Written by: Dr C. Williams

Computed tomography during intitial management and mortality among hemodynamically unstable blunt trauma patients: a nationwide retrospective cohort study. Tsutsam Y, Fukuma S, Tsuchiya A, Ikenoue T, Yamamoto Y, Shimizu S, Kimachi M, Fukuhara S. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2017;25:74 doi:10.1186/s13049-017-0396-7

Commuted tomography (CT) is often used as an initial diagnostic procedure in the management of severe trauma. Often jokingly known as the ‘tunnel of death’ or the ‘doughnut of death’ CT scans do not feature in the clinical guidelines for managing a haemodynamically unstable trauma patient. However, it is starting to be used in cases of blunt trauma to identify the source of bleeding and assess for occult internal injury. Evidence for the effectiveness of CT for unstable patients is inconsistent with studies showing benefits, no difference and negative outcomes. This study aimed to examine the association between CT and mortality in unstable patients by retrospectively looking at the data for >5800 patients registered on the Japan Trauma Data Bank between 2004-2014.

The results found that patients who did not have a CT were more likely to have severe physiological conditions and a lower probability of survival than those having a CT. This could be because in Japan, over 90% of unstable blunt trauma patient receive a CT during their initial management. Therefore it stands to reason that if patients are too unstable to have a CT they are likely to have more severe injuries and a lower survival rate. After adjusting for confounding factors they also found that there was not a statistically significant association between CT and mortality.

From these findings the authors state that the results do not support the recommendation of the current guidelines that only haemodynamically stable patients should have a CT. However, and most importantly, the authors go on to say that in almost all hospitals in the database, the CT scanner is located in or very close to the emergency room allowing for rapid CT for unstable patients. Further studies are definitely required before dismissing the very real and serious risk of transporting an unstable patient through hospital corridors, sometimes in lifts to different floors and then putting them through the CT scanner. The decision to do this is not one that should be taken lightly.

Improving care for patients with pancreatitis. Siriwardena AK, O’Reilly DA. British Journal of Surgery 2017 doi:10.1002/bjs.10585

Acute pancreatitis is a condition that can still have mortality rates of up to 30% despite treatment. The mainstay of treatment is rapid diagnosis and instigation of treatment with early identification of patients likely to require critical care. This article summarises the comprehensive 2016 UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) review looking at the quality of care provided to patients admitted to hospital with acute pancreatitis. Published as ‘Treat the Cause’ it looked at the care of almost 15,000 patients from Wales, England and Northern Ireland during the first 6 months of 2014. Via a survey, multidisciplinary and independent notes reviews and assessing each hospitals infrastructure and support services the patient journey was assessed using the 2012 guidelines for the management of acute pancreatitis produced by the International Association of Pancreatology/American Pancreatic Association (IAP/APA). Overall care was regarded as reasonable with 45% of patients receiving ‘good practice’ care. However there were some key findings that stand out:

  1. In the early stages acute pancreatitis is not infective therefore antibiotic prophylaxis is not recommended. Despite this 61% of patients received prophylactic antibiotics potentially contributing to later problems including side-effects, emergence of antibiotic-resistant bacteria and unnecessary healthcare expenditure.
  2. Gallstone-induced acute pancreatitis should be treated by removing the cause i.e. cholecystectomy. Only 56% of hospitals reported that patients would undergo a cholecystectomy either during the index admission or within the first 2 weeks. This may be reflected by the fact that 30% of recurrent acute pancreatitis admissions were due to untreated gallstones. The recommendation is made that cholecystectomy for mild gallstone-pancreatitis during the index admission should be the standard of care.
  3. Modern management of pancreatitis requires multi-disciplinary care. As patients continue to be admitted to small and medium-sized hospitals this may not be possible as these hospitals may lack the 24-hour specialist care for optimal treatment – recommended as on-call pain team, gastroenterology, specialist surgery, pancreatology, interventional radiology and interventional endoscopy. The suggestion is made for pancreatitis multidisciplinary teams with reference to the Dutch Pancreatitis Study group which introduced a 24-hour/365-day online nationwide multidisciplinary expert panel to guide individual care and give advice on transfer.

The most important lesson from this NCEPOD report is that most of the improvements can be incorporated quickly into routine practice without the requirement for a large-scale financial investment or service reconfiguration.

In reality the second and third key findings may be more difficult to achieve without some degree of service reconfiguration. Cholecystectomies added to the emergency list invariably get delayed from day to day until they disappear from the list as they are often the least urgent cases. Maybe the surgical teams need to embrace this report and use it to highlight the need for ‘hot’ cholecystectomy lists to hospital management?

Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer. A randomized controlled trial. Ommundsen N, Wyller TB, Nesbakken A, Bakka AO, Jordhøy MS, Skovlund E, Rostoft S. Colorectal disease 2017 doi:10.1111/codi.13785

This randomised controlled trial looked at whether tailored interventions based on a preoperative geriatric assessment could reduce the frequency of postoperative complications in frail patients having surgery for colorectal cancer. Patients over the age of 65 and fulfilling the criteria for frailty were randomised to either the intervention group or usual care.

The intervention group underwent a preoperative geriatric assessment followed by tailored intervention – all performed during one session, as soon as possible after the diagnosis of colorectal cancer and surgery was planned. The optimal time from intervention to surgery was hypothesised to be approximately 3 weeks. Interventions were optimisation of medication for conditions such as atrial fibrillation, coronary disease, diabetes mellitus, renal failure and COPD, addressing nutrition and advice to increase calorific intake along with vitamin D and iron supplementation as needed and stopping inappropriate medciation such as antihypertensives if found to be hypotensive and nephrotoxic medication for patients with renal failure. Staff on surgical wards were instructed on measures to avoid postoperative delirium and patients were encouraged to maintain physical activity.

The primary endpoint was the incidence of postoperative complications, defined as any deviation from standard postoperative recovery. Perhaps unsurprisingly there was no difference in the complication rate between the two groups either for the primary endpoint or the secondary endpoints of length of stay, discharge to own home, readmittance, reoperation within 30-day or 30-day and three-month mortality figures. The intervention group did have a lower rate of less severe complications although not significant.

There are certain elements of this study that jump out immediately as cause for concern. Despite an inclusion period initially of 2 years and then prolonged to 3 and a half years only 122 patients were included. This seems a very small number and below the number calculated by the authors as required to power the study. This is recognised by the authors as a limitation. There were other limitations in this study which may have contributed to the lack of effect such as a very short time between intervention and surgery, no access to a multi-disciplinary team such as physiotherapy and occupational therapy, and suboptimal improvement in preoperative physical function. Furthermore, although the time from intervention to surgery was planned to be 3 weeks the initiation of the study coincided with a political decision to reduce waiting times for cancer patients and the time available for optimisation was reduced to a median of 6 days – to my mind this would not count as optimisation in any way.

The conclusion by the authors is that preoperative geriatric assessment and intervention is not effective. As the authors rightly point out further randomised controlled trials are needed to explore this further. This study highlights that although instinctively prehabilitation and particularly improving the patient’s preoperative functional ability seems the right and sensible approach, we have not quite reached a consensus on how to achieve this. It may also be coming to the point where the governmental targets need to address the fact that some patients would benefit from preoptimisation. Although they may have a cancer that needs an operation, the patient is more than just a cancer or a number for a target. Some patients need preoptimisation and without it can have a stormy perioperative journey, some may not survive. Regarding the patient as a whole entity rather than just a condition requiring surgery may be the way forward. These issues were looked at in both the June* and July** journal watch, both worth a read but with a particulerly interesting article by Sothisrihari et al. asking precisely the question about whether pre-optimisation of colorectal cancer patients should come before the 62-day pathway?

*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

**Prehabilitation in perioperative care. Moorthy K, Wynter-Blyth V. British Journal of Surgery 2017;104(7):802-803. doi:10.1002/bjs.10516

Preoperatively screened obstructive sleep apnea is associated with worse postoperative outcomes than previously diagnosed obstructive sleep apnea. Fernandez-Bustamante A, Bartels K, Clavijo C et al. Anesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000002241 

About 80 to 90% of patients with obstructive sleep apnoea (OSA) are undiagnosed when presenting for surgery. Additionally, rates of OSA are increasing in parallel with obesity rates. OSA is known to be associated with perioperative morbidity, but what is not know is whether patients with a day-of-surgery screened OSA diagnosis are also at risk of perioperative adverse events.

This study looked at retrospective data for almost 29,000 patients. Patients were groups as diagnosed OSA, pre-operatively screened OSA or no OSA. Patients with suspected OSA compared to those with diagnosed OSA had higher rates of postoperative reintubation, ventilation and critical care admission, prolonged length of stay in hospital and all-cause 30-day mortality even after adjusting for demographic, health and surgical differences. This study indicates that patients with suspected OSA are a group that fall into a high-risk population and would probably benefit from increased medical attention and focused care. The STOP-BANG tool has been found to have the best predictive value for OSA screening. This study highlights a common problem in that the inability to obtain preoperative diagnostic testing for OSA contributes to the high proportion of patients at moderate/high risk for OSA presenting for surgery without a formal diagnosis. The results of this study indicate that anaesthetists can reliably detect patients with suspected OSA who would fall into a high risk group for postoperative complications. Interestingly the risk for these patients is greatest beyond the immediate postoperative period. This echos the findings of the paper studied in the July journal watch.*

It could be that the worse postoperative outcomes seen in patients with suspected OSA is a reflection of a lack of awareness and appropriate postoperative management of the preoperative screening diagnosis of OSA. What is not yet clear is the best way to manage these patients. Admitting everyone to a critical care area for observation would not be feasible option in the majority of centres, but it is clear that these are a group of patients that may benefit from multidisciplinary interventions and a higher level of postoperative care.

* Postoperative respiratory complications in patients at risk for obstructive sleep apnea: a single-institution cohort study. Ramachandran SK, Pandit J, Devine S, Thompson A, Shanks A. Anesthesia & Analgesia 2017;125(1):272-279 doi:10.1213/ANE.0000000000002132

Regional anesthesia in diabetic peripheral neuropathy. ten Hoope W, Looije M, Lirk P. Current Opinion in Anesthesiology 2017;30:000-000 doi:10.1097/ACO.0000000000000506

Diabetes mellitus is a steadily increasing and underestimated problem. The prediction of more than 350 million diabetic patients worldwide by the year 2030 was passed in 2011. Consequently, the predicted number of diabetic patients by 2040 is set at 642 million. Approximately 10% of diabetic patients are symptomatic for diabetic neuropathy. Added to this fact is that diabetic patients are estimated to require surgery at least twice as often as non-diabetic patients and due to their comorbidities and the types of surgery performed they are more likely to undergo procedures under regional anaesthesia such as creation of arteriovenous fistula.

Regional anaesthesia is generally well tolerated but neuropathy may alter the way nerves respond to nerve blocks or neuraxial techniques. There is no current consensus on whether regional techniques should be avoided or need to be adapted in these patients. The pathophysiology behind the development of diabetic neuropathy is complex. Chronic hyperglycaemia is thought to trigger several pathways initially leading to inflammation and oxidative stress then causing microvascular changes, local iscaemia and decreased axonal conduction velocity.

In practice the implications of these changes are:

  1. The threshold of nerve stimulation is markedly increased meaning ultrasound guidance rather than electric nerve stimulation is most likely safer.
  2. Nerve blocks last much longer in the presence of diabetic neuropathy – the precise mechanisms for this is not known and using clinically relevant doses no excessive toxicity of local anaesthetics have been demonstrated in animal models.
  3. If a peripheral nerve catheter is used, diabetes is an independent predispoising risk factor for infection.

Despite these findings the authors conclude that there is no good clinical data to suggest that regional anaesthesia should be withheld from diabetic patients.

Development and assessment of pictorial guide for improved accuracy of visual blood loss estimation in cesarean delivery. Homcha B, Mets EJ, Goldenberg MDF et al. Simulation in Healthcare 2017 doi:10.1097/SIH.0000000000000246 

It is known that visually estimating blood loss during surgical procedures is an inaccurate method. During caesarean section the decision to administer blood products is often influenced by the estimated blood loss combined with clinical signs. However, estimating blood loss at caesearean section is complicated by a large volume loss for a short period of time as well as the presence of amniotic fluid. Maternal physiological changes during pregnancy can also exacerbate existing underestimation and overestimation of blood loss. The decision to give blood products is a balance between the risk of a blood transfusion versus the risk of haemorrhage, shock and potential death.

Previous studies have shown that higher blood loss correlates with less accurate estimated blood loss. Early identification of postpartum haemorrhage is a key factor in patient outcome and should be recognized before clinical changes reflect significant blood loss. This study hypothesized that a pictorial guide depicting materials commonly used during caesarean section and various measured blood volumes with the addition of simulated amniotic fluids would improve clinician accuracy in visual blood loss estimates.

A simulated caesarean scene was used to assess the accuracy of blood loss estimation with estimates done before and after access to the pictorial guide with participants allowed 3 minutes to assess blood loss. Initially, 52% of participants estimated more than 25% above or below the actual blood loss volume. With the use of the pictorial guide clinicians became more accurate with 93% of anaesthetists and all obstetricans estimating within 25% of the actual blood loss value.

There were limitations to the study – it had a small number of participants, the number of nurses/midwives was too small to be analysed and it was a simulated scenario, not assessed in a clinical scenario. It does however highlight that an institution specific pictorial guide tailored to the materials used (swabs etc.) may help to improve estimated blood loss, identification of postpartum haemorrhage and ultimately improve management and patient outcome.

Intraoperative music application in children and adolescents – a pilot study. Buehler PK, Spielmann S, Buehrer A et al. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12935

Hospitalisation, surgery and anaesthesia may affect children or adolescents leading to new-onset maladaptive behaviour, emotional distress and trauma. Maladaptive behaviour can include separation anxiety, temper tantrums, night-time crying, enuresis, general anxiety or poor appetite and has been described in up to 50% of paediatric patients after general anaesthesia. Other common effects after surgery are pain levels and post-operative nausea and vomiting, the occurrence of which and the treatment may interfere with other behaviour related outcomes.

In adult patients, exposure to intraoperative music has been shown to significantly lower pain levels. This was a pilot study to look at the effect of applying intraoperative music to paediatric aptients and its effect on behaviour, pain, nausea and vomiting. Children aged 4 to 16 years scheduled for elective circumcision or inguinal hernia repair under combined general and regional anaesthesia were included. They all wore headphones intraoperatively and were either exposed to music or not. All staff involved were blinded. Post-operative behaviour was recorded by parents on day 7, 14 and 28 post-surgery using an adapted ‘Post Hospital Behavioural Questionnaire’.

This study showed that intraoperative music in children undergoing minor surgical procedures may reduce the incidence of post-operative maladaptive behavior within the first post-operative week. However, it does not affect post-operative patient comfort, pain level, nausea or vomiting. This was a pilot study with a small number of participant so there are still some unanswered questions. But on first glance music appears to be beneficial and be a non-invasive and feasible application with minimal cost and effort.

Randomized clinical trial of psychological support and sleep adjuvant measures for postoperative sleep disturbance in patients undergoing oesophagectomy. Scarpa M, Pinto E, Saraceni et al. on behalf of the QOLEC group. British Journal of Surgery 2017 doi:10.1002/bjs.10609

Sleep disturbance is a common problem in hospital patients. It is particularly severe in those patients requiring a stay in the intensive care unit (ICU) usually related to noise, light as well as the critical illness itself and treatment events. Disrupted sleep is associated with increased morbidity and mortality and often remains a significant issue at 6 months after discharge from ICU. Oesophagectomy is a complex operation with a 50% risk of medical or surgical complications. Each hospital varies slightly in its approach but post-operative admission to ICU is usually required for at least 1-2 days followed by strict monitoring on the ward for a further 4-5 days. During this time patients will usually have at a minimum a chest drain, a central line and a nasogastic tube. As well as causing discomfort they contribute to sleep disturbance. It is thought that by enhancing the quality of sleep after oesophagectomy early quality of life may be improved.

This was a randomised controlled trial aiming to assess the effectiveness of psychological interventions and/or sleep adjuvant measures on postoperative sleep disturbance following oesophagectomy. Patients were allocated to one of 4 groups: psychological counselling for support plus measures to reduce sleep-wake rhythm disorders during ICU stay (sleep adjuvant measures), psychological counselling alone, sleep adjuvant measures only or standard care.

The trial was terminated early due to a move to a different ICU. Consequently only small numbers of patients were included. However, the results suggest that psychological support did appear to improve the early postoperative quality of life and reduced the impairment on sleep quality, latency and duration. Sleep adjuvant measures (quiet corner of ICU, earplugs and eyemasks) made no difference. Additionally, psychological intervention led to a significant decrease in the need for hypnotic drugs which is an independent predictor of poor postoperative quality of life. Further studies would be needed to determine whether psychological intervention helps but it is clear that we should be addressing sleep issues early in our patients to aid postoperative recovery.