Written by: Dr C. Williams

Does the word ‘quiet’ really make things busier? Lam JN, Howard AJ, Marciniak J, Shenolikar A. The Bulletin of the Royal College of Surgeons of England 2017;99(4):133-136 doi:10.1308/rcsbull.2017.133

Many healthcare professionals are remarkably superstitious about saying the ‘Q’ word during a shift. It is a widely held belief that saying the word’ quiet’ will result in a substantial increase in workload. There is no hard evidence to prove this although plenty of anecdotal evidence! The aim of this study was to investigate precisely this idea that saying the word ‘quiet’ has the opposite effect. As the authors point out there is no reason why the principles of evidence-based medicine cannot apply to superstitious practices. This was a multicentre single blind randomized controlled trial. Night sessions were allocated to ‘quiet’ or not at the toss of the coin. This was done by the day orthopaedic registrar just before he attended handover at 8pm. On leaving handover the orthopaedic registrar either said ‘Have a quiet night. I’ll see you in the morning’ or ‘Have a good night. I’ll see you in the morning’. The primary outcome was the number of new referrals between 8pm and 8am that resulted in admission. The results showed that when the word ‘quiet’ was used there were a significantly higher number of admissions during the night-time period. The study suggests that avoiding the word ‘quiet’ could be a cost neutral, clinican-focused method to reduce workload on hosptials and ultimately have an economic benefit………….

Non-technical skills of surgeons and anaesthetists in simulated operating theatre crises. Doumouras AG, Hamidi M, Lung K et al. British Journal of Surgery 2017 doi:10.1002/bjs.10526

In April’s journal watch we looked at a paper which highlighted that teaching of non-technical skills is required at all levels of training including past-fellowship and beyond. This study aimed to look at the impact of non-technical skills in both surgeons and anaesthetists on the time it took to resolve a crisis in theatre. Surgical crises occur in approximately 1.5% of operation. Effective management needs an effective team and collaboration between all team members. Most of the research on non-technical skills has focused on routine operations. As many as 78% of claims highlight non-technical skills with a communication failure being the most common. This was a blinded observational study of surgeon and anaesthetist behaviours during simulated operating theatre crisis scenarions carried out at the Brigham and Women’s Hospital in Boston. The two different scenarios were intraoperative haemorrhage causing haemodynamic instability and a difficult airway resulting in hypoxia and an ultimate need for a surgical airway. Non-technical skills were assessed using the Non-Technical Skills for Surgeons (NOTSS) and Anaesthetists’ Non-Technical Skills (ANTS) rating systems. Surgeons had significantly higher NOTSS scores during the haemorrhage scenario whereas anaesthetists scored very similarly in both. Both groups had significantly higher scores before as opposed to during the crisis. Overall the study found that the most influential predictor of crisis resolution was the ANTS score – as the score increased the time to crisis resolution decreased. Not surprisingly a higher level of non-technical skills (task management, team working, situation awareness and decision making) led to faster crisis resolution. This may be an area where training can be focused for both surgical and anaesthetic trainees.

Randomised clinical trial of comprehensive geriatric assessment and optimisation in vascular surgery. Partridge JSL, Harari D, Martin FC et al. British Journal of Surgery 2017;104(6):679-687 doi:10.1002/bjs.10459

This was a study looking at patients aged 65 and over undergoing vascular surgery specifically elective aortic aneurysm repair or lower-limb arterial surgery. They were randomized to either have a standard preassessment or a preoperative comprehensive geriatric assessment and optimization. The primary outcome was the length of stay with secondary outcomes looking at new medical co-morbidities, postoperative medical or surgical complications, discharge to a higher level of dependency and 30-day readmission rate. The need for comprehensive geriatric assessment is becoming increasingly important as the number of older people undergoing surgical procedures is increasing. We already know that orthogeriatricians can have huge impacts on patient outcome from the work that has been done with orthopaedic and particularly elderly trauma patients. Vascular patients are a known high risk group with multiple risk factors such as smoking, hypertension, hypercholesterolaemia and a significant burden of undiagnosed cognitive impairment, high incidences of delirium, frailty and impaired functional capacity. This study looked at 176 patients – 91 allocated to standard preassessment (control) and 85 to the comprehensive geriatric assessment (Intervention). The mean length of stay was reduced by 40% or approximately 2 days in the intervention group. They also had lower proportions of postoperative delirium, cardiac complications, bladder/bowel issues and trends of lower infection rates and less need for blood transfusion. Having a comprehensive assessment meant that issues such as cognitive disorders, delirium risk, frailty and medical morbities were picked up beforehand. This meant that treatment could be started if needed and an appropriate perioperative plan put in place including longer term follow-up with primary care. These significant findings suggest that comprehensive geriatric preassessment may be of benefit to older patients having elective or emergency surgery across other surgical subspecialties.

Effects of hypercapnia and hypercapnic acidosis on hospital mortality in mechanically ventilated patients. Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M et al. Critical Care Medicine 2017 doi:10.1097/CCM.0000000000002332

Acute respiratory failure is a very common reason for ICU admission and may require invasive mechanical ventilation. With the adoption of lung-protective ventilation strategies to further prevent lung injury in these patients, hypercapnia and hypercapnic acidosis is seen more often. This was a multicentre retrospective study aiming to assess the impact of compensated hypercapnia and hypercapnic acidosis in patients receiving mechanical ventilation. A total of 252,812 patients were included and divided in to three groups – normocapnia and normal pH, compensated hypercapnia and hypercapnic acidosis. The highest mortality was seen in patients with hypercapnic acidosis and particularly hypercapnic acidosis during the first 24 hours of intensive care admission is more strongly associated with increased hospital mortality. The cause of the increased mortality was not clear from this study. Ultimately this study raises more questions and prospective controlled studies are needed to further clarify the effects of hypercapnia and hypercapnic acidosis. But it seems to support the control of carbon dioxide and pH encouraged by low tidal volume ventilation strategies used in the ARDS network study.

The implications of immunisation in the daily practice of paediatric anesthesia. Bertolizio G, Astute M, Angelo P. Current Opinion in Anaesthesiology 2017;30(3):368-375 doi:10.1097/ACO.0000000000000462

Vaccinations in childhood are a remarkable achievement in medical history. This is emphasized by the outbreaks seen in groups of children who are not vaccinated and the effects this can have on society. It is thought that vaccination prevents 2.5 million deaths worldwide each year. For vaccinations to be effective the child needs to develop an effective and antigen-specific adaptive immunity response which requires effective antigen-presenting cells (APCs). APCs consist mainly of monocytes, macrophages, endothelial cells, fibroblasts, fibrocytes and dendritic cells which help to process the antigen and present it to the adaptive immunity B and T lymphocytes. Surgery and anaesthesia are know to be immunosuppressive. There is a theoretical risk of altered responses to vaccines if surgery is performed too close to the time of vaccine administration (either just before or just after). The patient may be prone to vaccine-related complications dues to perioperative immunosuppression, alternatively surgical complications (such as fever or infection) may be misinterpreted as vaccine side-effects. The vaccination schedule is designed in order to maximize the efficiency of the immune system. A previous review in 2006 failed to reach a consensus in the delay of surgery after vaccination. The recommendations made by this paper include:

  1. Postpone and elective procedure that requires anaethesia rather than altering the vaccine schedule
  2. Postpone anaesthesia and surgery for 1 week after an inactivated vaccine is given (diphtheria, tetanus, pertussis, inactive polio, Hib and meningitis C)
  3. Postpone surgery and anaesthesia for 3 weeks after a live attenuated vaccine (measles, mumps, rubella, polio and BCG)
  4. If surgery cannot be avoided regional anaesthesia and the use of synthetic opioids rather than morphine cause less immunosuppression. The patient should be monitored closely after surgery.

Loss of resistance: a randomised controlled trial assessing four low-fidelity epidural puncture simulators. Pedersen TH, Meuli J, Plazikowski E et al. European Journal of Anaesthesiology 2017 doi:10.1097/EJA.0000000000000640

For a successful epidural insertion anaesthetists need to learn two important steps, firstly the correct identification of the epidural space and secondly the correct placement of the epidural catheter. Trainees can struggle with epidurals and it has been quoted that success rates may only be 80% after 90 attempts at epidural. This is lower than success rates for spinals (90% after 71 attempts) and brachial plexus blocks (87% after 62 attempts). Although the traditional way of learning was ‘see one, do one, teach one’ novices ideally now learn the technique on epidural simulators before transferring skills to clinical practice. Epidural simulators are designed to mimic the human lunar spine and usually incorporate an exchangeable puncture block. The price can vary a great deal (€1500 – 3000 is quoted in the paper). The ‘Greengrocer’s Model’ is quoted as an alternative to the epidural simulators – the banana has been described as the most suitable fruit to simulate the loss of resistance feeling. This study aimed to compare three commercially available epidural simulators with a banana. 55 consultant anaesthetists participated and they were blinded to which simulator they were using. They found that while none of the investigated simulators proved to be real substitutes for humans in learning the epidural technique they were useful in learning what a loss of resistance would feel like. Dedicated epidural simulators were statistically significant in providing a more realistic experience than the banana. But the rating were highly variable and the banana was comparable to the simulators in teaching the technique of loss of resistance. If identification of landmarks is not a key part of the simulation (and realistically landmarks can be taught clinically) then the banana may be a reasonable alternative to expensive simulators.

Challenging authority during an emergency – the effect of a teaching intervention. Friedman Z, Perelman V, McLuckie D et al. Critical Care Medicine 2017;XX:00-00 doi:10.1097/CCM.0000000000002450

Communication failures keep coming up as a threat to patient safety and have been the subject of extensive research. We already know that trainees or more junior colleagues are often unable to effectively challenge a senior’s wrong decision particularly during a crisis. This study aimed to assess whether a teaching intervention improved resident’s abilities to effectively challenge clearly wrong clinical decisions made by senior staff. Residents were randomized to either receive targeted teaching on cognitive skills needed to challenge a seniors decision or to receive general crisis management teaching. Two weeks after this teaching, they were put in a simulated crisis of a can’t intubate can’t oxygenate scenario and presented with opportunities to challenge clearly wrong decisions. Residents who had completed the targeted teaching were significantly better able to challenge the wrong decisions in this scenario. However, hierarchy-induced reluctance to speak up remains a major problem with significant implications for patient safety. We must make all trainees understand that it is their responsibility to speak up in these situation. Equally our senior colleagues must embrace open communication from their trainees and other junior colleagues. Senior team members have a responsibility to cultivate an environment in which ALL team members regardless of their training level are encouraged to speak up if they have any concerns.

Should pre-operative optimisation of colorectal cancer patients supersede the demand of the 62 day pathway? Sothisrihari S, Wright C, Hammond T. Colorectal Disease 2017 doi:10.1111/codi.13713

Pre-operative optimization (or prehabilitation) is becoming an increasingly important topic and is gathering momentum. For colorectal surgery, the benefits of thorough optimization before surgery are amplified by the epidemiology and pathophysiology of colorectal cancer. 58% of cases are diagnosed in patients over the age of 70 and in this group the incidence of other significant comorbidities is high. In patients over the age of 80, the post-operative 30-day mortality is 13-15% rising to double that at 60 days. Two-thirds of patients will not return to normal activity and require an increased level of support or package of care on discharge. However, in April 2015 the government in their election manifesto promised to reduce waiting times for cancers and pledged to reduce the current 18 month wait to 18 weeks from referral to operation. Cancer waiting times are now set at 62 days. Are we now doing a disservice to older patients in an attempt to meet targets? The 62-day target does not give the leeway a lot of patients require for proper preoperative optimization. Evidence increasingly suggests we may be doing more harm than good and not addressing risk factors can lead to longer hospital stays, higher infection rates, cardiovascular complications and increased mortality. Maybe the need for prehabilitation should ‘stop the clock’? Often when a full discussion on the reasons for delaying surgery is had with the patient most are happy to participate in prehabilitation. Not all patients require it but the ones that do should be identified with a proper pre-assessment process. As this paper points out this would require a central agreement from policy makers to adjust targets and recognize that sometimes individualized treatment plans correlate with better outcomes.