written by Dr C. Williams

Cartoons on facebook: a novel medical education tool. Junhasavasdikul D, Srisangkaew S, Sukhato K, Dellow A. Medical Education 2017;51(5):539-540 doi:10.1111/medu.13312

The popularity of social media is increasing. Cartoons or comics are increasingly being used in medical education. Combining the two seems to make sense and this is what this study aimed to look at. A previous study has shown that using cartoons on a website was associated with an improvement in post-learning test scores of health-care professionals. A prospective trial was carried out using a series of non-animated comic-style cartoons aimed to teach the physiology of breath sounds and their clinical examination. These were published on Facebook in March 2016 and viewers were encouraged to fill in a survey. To date the cartoon has had 30,000 views. More than 90% reported that the cartoons attracted their attention, helped them memorise the content, understand the physiology and improve their approach to conducting a physical examination. The views peaked at 10,000 on the first day, falling to 3000 the next day and then less than 100 views per week.

This study shows that using the popularity of social media for medical education may be successful in reaching a wider audience. It remains to be seen how effective this teaching method is in the long run.

Ventilation with high versus low peep levels during general anaesthesia for open abdominal surgery does not affect postoperative spirometry: a randomised clinical trial. Treschan TA, Schaefer M, Kemper J et al. European Journal of Anaesthesiology 2017;34:1-10 doi:10.1097/EJA.0000000000000626

It is well know that invasive mechanical ventilation during general anaesthesia for surgery causes atelectasis and a reduced long volume. Typically this is due to a cephalic shift of the diaphragm and decreased muscle tone following induction of anaesthesia. For patient undergoing abdominal surgery this is particularly true and the risk of atelectasis increases the closer the incision is to the diaphragm. Intraoperative atelectasis may impair oxygenation. But more importantly, it often continues in the postoperative period and can increase the risk of postoperative pulmonary complications (PPCs). PPCs are known to increase morbidity and mortality and are known to occur in up to 39% of patients.

The reduction in atelectasis and the effect on postoperative respiratory function can probably be modified somewhat by intraoperative ventilation strategies. Protective intraoperative ventilation strategies using low tidal volumes and positive end-expiratory pressure (PEEP) and recruitment manoeuvres are becoming more common place and could prevent the development of PPCs.

The protective role of PEEP has recently been challenged (PROVHILO trial, Lancet 2014; systematic review, Anaesthesiology 2015). This study was a substudy of the PROVHILO trial. It looked at patients having major abdominal surgery and split them into two groups: both groups having low tidal volume ventilation but one group with a PEEP of 12 cmH2O and the other with a PEEP of 2cmH2O. Patients than had their FEV1 and FVC measured every day for 5 days postoperatively. What this study showed was that both groups had approximately a 50% decrease in their spirometry compared to preoperative values. In both groups patients who had worse spirometry function on postoperative day 5 were more likely to develop PPCs.

This study seems to raise more questions about the optimal intraoperative ventilatory strategy. Do high levels of PEEP and recruitment manoeuvres really make as big a difference as we think? Does the ventilation strategy on emergency of anaesthesia influence lung function? Would extending PEEP into the postoperative period or prohibiting the use of 100% oxygen during extubation make a difference?

Optimisation of bodyweight before visceral surgery in obese patients. Bell SW, Warrier SK. British Journal of Surgery 2017 doi:10.1002/bjs.10504

Obesity is an epidemic in the developed world with dramatic rises in the number of people being classed as overweight or obese in the USA. This is a pattern that is replicated across Europe and Australasia. The WHO estimates that 2.8 million people die each year as a result of being obese. We know that life expectancy and quality of life is affected by obesity and it results in many complications including the development of diabetes, cardiovascular disease, musculoskeletal problems and neuromuscular compromise. What can not be ignored is the impact of obesity in the patient presenting for surgery particularly for visceral surgery. Obese patients can be technically challenging from a medical and anaesthetic point of view, a surgical point of view and nursing point of view. They are often challenging to operate on and consequently have compromised outcomes. They are more likely to need critical care, have a longer hospital stay, a prolonged recovery period and often need rehabilitation. In addition to the well known anaesthetic challenges of an obese patient there are surgical challenges to consider. With regards to colorectal surgery there are particular challenges: difficulty in laparoscopic identification of surgical planes, lack of access to critical views, difficulties in vessel visualisation and ligation, and in traditional open surgery difficulty in obtaining appropriate angles for dissection and safe division of the rectum.

Before bariatric surgery the use of very low-energy diets (VLEDs) is common. VLEDs have been shown to reduce total bodyweight, liver fat content and liver volume. The cause a disproportionate reduction n visceral adipose tissue compared to total body mass. Rapid weight loss leads to a reduction in liver volume and makes surgical access to the stomach and oesophageal hiatus easier so improving the technical ease of surgery. Although it is thought that VLEDs may be beneficial in other areas outside bariatric surgery there is very little evidence to support this. For colorectal surgery there has been a focus on preoperative optimisation and prehabilitation. Potentially a reduction in obesity through VLED meal replacement may compliment enhanced recovery programmes. Interventions to reverse some of the negative impact of obesity in the patient undergoing visceral surgery may result in significant benefits. In the field of rectal cancer, the ADIPOSe (Australian Decrease in Intra-Pelvic Obesity for Surgery) trial is looking at the efficacy of VLEDs in the perioperative period. Obesity rates looks set to continue to increase, as do visceral cancers particularly colorectal cancers – the development of which may be linked to obesity. The results of this study will be interesting to see and may result in the acute use of VLEDs for these patients.

Training in intraoperative handover and display of a checklist improve communication during transfer of care. An interventional cohort study of anaesthesia residents and nurse anaesthetists. Julia M, Tronet A, Framer F, Manville V, Fourcase O, Alacoque X, LeManach Y, Kurre MM. European Journal of Anaesthesiology 2017;34:1-6 doi:10.1097/EJA.0000000000000636

Having to handover a patient is common practice in anaesthetics – handover from anaesthetist to anaesthetist, to the recovery team, to the critical care team or to the ward staff are a few examples that spring to mind. How the patient is handed over and the information given is vital. Failure in communication at handover can contribute to morbidity and mortality. With the advent of shift working, having to hand over a patient during the intraoperative period is now not an uncommon occurrence. It has been shown that most preventable adverse events in medicine are because of communication errors and over half of these occur in relation to handover of patient care.

In my anaesthetic training I know of several audits in several different hospitals looking at handover practices from anaesthetists to recovery nurses. Despite our best efforts and training these audits have always shown that we fall below the expected standard. We know from other areas of anaesthetic practice that checklists can be useful and aid in tasks such as this. Handover checklists seem to be an easy way to standardise oral communication and to reduce the loss of information and studies have shown the positive effect of checklists on postoperative handover from anaesthetist to post-anaesthetic care unit nurses.

This study looked at whether intraoperative handover training and display of a checklist would improve communication during intraoperative handover of care. The participants (made up of residents and nurse anaesthetists) were split into two groups – the control group and a group who received handover training and had checklists displayed in the operating theatres. Before training both groups showed similar performances. Over the study period the control group showed no change in performance. In the intervention group, performances improved and this was sustained over a three month period without an increase in handover duration.

As much as checklists are hated by some they do appear to be effective in certain situations. Possibly handover between trainees at shift changes could be improved with their use. As we use more and more technology possibly the development of a smartphone application may further increase adoption be healthcare providers to improve patient safety?

Postoperative pain relief using local infiltration analgesia during open abdominal hysterectomy: a randomised, double-blind study. Acta Anaesthesiologica Scandinavica 2017;61(5):539-548 doi:10.1111/aas.12883

Total abdominal hysterectomy is a relatively common procedure carried out for both benign and malignant conditions of the uterus. In Sweden over 60% of hysterectomies performed each year are carried out via open abdominal surgery. Post-operative pain for the first 24 hours can be severe, particularly during movement and patients often require high doses of rescue analgesia. Pain control is important to promote early mobilisation. Poor pain control is associated with increased morbidity and can evolve into persistent post-surgical pain. There is no universal consensus on the best analgesic technique and evidence can be contradictory. Techniques that may be used range from central neuraxial blocks to peripheral nerve blocks, patient-controlled opioids and multi-modal oral analgesia.

Recently in orthopaedic surgery large volumes of local anaesthetic combined with non-steroidal anti-inflammatory drugs and adrenaline have been successfully used as an analgesic technique. The aim of this study was to see if systematically injected local anaesthesia infiltration compared with placebo can reduce the total rescue analgesic consumption. Patients included were ASA I-III women undergoing total abdominal hysterectomy for a benign uterine lesion. Patients were randomised and both patients and health-care professionals were blinded to the method of analgesia. All patients otherwise had a standard pre-medications, anaesthetic technique and post-operative plan for analgesia. The intervention group received local analgesia infiltration with 300mg of ropivacaine, 30mg ketoralac and 0.5mg of adrenaline. The control group received the same volume of infiltrate of 0.9% saline. The primary outcome was to look at the doses of rescues analgesia and pain scores over the first 24 postoperative hours.

The study found that patients who had local analgesia infiltrated had a lower opioid consumption during the first 24 hours, lower pain scores during the first two post-operative hours and a longer time before they needed a first dose of rescue analgesia. This suggests that local analgesia infiltration may be effective, at least in the short term. The study does have some limitations and ends by concluding that further studies are needed to improve and refine the technique. However, it is a relatively simple and low cost technique that seems to show promise.

Effect of endotracheal tube cuff shape on postoperative sore throat after endotracheal intubation. Chang JE, Kim H, Sung-Hee L, Jung-Man J. Anesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000001933

Having a postoperative sore throat is often seen as a minor and unavoidable compilation that we should not be concerned about. The reported incidence is between 21% and 74% and although a minor complication it can significantly impact on patient satisfaction and postoperative function. There are several factors that mediate the incidence of a postoperative sore throat including: endotracheal tube size, intracuff pressure and duration of intubation. Specifically the area of cuff-trachea contact has been implicated in the development of a postoperative sore throat and hoarseness. Current recommendations are to use high-volume low-pressure cuffs to reduce ischaemic complications due to high endotracheal cuff pressure. But the increased area of cuff-tracheal contact may exacerbate the incidence of a sore throat. An endotracheal tube with a distally tapered cuff has been developed – mainly because it is known that longitudinal folds along the endotracheal tube cuff can lead to aspiration of upper airway secretions and intubation-related pneumonia. A taper-cuff is thought to reduce this.

This study hypothesised that a tapered cuff may reduce the incidence of post-operative sore throat and hoarseness due to the decreased cuff diameter and decreased cuff-trachea contact area. Patient were randomised to be intubated with either a standard endotracheal tube (cylindrical-shaped cuff) or a tube with a tapered cuff. The primary outcome was the incidence of postoperative sore throat. The severity of the sore throat and the presence of hoarseness were secondary outcomes. The patients who were intubated with an endotracheal tube with a tapered cuff had significantly lower incidences and less severe postoperative sore throat.

This may prove to be a relatively easy method of reducing a complication that affects patient outcome after surgery.

Background noise lowers the performance of anaesthesiology residents’ clinical reasoning when measured by script concordance: a prospective randomised crossover volunteer study. Enser M, Moriceau J, Anily J et al. European Journal Aaesthesiology 2017;34:1-7 doi:10.1097/EJA.0000000000000624

Noise is present pretty much everywhere in hospital and more particularly operating theatres and intensive care units. Studies have been done on the negative effects of noise on patients and shown that it indices stress, discomfort and lack of sleep. The most commonly reported health consequence for clinical staff is hearing loss if exposed to high levels of noise. However, noise can impact negatively on the clinical performances of staff causing impaired communication, concentration and even short-term memory loss.

A study has shown that noise can interfere with perception of the pulse oximeter can the anaesthetist’s ability to detect a reduction in oxygen saturation. The WHO recommends that should levels should not exceed 35decibels for continuous sound and should remain below 40 decibels in hospitals at night. Average sound levels in several different studies give noise ranges of 56-71 decibels in operating theatres and 52-59 decibels in intensive care units with peak levels in both above 100 decibels. Residents were given clinical situations to work through with questions about diagnosis, investigation or management which were considered difficult for even experienced anaesthetists. They were given a scenario with pertinent details missing and asked to make a clinical decision. As they did another piece of clinical information was given and so on. The residents were split into two groups and each did one part of the assessment in a quiet environment and the other part in a noisy environment. The noisy environment was recreated using background noise from real emergency situations. Residents were found to have significantly poorer performances in noisy environments than in quiet environments. Junior residents seem to be affected to a greater extent than more senior residents.

Noise can widely affect communication between various personnel in an operating theatre and is a risk factor for medical error. Therefore it should be limited wherever possible. Studies in novice surgeons have also found that they are more likely to make errors when working in a noisy environment. The implementation of awareness campaigns could be a way of raising awareness about this issue. Another option that has been suggested is the adaptation of ‘sterile cockpit rules’ to eradicate non-essential communication during critical phases. However, in reality the silent operating room is rarely a realistic concept. An alternative approach may be for anaesthetists to adapt to working in noisy conditions so that they can function in the invariable loud environments of certain emergency situations.

The Association of Frailty with outcomes and resource use after emergency general surgery: a population-based cohort study. McIsaac D, Moloo H, Bryson G et al. Anaesthesia & Analgesia 2017;124(5):1653-1661 doi:10.1213/ANE.0000000000001960 

Patients over 65 years old have surgery more often than any other age group. We know that a small subset of high risk patients have the highest morbidity and mortality rates (Pearse et al. 2006). Age is an independent risk factor of adverse postoperative outcomes and the likelihood for the patient to need increased resources. In April 2017 we looked at an article describing how frailty is an important condition that should be assessed more commonly. The presence of frailty increases exponentially with age so it is an important area to look at particularly for emergency surgery.

The effect of frailty on outcomes after elective surgery is well documented but there is less work done on the association between frailty and outcome or rescue use after emergency surgery. This study looked at residents in Ontario aged over 65 admitted for emergency surgery. Patients were assessed for frailty and the primary outcome was death within 365 days of surgery. 25.6% of patients (out of a sample size of 77,184 patients) were identified as frail. Death within 1 year of surgery occurred in 33.5% of frail patients as opposed to 19.8% of non frail patients. Not unexpectedly frailty was associated with many other adverse postoperative outcomes, in particular for patients admitted from home a 5 times increased chance of discharge to a rehab or nursing facility.

Perhaps surprisingly the mortality and complication rate were highest in patients having more common and lower absolute risk mortality procedures such as appendicectomy and cholecystectomy. This may be because these procedures are perceived as lower risk and therefore the presence of frailty may not have raised as much concern i.e. a greater willingness to take a higher risk patient to theatre for a smaller procedure. This is similar to the pattern that has been reported for elective surgery. Emergency surgery is very different to elective surgery in that there is not the same length of time to optimise patients. However, it is clear that efforts need to be made to improve risk assessment, care and outcomes for older frail patients in the unique setting of emergency surgery.

Early systolic dysfunction following traumatic brain injury: a cohort study. Krishnamoorthy V, Rowhani-Rahbar A, Gibbons E et al. Critical Care Medicine 2017;45(6):1028-1036 doi:10.1097/CCM.0000000000002404

Previous studies have suggested that traumatic brain injury (TBI) may affect cardiac function. Patients with moderate-severe TBI often have episodes of hypotension early in their hospitalisation which can lead to decreased blood flow to an injured brain. Other studies of non-TBI such as subarachnoid haemorrhage suggest that acute systolic cardiac function may be responsible for the early hypotension seen in catastrophic neurologic processes. A study published in Neurocritical Care Journal in 2011 suggests that the most commonly used vasopressor in this situation is phenylephrine. But fluid therapy and vasopressor selection may be better directed if the cardiac function is known. Patients with moderate-severe TBI were compared with patients with mild TBI. All recruited patients had a transthoracic echocardiogram the day following their injury. For patients with moderate-severe TBI the echo was repeated within 2-4 and 7-9 days of injury. The primary findings of this study are:

  1. Early systolic dysfunction can occur in previously healthy patients following moderate-severe TBI
  2. Systolic function recovers within the week following injury
  3. Younger age and greater TBI severity are independently associated with the development of systolic dysfunction early after TBI
  4. None of the patients with mild TBI had evidence of early systolic dysfunction

This study provides clinically important information. Previously episodes of hypotension in patients with TBI and no other injuries were thought to be due to the physiologic stress of the brain injury, fluid shifts and/or the effect of sedative. Knowledge of early systolic dysfunction may allow a more rationalised approach to fluids and vasopressor use. Prevention of systolic dysfunction by the addition of beta-blockers may be a consideration for the future – beta-blockers have already been associated with a survival benefit in TBI patients (Systematic review and meta-analysis published in Neurocritical care in 2014).

This is a small study but it does throw up some new information. Larger studies are now needed to confirm this and future research needed to looks at the factors associated with cardiac function and TBI and test therapies that may optimise cardiac function.