Welsh Anaesthetic Trainees Journal Club


November 2017

Journal Club 28th November 2017

Fluid therapy in the perioperative setting—a clinical review

Journal of Intensive Care. 2016;4:27. 

Presented by Dr. M. Creed


  • Perioperative hypovolemia and fluid overload have effects on both complications following surgery and on patient survival.
  • Therefore, the administration of intravenous fluids before, during, and after surgery at the right time and in the right amounts is of great importance.
  • This review analyzes the literature concerning perioperative fluid therapy in abdominal surgery and provides evidence-based recommendations for clinical practice.

Design & Setting

  • Clinical Review Article


  • Preoperative oral or intravenous administration of carbohydrate containing fluids has been shown to improve postoperative well-being and muscular strength and to reduce insulin resistance. Hence, the intake of fluid (preferably containing carbohydrates) should be encouraged up to 2 h prior to surgery in order to avoid dehydration.
  • Excessive intravenous fluid administration adds to tissue inflammation and edema formation, thereby compromising tissue healing.
  • During major abdominal surgery a “zero-balance” intraoperative fluid strategy aims at avoiding fluid overload (and comparable to the so-called restrictive approach) as well as goal-directed fluid therapy (GDT). Both proved to significantly reduce postoperative complications when compared to “standard fluid therapy”.
  • Trials comparing “restrictive” or zero-balance and GDT have shown equal results, as long as fluid overload is avoided in the GDT group as well (categorized as “zero-balance GDT”).
  • It is possible that high-risk surgical patients, such as those undergoing acute surgery, may benefit from the continuous monitoring of circulatory status that the GDT provides. Data on this group of patients is not available at present, but trials are ongoing.


  • In elective surgery, the zero-balance approach has shown to reduce postoperative complications and is easily applied for most patients.
  • It is less expensive and simpler than the zero-balance GDT approach and therefore recommended in this review.
  • In outpatient surgery, 1–2 litres of balanced crystalloids reduces postoperative nausea and vomiting and improves well-being.


  • Good review of literature, assessing/referencing 71 papers.
  • Data well presented for comparison between trials (Tables 1, 2) and also including data from selected meta-analysis (Fig 1).


  • An overview of a very broad subject, therefore wide ranging.
  • Review not conducted as a Systematic review and no description of search methodology in arriving at source articles.
  • No meta-analysis of reviewed data other than that taken from other articles.

Potential for impact

  • Provides focus to reflect on perioperative fluid management.
  • May provide opportunity to alter individual practice to reflect current evidence base.

Journal Club: 21st November 2017

Predicting postoperative morbidity in adult elective surgical patients using the Surgical Outcome Risk Tool (SORT). Wong DJN, Oliver CM, Moonesinghe SR.

British Journal of Anaesthesia 2017;119(1):95-105 doi: 10.1093/bja/aex117

Presented by: Dr Alex Cormack


  • Perioperative risk assessment is a key part of the consent process
  • Risk stratification tools also allow comparison between outcomes of different institutions
  • Morbidity following surgery can have a significant impact on quality of life and needs to be a consideration when considering surgical options
  • Morbidity is more common than mortality following surgery and potentially provides a more sensitive measure of comparison between different healthcare providers
  • P-POSSUM and POSSUM are currently the most frequently used tools for perioperative risk prediction


  • Physiological and Operative Severity Score for the enumeration of Mortality and morbidity
  • Developed in the 1990s
  • For use in elective and emergency general surgical procedures
  • Does not apply to trauma patients
  • Calculated at the time the decision to operate is made
  • Variants include CR-POSSUM, Vascular-POSSUM and O-POSSUM
  • Requires 12 physiological and 6 operative parameters to calculate


  • Portsmouth modification of the Physiological and Operative Severity Score for the enumeration of Mortality and morbidity.
  • A variation of the POSSUM tool


  • Surgical Outcome Risk Tool
  • Developed after the 2011 NECEPOD report
  • Uses six parameters collected preoperatively
  • Designed to predict probability of 30 day mortality following surgery
  • The authors state that it ‘compared favourably with other previously validated risk stratification tools’ and ‘has been externally validated recently in a cohort of patients undergoing hip fracture surgery’.
  • Predictor variables: ASA grade (III, IV or V), surgical urgency (expedited, urgent or immediate), high risk specialities (GI, thoracic or vascular surgery), surgical severity (major or complex), malignancy, age (65-79 or >80)

 Design and Setting

  • Single centre prospective study at University College London Hospital to:

“develop and validate a new model to predict the likelihood of postoperative                       morbidity using predictor variables found in SORT, and then compare its      performance against POSSUM.”

  • 3 year period (June 2009 – May 2012)
  • Data collection carried out by trained research staff independent of the clinical teams responsible for the patient


Inclusion criteria:

  • Patients undergoing elective major inpatient operations
  • 1934 patients included

Exclusion criteria:

  • Patients with duplicated or missing data
  • Patients who did not have POMS (Post Operative Morbidity Survey) scores recorded on Day 7


  • Data collected:
    • 1934 patients identified, 1583 patients included
    • 58% female
    • 45% orthopaedic and 39% abdominal procedures
    • 6 deaths within 30 days of surgery
  • Data excluded:
    • 351 patients excluded
    • Missing predictor variables: DOB, ASA status, surgical speciality, malignancy status
    • Missing POMS outcomes: duplicated or missing entries
    • Clear summary of reasons for exclusion, no patients unaccounted for
  • POMS administered prospectively to patients at several time points postoperatively (day 3,5,7 or 8, 14 or 15 and 21)
  • Morbidity outcome measure selected was POMS-defined morbidity recorded after postoperative day 7 or 8
  • Data randomly split into two groups
    • 1/3 validation group (n=527)
    • 2/3 derivation group to define new model (n=1056)


  • Predictor variables from the original SORT variables were adjusted to generate SORT-morbidity models
  • Outcome variable was set as the presence of POMS defined morbidity on postoperative day 7 or 8
  • SORT-morbidity models then tested in the validation group using statistical analysis
  • Final model then tested against POSSUM


  • No statistically significant difference between new SORT-morbidity model and POSSUM at discrimination of morbidity at 7 days post surgery
  • Linear shrinkage factors estimated to improve prediction of morbidity at later time points


  • New SORT-morbidity model is comparable to POSSUM at prediction of morbidity 1 week post operatively
  • Linear shrinkage factors can be applied to improve morbidity prediction further in the postoperative course


  • Morbidity is an important consideration within the surgical consent process
  • Data collection carried out by research staff independent of clinical teams
  • Clear documentation of reasons for exclusion
  • Good number of data sets
  • New SORT-morbidity model found to compare favourably to POSSUM
  • POMS is a validated measure of morbidity to use in data collection


  • Morbidity defined as POMS defined morbidity after day 7
    • Patients discharged prior to this time period excluded despite possible morbidity
  • Only looked at elective patients
  • Single centre study
  • Unequal representation of surgical specialities
  • Comparatively low mortality rate (0.31%) documented – the authors comment that rates of 0.37-0.67% have been documented elsewhere in the literature
  • POMS domains include some relatively minor measures of morbidity that may influence the results (for example urinary catheter following elective urology cases)
  • Required ‘linear shrinkage factors’ to enable morbidity to be predicted later than 7 days postoperatively

Implications and Potential for Impact

  • Possible development of a new tool to use alongside existing risk assessment tools
  • SORT-morbidity was only used in elective cases and therefore could not be used in a CEPOD setting without further studies
  • Potential for further studies to develop the SORT-morbidity tool for more widespread use
  • P-POSSUM currently universally understood amongst the theatre MDT whereas SORT is less widely understood
  • SORT and SORT-morbidity require fewer variables to calculate, however this is less relevant as SORT-morbidity has only been developed using elective cases

The use of SORT-morbidity as an alternative to P-POSSUM does not yet seem a realistic prospect. P-POSSUM is understood amongst surgical and anaesthetic professionals and allows management decisions to be made appropriately. It is used for both emergency and elective patients, and arguably its most important use is in planning the management of emergency patients. This is an area that the SORT-morbidity tool has not been developed for. Further studies and multi-centre validation would be required before it could reliably be used in clinical practice.



Journal Club: 14th November 2017

Serratus plane block: a novel ultrasound-guided thoracic wall nerve block

Anaesthesia 2013;68:1107-1113 doi:10.1111/anae.12344

Presented by: Dr. A. Gańska


  • The serratus plane block is an alternative block to paravertebral block and thoracic epidural (which are more challenging and have higher potential side-effect profile
  • It can provide a long lasting analgesia for breast, axilla surgery and prevention of acute pain progressing to chronic pain
  • It has fewer side-effects, is safe and easy to perform

Design and Settings

  • Descriptive study on 4 volunteers and 3D reconstruction of local anaesthetic spread using fat-suppression MRI imaging


  • 4 female volunteers


  • USS guided injections, two per volunteer of solution of 0.4ml/kg 0.125% levobupivacaine mixed with 0.1mmol/kg gadolinium.
    • First superficial to serratus anterior
    • Second underneath the muscle at level of 5th rib in midaxillary line.
  • Thoracodorsal artery was used as an extra reference point


  • Test of sensory loss after 30min with hypodermic needle
  • MRI scan after 1h to show distribution of gadolinium
  • Two observers compared images with MRI atlases


  • T2 – T9 dermatomal paresthesia
  • Weak crossed-arm adduction movement


  • injection I: 752min duration of paresthesia for sensory nerves and 43min for motor nerves
  • Injection II: 386min duration of paresthesia for sensory nerves and 150min for motor nerves
  • MRI showed good spread with both injections

Study limitations

  • Descriptive study on volunteers
  • Small number of participants
  • Needs randomised controlled trial
  • MRI distribution of gadolinium may mimic fat tissue, image analysis software had to be used
  • Possibility of false impression of extent of LA spread – there was greater extension of the clinical effect then MRI suggested

Potential for impact

  • The serratus plane lock appears to give predictable and long lasting regional anaesthesia
  • Alternative to surgical LA infiltration, paravertebral blocks, thoracic epidural and intercostal nerves blocks
  • Compared with above this technique could be better for day case surgery
  • Superficial block was more effective

Journal Club: 7th November 2017

A Perioperative Smoking Cessation Intervention with Varenicline, Counseling, and Fax Referral to a Telephone Quitline Versus a Brief Intervention: A Randomized Controlled Trial

Anesthesia & Analgesia 2017;125(2):571-579 doi:10.1213/ANE.0000000000001894

Presented by Dr T. Sheppard


  • Smoking is addictive
  • High health burden with smoking-related diseases (but also high tax revenue)
  • Increased incidence of surgical complications associated with smoking
    • Wound
    • Pulmonary
    • Infection
  • Treatment with chemical & behavioural interventions is effective in reducing smoking in surgical patients – but has not been tested in a pre-op assessment clinic setting
  • Varenicline (Champix®) is effective in increasing abstinence in both surgical & non-surgical patients

Design & Setting

  • RCT
  • Open label
  • Prospective
  • Pre-op assessment clinic with 6 anaesthetists and 1 pharmacist delivering BOTH interventions


  • Elective ambulatory and inpatient surgery
  • Preoperative surgical clinics: general surgery, orthopaedics, urology, plastic surgery, vascular surgery, otolaryngology, ophthalmology, and neurosurgery
  • Smokers of at least 10/day with no abstinence for 3 months in past year
  • Equal proportions based on “Stage of Change” i.e. readiness to quit smoking


  • Patients with contraindications to varenicline (Champix®), pregnancy or breastfeeding, use of nicotine replacement therapy in last 3 months, use of tobacco products other than cigarettes


Randomised to either;

A 10- to 15-minute structured preoperative counselling session


Pharmacotherapy with a free 3-month supply of varenicline


An educational pamphlet


A fax referral to a quitline for proactive telephone counselling and follow-up


Control group that received brief advice regarding smoking cessation and quitline                information for self-referral



  • 7-day point prevalence (PP) abstinence at 12 months after surgery


  • Abstinence at 1, 3, and 6 months
  • Measurement of urinary cotinine (metabolite of nicotine) levels and expired-air carbon monoxide levels used to prove smoking cessation


  • 18-month period
  • 296 patients randomised (8570 pts screened, 1024 smokers, 788 excluded)
  • Significant increase in smoking abstinence in intervention group vs control (42.4% vs 26.2% (RR, 1.62; 95% CI, 1.16–2.25; P = .003))
  • Significant increase in PP of secondary outcome measures;
    • 1 month: 45.7% vs 25.5% (RR, 1.79; 95% CI, 1.29–2.49; P < .001)
    • 3 months: 46.4% vs 26.9% (RR, 1.72; 95% CI, 1.25–2.37; P ≤ .001)
    • 6 months: 45.0% vs 26.2% (RR, 1.72; 95% CI, 1.24–2.38; P < .001)


  • Smoking abstinence significantly increased in intervention group and was also sustained for a longer period
  • Increased nausea reported in the intervention group, but other complications were no different
  • Significantly greater effect on in-patients than day-surgery


  • Significant reduction in short-term and long-term smoking habits
  • Representative cohort of surgical patients


  • Observer bias – advice given by anaesthetists & pharmacist as opposed to independent researcher
  • Details of surgery were not explored
    • Malignancy
    • Prolonged in-patient stay
    • ITU stay
  • Open label – significant reductions in smoking in both groups
  • Multiple interventions in the intervention group
  • Which part had the biggest impact?
  • Free prescription of Champix® – would otherwise have to be paid for


  • The smoking cessation methods on display in this trial were very effective
  • Unclear what the potential for long-term outcomes would be compared with a “control” population re: wound healing, pulmonary complications

Potential for impact

  • Some form of smoking cessation advice for surgical patients would likely lead to some reduction in smoking habits
  • With the move to day-of-surgery-admissions it is difficult to find an appropriate time for discussion about smoking cessation
  • Pre-op clinics themselves are extremely busy and with all the other important pieces of information, would smoking cessation be lost in a cloud of do’s and don’ts before surgery?

November 2017

Written by Dr C. Williams

Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. British Medical Journal 2017;359:j4366 doi:10.1136/bmj.j4366

This is a very interesting article published during a time when the argument about males vs females rages on. One only has to do a quick google search to see some of these arguments relating to the medical profession – from female medics have better outcomes to how the high number of female doctors are destroying the NHS.

This population based, retrospective, matched cohort study looked at patients who had surgery between 2007 and 2015. It looked at death rates, readmissions and complications based solely on the sex of the surgeon. The results suggest that patients treated by female surgeons were less likely to die within 30 days but there was no significant difference in readmission or complication rates. This difference in mortality was small and whether it makes any difference to long term survival is unclear. Interestingly no differences were found for patients who were operated on in emergency situations.

This study was done in Canada where, unlike the NHS, patients can freely choose their operating surgeon. The differences seen for elective surgery would suggest confounding factors play a role. The lack of difference in patients having emergency surgery would back this up. So, although an interesting study it would not suggest that one should pick a surgeon based on their sex alone.

Effect of various duration of smoking cessation on postoperative outcomes: A retrospective cohort analysis. Turn A, Koyuncu O, Egan C et al. European Journal of Anaesthesiology 2017 doi: 10.1097/EJA.0000000000000701 

There is now a solid evidence base that smoking is an independent risk factor for perioperative complications. Smokers are 1.4 times more likely to die after surgery than patients who have never smoked. Active smokers also have higher risks of respiratory, cardiovascular and neurological adverse events and are more likely to have problems with infections.

Preoperative smoking cessation would be expected to reduce postoperative smoking and it would be reasonable to expect that longer period of abstinence would correlate with stronger benefits. But the optimal period of preoperative smoking cessation remains controversial. Several randomised trials conclude that 3 to 8 weeks of preoperative cessation reduce wound complications but briefer periods do not seem to reduce respiratory complications. However, a meta-analysis published in 2011 suggested that each additional week of smoking cessation has a significant impact in the reduction in post-operative complications.

Prospective evaluation of the effects of smoking cessation on postoperative outcomes is not easy – a substantial number of patients do not want to stop smoking and even among those that attempt to stop the success rate is thought to be about 50% which makes it difficult to recruit patients in the context of a defined protocol. This paper was a retrospective cohort analysis of adult patients undergoing non-cardiac surgery with the main outcome easier being the relationship between smoking cessation and in-hospital morbidity/mortality.

The summary of the results is that smoking cessation is associated with reduced in-hospital morbidity and mortality – importantly this was shown to be independent of the cessation interval. From a clinical perspective, patients should be encouraged to stop smoking regardless of the time period before surgery.

Incidence of venous thromboembolic events in enhanced recovery after surgery for colon cancer: a retrospective, population-based cohort study. Moms MI, Vendler TA, Haidari JE et al for the Copenhagen cOmplete Mesocolic Excision Study group (COMES). Colorectal disease 2017 doi:10.1111/codi.13910

Abdominal surgery in patients with cancer is associated with an increased risk of venous thromboembolism (VTE). Both the Danish and NICE guidelines recommend prolonged thromboprophylaxis with low-molecular weight heparin for 28 days after executive surgery for colon cancer. The evidence behind these guidelines relies on randomised controlled trials that included both benign and malignant colorectal disorders or colorectal abdominal cancers pooled with other gastrointestinal tract, urinary tract and gynaecological malignancies including palliative surgery. None of these trials included enhanced recovery after surgery (ERAS) programmes.  This study aimed to investigate the risk of symptomatic VTE in patients undergoing elective resection of colon cancer following an ERAS without prolonged VTE prophylaxis.

This was a retrospective analysis of patient who underwent surgery between 2008 and 2013. The median length of stay was 4 days. Of the 1893 patients included, 4 (0.2%) had a non-fatal symptomatic VTE. All 4 of these patients had other postoperative complications prior to the VTE. The rate of VTE found in this study is much lower that the overall 14% risk quoted after major abdominal or pelvic surgery.

It would appear that the risk of symptomatic VTEs is negligible in patients having colon cancer resection following an ERAS programme with an uncomplicated post-operative recovery. It may be that the early mobilisation in an ERAS programme may contribute to the lower risk. The findings of this study suggest that there is a possibility that prolonged VTE prophylaxis may not be cost-effective in these patients.

However, before any changes are made or guidelines rewritten – this is a retrospective study. It does raise questions but further randomised trials are needed to investigate this further.

Randomised feasibility trial of high-intensity training before elective abdominal aortic aneurysm repair. New GA, Batterham K, Colling J et al. British Journal of Surgery 2017 doi:10.1002/bjs.10669

Abdominal aortic aneurysms (AAAs) are usually asymptomatic until they rupture which then carries an overall mortality rate in excess of 80%. Elective surgery, either open or endovascular, is the most effective treatment for preventing AAA-related rupture and death. Open aneurysm repair in particular is associated with neuroendocrine, metabolic and inflammatory changes that lead to an increase in global tissue oxygen uptake of up to 50%. Patients who have a low cardiorespiratory fitness levels are less able to meet these extra demands which can lead to tissue hypoxia and life-threatening complications. A study published in 2010 found that up to half of the patients presenting for intra-abdominal surgery did not have the fitness levels to be deemed at low risk of perioperative complications as quantified by cardiopulmonary exercise testing.

It seems intuitive that improving cardiorespiratory fitness would lead to reduced complications rates after surgery. The clinical effectiveness and cost effectiveness of preoperative exercise testing has not yet been established. It is unclear whether meaningful improvements in cardiorespiratory fitness can be achieved for patients with a large AAA in the limited window available before surgery (usually 4-6 weeks). This study aimed to look at the feasibility and acceptability of high-intensity training (HIT) for preoperative optimisation of patients with a large AAA. Patients were either randomised to usual care or preoperative HIT consisting of three exercise sessions a week for four weeks.

The preoperative HIT seemed to be feasible and acceptable to patients although twenty of the twenty-seven exercise participants had to have their exercise aims adjusted due to triggering safety criteria (such as a systolic blood pressure over 180mmHg). This may have contributed to the fact that measured cardiorespiratory fitness did not change substantially at group level. However, the results seem to point to a beneficial effect of the exercise programme on health status and physical function for up to 12 weeks after hospital discharge.

This feasibility study points to the fact that preoperative exercise and improving cardiorespiratory fitness could be beneficial. Large, multicentre trials that explore clinical and cost effectiveness are needed before recommendations can be safely made about preoperative exercise programmes.

Echocardiography and passive leg raising in the postoperative period: A prospective observational study. El Hadouti Y, Valencia L, Becerra A et al. European Journal of Anaesthesiology 2017;34(11):748-754 doi:10.1097/EJA.0000000000000679 

Perioperative fluid management is a controversial and challenging issue. Both over hydration and conservative fluid therapy can lead to postoperative complications. The difficulty is that many patients have signs that could suggest hypovolaemia (such as oliguria, tachycardia and hypotension) but not all these patients will respond to fluid administration.

Passive leg raising has been demonstrated to simulate preload increase and distinguish fluid responders from non-responders. Studies validating passive leg raising have been carried out most frequently on non-surgical patients. In this study patients in whom low cardiac output was suspected in the immediate postoperative period were included. A baseline echocardiogram was done then repeated 90 seconds after the patients legs had been elevated by 45 degrees. The measurements were repeated after legs had been lowered and finally repeated again after 500mls of fluid administered as a bolus. An increase in cardiac output of greater than 11% after passive leg raising predicted a volume response following fluid with 68% sensitivity and 100% specificity.

This study had a very low sample size and a note is made of difficulty in carrying out the echocardiogram as left lateral decubitus position is best for the echocardiogram but passive leg raising in this position is not really possible. Despite the positive results the potential benefits or clinical uses of using echocardiography and passive leg raising to determine fluid responsiveness remain to be seen.

Acute kidney injury in trauma patients. Harris A, Libert N, Duranteau J. Current Opinion in Critical Care. 2017 doi:10.1097/MCC.0000000000000463 

Multiple organ failure is a later complication of severe trauma that substantially increases morbidity and mortality. Acute kidney injury (AKI) after trauma is associated with an independent association with prolonged hospital stay and mortality. Severe trauma is a time when several renal aggressions occur at the same time making it challenging to establish a strategy to prevent AKI. Factors such as haemorrhage, rhabdomyolysis, traumatic inflammation and renal hits due to emergency surgery or infections may cause acute renal disorders.

The incidence of severe AKI ranges from 9 to 23% and a total of 2 to 8% of trauma patient will require renal replacement therapy. The main risk factors for the development of AKI in trauma patients include haemorrhage, rhabdomyolysis, trauma inflammation, excessive fluid resuscitation and abdominal compartment syndrome.

Trauma care aims at stopping haemorrhage as soon as possible. The earlier this is achieved the better for tissue perfusion. Post traumatic vasoplegic shock can occur and in this situation attention should be paid to arterial pressure to try to optimise renal perfusion. Fluid resuscitation with balanced solute solutions seem to be the most beneficial for trauma patients with regards to AKI although there are no randomised controlled trials looking at this. What this paper makes clear is that AKI is a very real risk for trauma patients and once the initial trauma resuscitation has been carried out special attention should be paid to maintaining renal perfusion. Given the diverse nature of why patients develop AKI after trauma it is difficult to have one protocol to try to reduce the risk.

Sex differences in mortality after abdominal aortic aneurysm repair in the UK. Sidloff D, Saratzis M, Sweeting J et al.  British Journal of Surgery 2017;104(12):1656-1664 doi:10.1002/bjs.10600

Abdominal aortic aneurysm (AAA) screening has been shown to be effective in men both at reducing AAA-related mortality and in cost-effectiveness. Consequently there is now an established AAA screening programme for men over the age of 65 in England and Wales. The benefit of screening for women has not been established. However, one in seven elective AAA repairs are on women and women account for approximately one-third of all deaths from ruptured AAA. Furthermore women have a fourfold higher rupture rate than men at equivalent aortic diameters which suggests there is a strong case for intimating AAA screening in women. Perioperative risk is critical in determining the effectiveness of a screening programme and risk estimates are lacking for women having AAA repairs.

Data from the UK National Vascular Registry was analysed for a 4 year period from 2010 to 2014 with the primary outcome being in-hospital mortality. 13% of the patients included were women. Mortality rates were higher in women for both elective AAA repair (open or endovascular) and emergency repair. The excess mortality rate was found to be largely independent of age, aneurysm diameter and smoking status. It is not clear why this difference in mortality exists although the Canadian Society for Vascular Surgery Aneurysm Study Group identified that women are more likely to be older, have a positive family history of AAA and have significant aortoiliac occlusive disease.

A well designed trial of matched women and men undergoing elective AAA repair would be needed to explain the differences seen. The higher mortality rate in women may have an impact on the benefit offered by any AAA screening programme.

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