.

Impact of a perioperative quality improvement programme on postoperative pulmonary complications. Anaesthesia 2017;72:317-327

Postoperative pulmonary complications are

  1. common (incidence of between 2-40%)
  2. associated with adverse outcomes (death/increased length of stay/survival)

Enhanced recovery programmes don’t really address this. A team in Manchester developed an ERAS+ programme aimed at reducing pulmonary complications. It incorporated ICOUGH and surgery school (with videos via youtube). In patients undergoing major surgery admitted to critical care postoperatively, pulmonary complications reduced from 19.3% to 10.5% post implementation of ERAS+. One year after ERAS+ was introduced pulmonary complication rate was 8.7%. Patient surveys showed satisfaction with the surgery school. From the data presented it appeared a relatively low-cost programme to set up. Is the new type of peri-operative pathway involving the patients and their families working with multi-professional healthcare teams where we should be heading? On first glance it seems low-cost, effective and well received by patients………

Surgery School focused on:
Nutrition
Breathing
Activity
Oral health
Psychological support
General health
Family support

 

I incentive spirometry
C cough/deep breathing
O oral care
U understanding patient education
G get out of bed
H head of bed elevation

 

Implantation of an Artificial Larynx after Total Laryngectomy. New England Journal of Medicine 2017;376:97-98 doi:10.1056/NEJMc1611966

Total laryngectomy is a lifesaving operation in patients with advanced laryngeal and hypo laryngeal cancer. But it comes with a substantial reduction in the quality of life.  This is a case report of a patient from France who had an artificial larynx implanted in 2015. The artificial larynx consists of a permanent tracheal prothesis with a removable open-ventilation cap that allows continuous passage of air while protecting the patient’s airway from aspiration. This cap allows the patient to breathe and drink fluids. It also opens transiently with coughing to allow secretion expulsion. Over a 16 month follow-up period the patient was able to breathe and expectorate through the upper airways and maintain oxygen saturations on air. He was able to swallow saliva although occasionally aspirated food.

A very short case report and clearly more work may be needed before this becomes a common place procedure but could this be the future for patients needing total laryngectomy?

Anaesthesia and Developing Brains – Implications of the FDA warning. New England Journal of Medicine 2017 doi:10.1056/NEJMp1700196

For a long time there has been a lot of debate about the neurotoxic effects of anaesthetic agents on the neurodevelopment of young children and foetuses. In 2014 an FDA Science Board meeting found that all anaesthetic agents have ‘immediate neuroanatomical consequences and are associated with long-lasting, if not permanent functional effects’.

Clinically this is a little more difficult to interpret. Healthy children rarely undergo repeated or long procedures under general anaesthetic. Brains of premature or children with congenital heart disease may have already been injured by inflammation or chronic hypoxia before having general anaesthetic. More recent studies have shown that a brief single exposure to general anaesthesia is not associated with poorer neurodevelopment outcomes. More results are expected later this year with the conclusion of the Mayo Anesthesia Safety in Kids (MASK) study.

Yet in December 2016 the FDA issued a ‘Drug Safety Communication’ warning that repeated or prolonged (>3 hours) anaesthesia in children under 3 years old and in women in their third trimester may affect the development of children’s brains. Rarely can procedures be safely delayed if indicated during these periods of life. Is the FDA warning wise?

This will already be a time of high stress for parents and families, and there is a risk that the FDA warning may cause delay in procedures that are needed. Parents, patients and doctors must be careful when considering the risk of delaying procedures due to this warning, especially given it states that ‘additional high quality research is needed’. We must be prepared for this question to be asked given that this was covered in the mainstream media and tabloids at the time………