Written by Dr C. Williams

Sexual harassment in medicine – #MeToo. Jagsi R. New England Journal of Medicine 2017 doi:10.1056/NEJMp1715962

This is a short but highly interesting article looking at the phenomenon of sexual harassment in medicine. Currently it seems that not a week passes without the media filled with news of celebrities engaged in sexual misconduct. This article is written by a medical academic who has led a study of workplace sexual harassment in medicine. She describes the numerous incidents reported to her of sexual harassment in medicine and how victims often do not report incidents and the ones that do experience marginalisation, retaliation, stigmatisation and worse. Despite the #MeToo movement, reporting such behaviour is still not straightforward.

But what is sexual harassment. Working in an operating theatre still seems to be a male dominated environment and often an environment where lewd ‘locker-room’ humour dominates. But at what point does this humour cross the line into sexual harassment? One only has to have a few conversations with other healthcare professionals to start to hear stories, often told in jest, of incidences that clearly cross this line. I too have multiple stories which when looking at them objectively are clearly examples of unacceptable behaviour. I was relating one such experience to a colleague as a humorous story (which it was – although not so much at the time). I was asked to formally report the event……..but I didn’t, for several reasons, not least the concern that it would effectively be career suicide. This is also touched upon in the article.

This article concentrates on females being subjected to sexual harassment. But females aren’t the only ones affected. I have witnessed a male colleague being harassed by a bay of 80-plus year old female patients. If the situation had been reversed then I suspect there may have been a different attitude to the event by the female nursing witnesses.

The article mentions an interesting concept devised by academic astronomers. They recognised that mandatory reporting dissuades people so developed a rescue system, or a list of ‘astronomy allies’. These are senior female astronomers who wear prominent buttons at national society meetings and make themselves available to remove colleagues from problematic situations (www.astronomyallies.com). The aim is to provide ‘judgement-free’ help if someone believes it is needed. As the author points out, it raises questions about our society and how sexual harassment is viewed that such a system is required in a professional setting. Maybe such a system is needed in medicine. Much work is clearly still needed on this but the fact we are now openly talking about is a start.

Risk of epilepsy in surgical patients undergoing general or regional anaesthesia. Chang HC, Liao CC, Chang CC et al. Anaesthesia 2017 doi:10.1111/anae.14099

This study looks at the rates of new-onset epilepsy occurring in patients after surgery where they have had either a general or a neuraxial anaesthetic. It is well known that patients who have epilepsy, especially poorly-controlled epilepsy, are at risk, as are patients undergoing brain surgery, open-heart surgery or liver transplantation. But new-onset epilepsy is not something generally that many anaesthetists would consider although both stress and anaesthetic medication have been associated with epilepsy. Previous studies looking at this issue have had many limitations. This nationwide retrospective cohort study of patients in Taiwan sought to evaluate the one-year risk of epilepsy after surgery in patients receiving general or neuraxial anaesthesia.

The Taiwan National Health Insurance Research Database was used to identify patients. Over 200,000 patients were included in each group (general or neuraxial anaesthesia). During the one-year follow-up period the incidence of postoperative epilepsy after general anaesthesia was 0.41 per 1000 and after neuraxial anaesthesia 0.32 per 1000 persons. Compared with patients who had neuraxial anaesthesia, the risk of postoperative epilepsy significantly increased in patients with general anaesthesia when co-existing medical conditions and postoperative complications were included.

This study raises questions about the epileptogenic effects of various anaesthetic agents. But it has limitations. Information about blood biochemistry, lifestyle factors, genetic susceptibility, drug use and the anaesthetic agents used is not available on the database and these could have significant impact on the risk of developing seizures post-operatively. Further clinical studies are needed to be able to draw and firm conclusions.

Doppler-guided goal-directed fluid therapy does not affect intestinal cell damage but increases global gastrointestinal perfusion in colorectal surgery: a randomised controlled trial. Resigner KW, Willigers HM, Jansen J et al. Colorectal disease 2017;19(12):1081-1091 doi:10.1111/codi.13923

Fluid management for colorectal surgery has been much debated recently – should we aim for a restrictive fluid regimen or more liberal fluid treatment? It has been suggested that both restrictive and liberal fluid regimens induce hypo perfusion, the former due to local tissue oedema and the latter due to hypovolaemia. It is also now thought that fluid management in the first hours following surgery may be as important as intra-operative fluid management in improving tissue perfusion and oxygenation. Goal directed fluid therapy (GDFT) has been proposed as a way to reduce complicaations, mortality and length of hospital stay after major colorectal surgery. This study hypothesised that oesophageal doppler guided GDFT as opposed to standard fluid therapy decreased intestinal injury and improved gastrointestinal perfusion during surgery and in the first few hours after surgery.

Patients having elective colorectal cancer surgery with a primary anastomosis were enrolled either to have doppler guided GDFT or standard fluid therapy. All patients had an oesophageal doppler probe inserted and this was kept in situ for a maximum of six hours postoperatively or until the patient could no longer tolerate the probe.

Intestinal damage was determined by measuring intestinal fatty acid binding protein (I-FABP) plasma levels with increasing levels said to correlate with gut-hypoperfusion. Gastric tonometry measuring the intramuscosal carbon dioxide pressure was used to detect gastrointestinal hypoperfusion with the gastric tonometry catheter also left in place for six hours postoperatively.

Interestingly the amount of fluid given did not differ between the intervention and the control groups. The results also showed no difference between the I-FABP levels although the gastric tonometry results indicated better global gastrointestinal fluid perfusion in the intervention group. The clinical outcomes were not statistically analysed but there seems to be relatively little difference between the two groups, although the patients in the intervention group stayed a median of 11 days in hospital as compared to the control groups median of 8 day stay!

Unfortunately this study fails to shed any more light on the best way to manage fluid therapy during major colorectal surgery. Although the authors state that the gastric tonometry results indicated better global gastrointestinal perfusion it is not actually known whether gastric tonometry correlates with colonic perfusion. It is unlikely that these findings will affect current clinical practice anytime soon.

Sugammadex and oral contraceptives: is it time for a revision of the anaesthesia informed consent? Cora DM, Robards CB. Anesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000002677 

This is an interesting letter to the editors raising concerns abut potential issues for women on oral contraceptives who receive sugammadex in the perioperative period. Sugammadex administration can cause certain drugs, including oral contraceptives, to becomes less effective due to lowering of the free plasma concentration. The letter goes on to point out that the drug information that comes with sugammadex states that ‘in vitro binding studies indicate that Bridion may bind to progestogen………the administration of Bridion is considered equivalent to missing dose(s) of oral contraceptives containing oestrogen or progestogen’. The makers of sugammadex recommend that is the patient is taking oral contraceptives and receives a dose of sugammadex then they should be advised to use an additional non-hormonal contraceptive method for the next 7 days.

Sugammadex is not the only drug administered in the perioperative period that could affect oral contraceptives. Many of the routinely used antibiotics can have a similar effect. Currently, there is little emphasis on discussion and counselling patients about these potential drug interactions. The authors suggest that a revision of the anaesthetic consent should contain a general statement to make patients aware that certain medications given during the anaesthetic may interfere with the effectiveness of oral contraceptives. Maybe this is needed but a good starting place would be raising awareness of the issue amongst anaesthetists – in my questioning of a cross-section of anaesthetic colleagues about this issue, no one was aware that sugammadex may interfere with oral contraceptives.

Surgery and discontinuation of angiotensin converting enzyme inhibitors: current perspectives. Bardic N, Povsic-Cevra Z. Current Opinion in Anesthesiology 2017 doi:10.1097/ACO.0000000000000553 

Angiotensin-converting enzyme inhibitor (ACEIs) have been used since the 1970s to treat hypertension with angiotensin II receptors blockers (ARBs) introduced in the 1990s. These medications, collectively known as renin-angiotensin system or RAS antagonists) are thought to work be four different mechanisms:

  1. Cardiovascular protection via reduction of ischaemia
  2. Improvement in cardiac function and short-term survival after myocardial infarction
  3. Antihypertensive effects
  4. Delay in nephropathic progression in diabetic patients

Their use in the perioperative period continues to be a subject of debate. Although the general consensus amongst many anaesthetists is that these drugs should be omitted during the perioperative period in the context intraoperative vasoplegia, previous studies and review articles fail to make any clear recommendations. Multiple studies suggest that patients who take ACEIs or ARBs to treat hypertension are at increased risk of developing severe prolonged hypotension intraoperatively, commonly immediately after induction of anaesthesia.

A large multicentre study published in 2017 (as part of the VISION study) compared patients given ACEIs or ARBs on the day of surgery versus withholding them for 24 hours preoperatively. Their findings suggest that withholding RAS antagonists before major non-cardiac surgery was associated with less risk for complications or death. However, the data from this study had various limitations and it is important to note that withdrawal of ACEIs after surgery is associated with a significant risk of fatal and nonfatal complications postoperatively.

Overall, this article gives a good summary of the recent evidence surrounding RAS antagonists during the perioperative period but still does not provide an answer to the question of whether these drugs should be withheld before surgery or not. It does makes some sensible suggestions as to how to manage these patients:

  • The decision to discontinue RAS antagonists should take into account the original indications for their use, the patient’s clinical status, variability in the patient’s blood pressure and the type of surgery
  • Special attention is needed in surgery with presumed larger blood loss or haemodynamic instability
  • If ACEIs or ARBs are discontinued, they should be restarted as soon as the patient’s condition allows.

Postoperative nausea and vomiting after unrestricted clear fluids before day surgery: a retrospective analysis. McCracken GC, Montgomery J. European Journal of Anaesthesiology 2017 doi:10.1097/EJA.0000000000000760 

Nil by mouth timing remains a contentious issue and a topic that continues to be discussed to great extent in the literature. Current European guidelines encourage the intake of oral fluids until up to two hours before induction of general anaesthesia. The reality is that many patients continue to be starved from the early hours of the morning before surgery and that it is difficult to give patients a true two hour cut-off time for clear fluids.

This study was carried out at Torbay Hospital Day Surgery Unit with a change in the day surgery policy permitting unrestricted clear oral fluids up until the time of transfer to theatre. The aim was to assess the incidence of postoperative nausea and vomiting (PONV) before and after the change to unrestricted pre-operative clear oral fluids.

A total of 11500 patients who received either sedation, general anaesthesia, regional anaesthesia or a combination were included. The results showed a reduction in PONV from 5.2% in patients who could not drink within 2 hours or surgery to 3.8% in patients who had unrestricted clear oral fluids. This suggests that the liberal consumption of clear fluids before the induction of day case anaesthesia reduces PONV.

During the time of the study there were no recorded adverse events of pulmonary aspiration of gastric content requiring patient admission. Since the conclusion of the study a further 10487 patients have undergone surgery on the ‘new’ day surgery pathway which continues to include liberal preoperative clear fluid consumption. During this time there was one episode of aspiration by a patient breathing via a supraglottic airway – the review of the case would suggest that possibly a supraglottic airway was not the most suitable choice for this patient!

This study does seem to present a strong argument that allowing clear oral fluids up until the time of transfer to theatre in day surgery patients is safe, reduces PONV, is not associated with increased episodes of aspiration and gives an improvement in patient satisfaction.