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Welsh Anaesthetic Trainees Journal Club

June 2017

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.

 

Journal Club: 7th June 2017

Objective model using only gender, age and medication list predicts in-hospital morbidity after elective surgery. Blitz JD, Mackersay KS, Miller JC, Kendale SM. British Journal of Anaesthesia 2017;118(4):5444-5550

Presented by: Dr C. Thomas

Background

  • Recognised need for objective, customised risk evaluation tool for elective surgery
  • For patient and physician
  • Aid informed consent
  • Improve safety by identification of high risk patients
  • Current models require physician input / lab data etc.
  • Aim – objective predictor of inpatient post op morbidity
  • Simple to use
  • Easy to include
  • Simple data – age, gender, list of medications
  • Hypothesis:
  • Gender, age and medication list could provide information about post-operative morbidity
  • Certain medications elevate risk
  • Simplified to number of medications / gender / age

Design and Setting

  • Review board approval – patient consent waived as no intervention mandated
  • Restrospective database study
    • Single centre
    • 2 year period
    • Electronic database (Clarity) – access to ICD-9 codes
    • ASA scores from anaesthetist at time (database)
  • Quaternary Care academic Centre – New York City
    • Large inpatient location, ambulatory locations
    • Patients with mod – high access to healthcare
  • Morbidity outcome was in hospital morbidity by
    • Post op complications – presence of any during admission
    • AF, PE, MI, VTE, CCF, Resp Failure, AKI
  • ICD-9 coding limited – excudes:
    • Haemorrhage, sepsis, cardiac arrest
  • Secondary database created:
    • 46 selected medications – presence or absence each patient (on admission)

Subjects

  • 26629 Adult surgical encounters (>18 years)
  • 02% separate patients, 16.98% >1 surgery/patient
  • Anaesthesia – GA / Regional / Neuraxial / Monitored anaesthesia care
  • Exclusions
    • Emergency surgery
    • No ASA score on database

Intervention

  • Developed predictive models for in hospital morbidity based on outcomes above
  • GAMMA – Gender-Age-Medications Morbidity Assessment
    • Morbidity based on gender, age and medications
    • Logistic regretion based on database
  • ASA-M
    • Morbidity using ASA score as independent variable
  • GAMMA-N –GAMMA-Number modification
    • Morbidity solely on gender age and number of medications
  • Binary logistic regression analyses – assessed for discrimination and power by c-statistic (binary outcomes ie yes or no to condition) – >0.8 indicates strong model.
  • Calibration assessed by Brier score (compares actual events with predicted). Score close to 0 suggests accurate.
  • Chi-Square for model significance.
  • Models developed with full data set and validated with k-fold cross validation – 10 folds.

Outcomes

  • Morbidity Risk from gender, age and medications
  • Morbidity Risk from ASA score
  • Morbidity Risk from gender, age and number of medications

Results

  • GAMMA – predicts post operative morbidity with high accuracy (c statistic 0.819, Brier 0.034)
  • ASA similar (c-statistic 0.827, Brier score 0.033)
  • GAMMA-N less predictive (c-statistic 0.795, Brier 0.050)

Conclusions

  • Authors conclude that combination of age, gender and medication list reliably predict post-operative morbidity.
  • Model has increased objectivity, can be used pre-operatively (lab values etc not required, different to models such as PPOSSUM)
  • Limited medical knowledge required therefore could be patient led.

Strengths

  • Large database
  • Authors recognise limitations
  • Easy to access data – on the whole not subjective (except ASA)

Weaknesses

  • Exclusion of haemorrhage, sepsis and cardiac arrest as complications
  • Other outcomes that patients would consider as morbidity? – very limited number of outcomes studied
  • Patient population – excludes limited resource patients – ? therefore not comparable nationally / internationally or patients not on medications for existing disease due to insurance limitations etc therefore risk may be underscored.
  • Limited list of medications included (46) therefore risk may be underscored for patients on less common or new medications etc. How would this be updated with advances in pharmaceuticals?

Implications

  • Difficult to assess from available information
  • If this tool was studied for other populations and proved accurate it could be implemented as a simple risk stratification tool for elective patients but further study would be required.

Potential for impact

  • Development of a patient led tool for risk assessment – patient led care
  • Pre-operative optimization – reduce their score by improving lifestyle etc to reduce medications
  • Risk stratification for allocation of resources? – such as elective joints requiring lowering of BMI before listed for surgery in some areas.

Journal Club: 2nd May 2017

A randomised double-blind trial of phenylephrine and metaraminol infusions for prevention of hypotension during spinal and combined spinal–epidural anaesthesia for elective caesarean section. McDonnell NJ, Paech MJ, Muchatuta NA, Hillyard S, Nathan A. Anaesthesia 2017;72:609-617

Presented by: Dr K. Kelly

Background

  • Preventing a substantial decrease in maternal blood pressure after spinal anaesthesia for caesarean section is considered fundamental to avoid maternal nausea, vomiting and syncope, as well as neonatal hypoxaemia and acidosis.
  • Maintenance of maternal systolic arterial pressure at near-baseline values has been recommended
  • Metaraminol has undergone limited investigation in obstetric anaesthesia for this purpose, particularly in comparison with phenylephrine.
  • Prophylactic vasopressor administration is commonly recommended to reduce maternal hypotension during spinal anaesthesia for caesarean section.
  • Ephedrine has largely been replaced by phenylephrine, because of improved maternal outcomes and reduced neonatal acidosis when using phenylephrine.
  • Authors hypothesised that use of a prophylactic metaraminol infusion to reduce maternal hypotension would not be inferior to phenylephrine infusion with respect to neonatal acid-base status.

Design and Setting

  • A randomised, double-blind, active control, parallel group, multicentre non-inferiority trial was to compare prophylactic infusions of phenylephrine and metaraminol in women undergoing elective caesarean section under spinal or combined spinal–epidural (CSE) anaesthesia.
  • The study was conducted at between February 2013 and June 2015 in two Australian Hospitals.

Subjects

  • Women of ASA 1–2
  • BMI 20–35 with a singleton term pregnancy,
  • Scheduled for elective caesarean section under spinal or CSE anaesthesia.

Exclusions

  • Diabetes, pre-eclampsia or other cardiovascular or cerebrovascular disease, a foetal abnormality or intra-uterine growth restriction.
  • Inadequate sensory block to cold sensation up to T4.

Outcomes

Primary outcome

  • The primary outcome was the difference in umbilical arterial pH between groups.

Secondary outcomes

  • Other neonatal acid-base measures,
  • Maternal haemodynamic changes.

Interventions

Neuroaxial Technique

  • 2.2– 2.5 ml hyperbaric bupivacaine 0.5% together with 15mcg of fentanyl.

Vasopressors

Commenced at the time of spinal injection.

  1. 30 ml/hr infusion of the study drug, equivalent to 50 mcg/min of phenylephrine (10mg in 100ml)
  2. 250 mcg/min of metaraminol (10mg in 20ml)

Results

  • The mean (SD) umbilical arterial pH was 7.28 (0.06) in the phenylephrine group vs. 7.31 (0.04) in the metaraminol group (p = 0.0002).
  • Apgar scores did not significantly differ between groups.
  • There was a higher incidence of hypotension, defined as systolic arterial pressure < 90% baseline, in the phenylephrine group.
  • There was a higher incidence of hypertension and severe hypertension (systolic arterial pressure > 110% and > 120% baseline, respectively) in the metaraminol group.
  • There was no significant difference between groups in the incidence of nausea, vomiting or maternal bradycardia.

Conclusions

  • There was a higher incidence of hypertension and severe hypertension (systolic arterial pressure > 110% and > 120% baseline, respectively) in the metaraminol group.
  • There was no significant difference between groups in the incidence of nausea, vomiting or maternal bradycardia.

Strengths

  • Well described outcome measures.
  • Well matched groups.
  • Statistical tests clearly outlined.

Weaknesses

  • Large proportion of CSE.
  • BMI may not represent local population.
  • It was conducted during elective surgery in healthy term pregnant women and infants.
  • Findings may not apply to premature infants or to the non-elective setting.
  • Based in two hospitals only

Implications

  • Metaraminol may be a viable alternative if phenylephrine is not available.
  • Use of infusions preferable to bolus dosing to pre –empt the predicted drop in blood pressure due to neuroaxial block.

Potential for Impact

  • Largest clinical trial to compare phenylephrine and metaraminol for the prevention of hypotension during spinal and CSE anaesthesia at caesarean section.
  • Should we move to infusions rather than bolusing?

Journal Club: 18th May 2017

Randomized Clinical Trial Of Preoperative Oral Versus Intravenous Iron In Anaemic Patients With Colorectal Cancer. Keeler BD, Simpson JA, Ng O, Padmanabhan H, Brookes MJ, Acheson AG on behalf of the IVICA Trial Group. British Journal of Surgery 2017;104:214-221

Presented by: Dr D. John

Background

  • Bad things
    • Anaemia – Common – 40% of colorectal cancer patients
  • Adverse associations with blood transfusion
    • Dose independent factors – Expensive, scarce, infection, immunological reactions
    • Dose dependent factors – Biochemical derangements, post-operative infections, length of stay, cancer recurrence, mortality
  • Connected things
    • Pre-operative anaemia and peri-operative blood transfusion
  • Good things
    • Correcting pre-operative anaemia
  • Anaemia in colorectal cancer
    • Almost always due to chronic blood loss
    • Can be corrected with iron therapy
  • Pre-operative recommendations
    • FBC 6 weeks before surgery
    • Oral iron should be first line (ideally until 3 months after restoration of ‘normal’ Hb
      • Cannot be used post-operatively
    • Intravenous iron should be used for those intolerant to oral iron
      • Can be used post-operatively
    • Erythropoetin should not be used (not cost-effective)
  • Peri-operatively
    • Consider transfusion when Hb below 80g/l
    • Give transfusion when Hb below 70g/l
    • Clinical assessment trumps transfusion triggers
    • Transfusion should be by single units
    • Above applies to those with cardiovascular disease

Objectives

  • Determine whether oral iron or intravenous iron is better:
    • At correcting pre-operative anaemia
    • At reducing the need for perioperative blood transfusion

Design and Setting

    • Ethical approval, trial registered
    • Multicentre randomised controlled trial
      • 7 UK sites
      • Transfusion practice in accordance with:
        • Joint UK Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee Guidelines for Surgery

Subjects

  • Patient selection
    • May 2012 – June 2014
    • Colorectal adenocarcinoma
    • Anaemia – ‘to 1g/dl [10g/l] below WHO definition of anaemia of <12g/dl [120g/l] for men and <11g/dl [110g/l] for women’
      • WHO definition of anaemia is 10g/l greater in both sexes – erroneous or poor expression
  • Exclusions
    • Clinical
      • Metastatic disease, pre-existing haematological disease, renal or hepatic failure, chemotherapy, iron contraindications – iron overload, allergy, symptomatic anaemia necessitating transfusion
    • Logistic
      • Children, prisoners, pregnant women, lactating women, women planning pregnancy, previous alimentary tract surgery (>50% of stomach or terminal ileum resected), urgent surgery, previous anaemia not due to colorectal cancer, incapable patients, planned blood donation for surgery, any other significant disease or disorder which may put the patient at risk or influence the trial result (investigator’s opinion), patient unable to comply with study’s requirements (investigator’s opinion), patient unwilling to disclose information to surgeon or GP,

Interventions

  • Randomisation
    • Web-based system
    • Stratified by sex and age
    • Independent of the trial investigaotrs
  • Blinding
    • None

Randomised to:

  • Oral iron
    • Ferrous sulphate 200mg bd until surgery (BNF recommends tds for treatment of anaemia)
  • Intavenous iron
    • Ferinject dosed by Hb and weight (as advised)
    • If two doses required 7 day interval given

How did they go about things?

  • First consultation
    • At least 14 days prior to surgery
    • History, physical examination, randomisation done
    • Iron administration commenced on same day (pre-existing iron supplementation discontinued – investigator should exclude?)
    • If second intravenous dose required then done a week later
  • Peri-operative
    • Pre-operative review (‘around the time of surgery’)
    • Day 2 following surgery
    • Interval reviews until first post-operative clinic (2-3 months usually)
      • End of trial (or if unresectable at surgery, if dead at death, if lost at discharge)
  • At each visit
    • Blood transfusion requirements assessed
      • Volume, date and complications noted
      • Electronic blood bank database and case notes reviewed
    • Hb, ferritin, transferrin saturations
      • Pre-trial and day before surgery
  • Other data recorded
    • Operative blood loss (suction, swab weight), volume and type of intravenous fluid used intra-operatively documented at the time
    • Tumour location, size and grade fom histology report

Outcomes

  1. Primary Outcome – Reduction in perioperative blood transfusion
  2. Secondary outcome – Correction of preoperative anaemia

Results

  • Population
    • Power calculations done – power of 90% of p<0.05
      • Assuming 1 unit difference between groups
      • 116 patients (accounting for drop-outs)
  • Statistics
    • Intention to treat
      • Non-Gaussian paired data used Wilcoxon signed rank
      • Non-Gaussin independent data used Mann-Whitney U
      • Gaussian data used Student’s t
      • Categorical data used Chi-squared
    • P<0.05 was cut off for significance
  • 116 patients
    • 55 to oral therapy
    • 61 to intravenous therapy
    • No demonstrable demographic difference
    • Median time between commencement of therapy and surgery was 21 days in both
    • 11 (6 oral, 5 intravenous) had surgery before 14 days of therapy (3 due to clinical reasons, 8 due to earlier date availability)
    • Median time between surgery and first out-patient appointment was 97 days for oral therapy and 87 for intravenous therpy
  • Adherence
    • Oral therapy by 91%
      • 3% (2 patients) reduced dose due to adverse reaction, 3% increased dose on clinical advice, 3% changed to ferrous fumarate
      • None converted to intravenous therapy
    • Intravenous therapy by 93%
      • 3.5% (2 patients) could not attend second appointment, 3.5% had surgery brought forward
      • 5.5% (3 patients) had post-infusion headache
      • 2% (1 patient) had a rash (oral antihistamines)
  • Cancelled surgery
    • 4 had surgery cancelled due to health decline
    • 1 died during anaesthesia
    • 1 unresectable
  • Blood transfusion (Primary outcome)
    • Pre-operative
      • Oral therapy – 2 patients
    • Intra-operative
      • Oral therapy – 6 patients
      • Intravenous therapy – 6 patients
        • No difference in number transfused (P=0.894)
      • No difference in volume transfused (P=0.863)
    • Post-operative
      • Oral therapy – 14 patients
      • Intravenous therapy – 10 patients
        • No difference in number transfused (P=0.470)
      • No difference in volume transfused (P=0.841)
  • Haemoglobin (Secondary outcome)
    • At recruitment – no significant difference
    • At surgery – significant difference
      • Median rise in oral therapy 5g/l (IQR -1.3 – 13.3), intravenous therapy 15.5g/l (9.3 – 25.8) (P<0.001)
      • Percentage still anaemic in oral therapy 90%, intravenous therapy 75% (P=0.048)
      • Percentage requiring iron therapy in oral therapy 54%, intravenous group 7% (P<0.001)
  • Other measures
    • At surgery
      • Median ferritin level in oral therapy 27.5mcg/l (IQR 17 – 51.5), intravenous therapy 558mcg/l (330-1085) (P<0.001)
      • Median transferrin saturation in oral therapy 9 (IQR 5 – 14), intravenous therapy 19 (16 – 29) (P<0.001)
    • At discharge
      • No difference in length of stay (6 days)
    • Mortality, morbidity, post-operative infection, grade of malignancy
      • No difference

Conclusions

  • Intravenous therapy better than oral therapy
  • No difference in transfusion
  • No difference in morbidity, mortality, length of stay
  • Intravenous iron not inferior
    • No significant adverse reaction

Strengths

  • Randomised controlled trial
  • Multicentre
  • Each centre followed the same transfusion practice in accordance with the Joint UK Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee Guidelines for Surgery
  • Asking a very relevant question

Weaknesses

  • Admitted limitations
    • Lower transfusion rate than expected
      • Higher rate of laparoscopic surgery than previous studies (and consequent lower blood loss)
        • Potential type II error (incorrect acceptance of null hypothesis)
        • Inadequately powered
    • Inadequate duration of therapy prior to surgery
      • Most studies suggest 21 days of therapy is inadequate
      • Would adherence be lower with longer duration of oral therapy in clinical practice?
    • Conflicts of interest
      • Ferinject manufacturer donated drug to most centres and have provided grants, honoraria and travel expenses to many of the paper authors

Implications

  • IV iron probably better than oral
  • Treating anaemia important

Potential for Impact

  • Study not well conducted but may reflect clinical reality
  • Potential for bias significant
  • Probably underpowered

Journal Club: 13th June 2017

Relevance of induced and accidental hypothermia after trauma-haemorrhage – what do we know from experimental models in pigs? Hildebrand et al. Intensive Care Medicine Experimental 2014, 2:16

Presented by : Dr A. Byford-Brooks

Background

  • ‘Lethal triad of trauma’ current model
  • Induced, rather than accidental hypothermia, in animal models has shown potential benefit including:
    • Anti-inflammatory
    • Haemodynamic
    • Reduction of metabolic stress
  • Coagulopathy still a concern
  • Method and technique of cooling could be key

Objectives

  • Benefits/Risks of induced hypothermia
  • Methods of inducing hypothermia
  • Magnitude/Timing/Speed/Duration

Design and Setting

  • Literature review up to July 2013
  • Porcine models of trauma, haemorrhage or combined trauma-haemorrhage
  • Accidental or induced hypothermia
  • Keywords: accidental hypothermia’, ‘spontaneous hypothermia’,‘induced hypothermia’, ‘therapeutic hypothermia’, ‘pigs’, ‘swine’, ‘trauma’, ‘injury’, ‘hemorrhage’, ‘fracture’ and ‘bleeding
  • 36 papers in total

Subjects

  • Porcine models
  • Haemorrhage

1. Controlled à CVC and/or arterial line as %BW

2. +/- Uncontrolled à Surgical insult e.g. Combos of visceral +/- vascular +/- bony trauma

  • Hypothermia

Range:10-35 degrees Celcius (33 deg commonest)

Time: 20mins – 11.5h (2hrs commonest)

Interventions

  • Delay until resuscitation
    • Approximately 0-30s for uncontrolled
    • Approximately 30-40min for controlled
  • Type of resuscitation fluid
    • Crystalloid/colloid (n=19)
    • Blood products (n=3)
    • Combination (n=10)
    • None (n=4)
  • Method of cooling
    • Intraperitoneal packs
    • Cold IVI
    • Cooling blankets
    • Icepacks
    • Roller pump (heparin-free) or CPB (heparin)
  • Method of warming
    • Intraperitoneal lavage
    • Warm IVI
    • Bair hugger
    • Roller pump or CPB
    • No warming

Outcomes

  • Endpoints
    • Mortality
    • Haemostasis
    • Correction of coagulopathy
    • Organ damage e.g. Lactate
    • Use and/or dose of agents being studied e.g. Factor concentrates or haemostatic agents

Conclusions

  • If normothermic – induce hypothermia after primary haemostasis in solid organ damage
  • If accidental hypothermia – correct until haemostats achieved then induce hypothermia (ICU)
  • Rapid cooling better than slow e.g. 2 degrees/min (roller pumps!)
  • Intracorporeal cooling better than extracorporeal (unless also rapid)
  • 34 degrees a good endpoint
  • For aortic trauma – DHCA not more than 60 mins and 10 degrees better than 5 degrees
  • Adequate anaesthesia and relaxation key
  • Rewarming around 0.5 degrees/h
  • No derangements in TEG, coag or Plt between 33-35 degrees
  • Hypothermia reduces plasma levels of inflammatory markers
  • Acidosis in some models due to increased fatty acid vs CHO metabolism and/or slow vs rapid cooling

Strengths

  • Early look at a controversial topic with live subjects
  • Considered multiple models of trauma
  • Compared cooling/rewarming goals and techniques
  • Duration and magnitude of hypothermia

Weaknesses

  • Studies
    • Huge variety in study protocols
    • Circumstances of trauma still artificial and unrealistic
    • Small sample sizes (often <50 total)
    • Type of anaesthesia variable
    • Resuscitation methods (i.e. Crystalloids)
    • Hypothermia often secondary to the study aim
  • Species-specific differences
    • Pigs are hypercoagulopathic compared to humans
    • Acute coagulopathy of trauma (ACOT) has yet to be demonstrated in pigs
    • Despite polytrauma and crystalloid+++, many studies could not induce a coagulopathy
    • Different haemodynamic physiology
  • Long-term effects not investigated
    • Rebleeding
    • Infection
    • Delayed rebound inflammatory response
    • Organ dysfunction on rewarming
    • Posttraumatic apoptosis
  • Subjects with ‘disease states’ not investigated
    • Human population older with comorbidites

Implications

  • Analysis of long-term outcomes not considered
    • Expensive
    • Essentially requires a staffed ICU for the pigs!
  • May lead initially to pragmatic, single-intervention studies on ICU in humans
    • For example in a similar manner to  post-operative cooling in a similar way to out of hospital cardiac arrest or traumatic brain injury
  • Investigation of role of roller pumps in tight thermoregulation and resuscitation

Potential for impact

  • Unlikely to alter current clinical practice with regards to the Lethal Triad
  • However studies suggest mild hypothermia to 34 degrees may not be as deleterious as we think

May 2017

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.

April 2017

written by Dr C. Williams

Frailty and anesthesia. Current Opinion on Anesthesiology. Shem Tov L, Matot I. 2017 doi:10.1097/ACO.0000000000000456

Frailty is increasingly becoming a subject discussed, particularly relating to the perioperative period. It was not until 2001 that the concept of frailty as a biological condition was identified. The phenotype of frailty is defined by the presence of three or more of the following criteria: self-reported exhaustion, poor grip strength, unintentional weight loss, slow walking speed and low physical activity. These characteristics have been demonstrated to be predictive for falls, hospitalisations, disability and death. They are also predictive for postoperative severe morbidity and mortality. There are numerous tools available to assess frailty. There is considerable debate as to whether frailty can be an interventional target. Measures that reduce the severity or prevalence of frailty would have huge benefits for individuals, families and society.

Prehabilitation, defined as the enhancement of preoperative condition of a patient, is a potential strategy for improving postoperative outcome. The Proactive care of the Older Patient undergoing Surgery (POPS) implemented at Guys and St Thomas’ NHS Trust, London is a pathway for the high-risk elderly patient having surgery and shows promising results. Widespread assessment of frailty is not common and we probably should be looking at this more often. What is important though is not just to identify frail patients but attempt to implement interventions to improve their perioperative outcome.

Impact of hepatobliary service centralisation on treatment and outcomes in patients with colorectal cancer and liver metastases. Valance AE, vanderMeulen J, Kuryba A, Botterill ID, Hill J, Jayne DG, Walker K. BJS 2017 doi:10.1002/bjs.10501

Colorectal cancer is the fourth most common cancer in the UK after breast, lung and prostate (Cancer Research UK). About 20% of patients with colorectal cancer have liver metastases at diagnosis. In this scenario, chemotherapy has a median survival of between 6-22 months. However, in suitable patients liver resection has 5 year survival rates of between 44 to 74%. In 2001 the English Department of Health recommended that hepatobiliary surgery should be centralised. This follows increasing evidence that centralisation of specialist surgical services creates units that treat higher-volumes of patients that have better patient outcomes.

This cohort study aimed to compare patients with primary colorectal cancer and liver metastases being treated at a hepatobiliary centre (‘hubs’) compared to those treated at a centre which did not offer hepatobiliary surgery (‘spokes’). The study highlighted the need for a standardised assessment and onward referral pathway with clearly defined and nationally agreed referral protocols for patients with metastatic colorectal cancer. Referring all patients with liver metastases would prove resource intensive as many patients would benefit from palliative treatment compared to resection. This is likely to be an increasing problem as more specialised services are centralised.

Solutions suggested in this article include video-conferencing, hepatobiliary surgeons attending colorectal MDTs at so called ‘spoke’ hospitals and an education programmes from hepatobiliary MDTs to colorectal cancer surgeons. Could this be the aim for future service development?

Surgical and not analgesic technique affects postoperative inflammation following colorectal cancer surgery: a prospective, randomised study. Siekmann W, Entree C, Magnuson A, Sjölander A, Matthiessen P, Myeloid P, Gupta A. Colorectal Disease 2017 doi:10.1111/codi.13643

We know that surgical trauma causes the release of both pro- and anti-inflammatory cytokines. These molecules affect a range of cells that have a major role in the body’s defence against infection and tumour metastases. The stress response from surgery is also known to suppress cellular immunity. The bigger the surgical trauma the greater the inflammatory response. We also know that the anaesthetic and analgesic drugs and techniques we use can affect the stress response, cellular immune response as well as the inflammatory response to surgery. To what extent this is significant is still being studied and we are learning more all the time. However, it has been demonstrated that epidurals reduce the stress response and can attenuate immunosuppression associated with major surgery. This study aimed to compare the inflammatory response in patients receiving epidurals versus those receiving intravenous morphine for analgesia. It also compared open surgery and laparoscopic surgery with regard to inflammation and stress response.

The study authors found that the choice of analgesic technique (epidural or I.V. opiates) had only a minor effect on postoperative inflammation. In contrast, the surgical technique (open vs. laparoscopic) influenced the inflammatory response. Patients having open surgery were found to have significantly higher concentrations of several pro- and anti-inflammatory serum cytokines during open surgery. Although they do note that this seems to be a short-lived response and there were no differences in cytokine levels after 3-5 days. This is not a conclusive study and possibly raises more questions than it answers but maybe for once, anaesthetists aren’t to blame…………….

Risk factors for severe postpartum haemorrhage after cesarean delivery: case-control studies. Butwick AJ, Ramachandran B, Hegde P, Riley E, El-Sayed Y, Nelson LM. Anaesthesia & Analgesia. 2017 doi:10.1213/ANE.0000000000001962

Severe postpartum haemorrhage (PPH) remains an important cause of maternal morbidity and mortality. Compared with vaginal delivery, women undergoing caesarean section have a higher risk of PPH. Evidence also suggests that PPH is occurring more frequently. In the US between 1994 and 2006, the rate of atonic PPH increased 160% among women undergoing caesarean section after induction and 130% in women having an elective caesarean section. The International PPH Collaborative group has called for more studies using clinical data to better understand relevant and potentially preventable risk factors associated with PPH. Risk factors included some that are expected such as general anaesthesia, multiple pregnancies, placenta praevia and chorioamnionitis. Some other risk factors for PPH were identified such as CSE anaesthesia, predelivery anaemia (especially if haemoglobin <9.9g/dL) Hispanic race, gestational diabetes, younger patients, those receiving government-assisted insurance and primary caesarean section. In all cohorts of patients studied general anaesthesia had the highest adjusted odds of severe PPH – whether this is related to the fact that many anaesthetists would choose to give a general anaesthetic to patients who have conditions such as placenta praevia is unclear.

Being able to identify the risk factors would be important to be able to plan resources and interventions for high-risk patients undergoing elective or intrapartum caesarean section.

Update on developmental anaesthesia neurotoxicity. Vutskits L, Davidson A. Current Opinion in Anesthesiology. 2017. doi:10.1097/ACO.0000000000000461

Adverse long-term impact general anaesthesia on the developing brain is a current hot topic. In January’s journal watch we briefly looked at a paper related to the ‘Drug Safety Communication’ warning issues in December 2016 by the FDA that repeated or prolonged (>3 hours) anaesthesia in children under 3 years old and in women in their third trimester may affect the development of children’s brains. This review looked at the most recent experimental and clinical observations. Evidence from rodent experiments strongly suggests that anaesthetics can result in long-lasting changes in neuronal plasticity. However, the two most robust clinical studies (General anaesthesia compared to spinal anaesthesia and Paediatric Anesthesia Neurodevelopment Assessment) did not find an association between brief exposure to anaesthetic agents and poorer neurodevelopment outcome.

Clearly, more research is needed to clarify this important issue. This review fits with the FDA warning which stated that ‘additional high quality research is needed’. Procedures requiring anaesthesia in this group of patients are rarely carried out if not absolutely necessary. The risk vs benefits of delaying or proceeding with anaesthesia should be considered on a case by case basis with discussion between parents and doctors. We should however be prepared to be increasingly questioned this topic as evidence continues to emerge……….

What do UK medical students value most in their careers? A discrete choice experiment. Cleland J, Johnston P, Watson V, Krucien N, Skåtun D. Medical Education 2017 doi:10.1111/medu.13257

Medical workforce planning involves attempting to predict demand and supply of healthcare professionals to meet the populations healthcare needs. The aim of medical education and training pathways is to provide appropriately trained and adequate numbers of doctors to fulfil this need. These predictions rely on doctors progressing through their careers in a predictable manner so maintaining the status quo. Yet currently nearly one in tow medical graduates leave training in the UK at the first opportunity to do so while keeping their options for returning open. What is not fully understood is the reasons behind this. Improved knowledge of the relative importance of different career-related values of senior medical students is essential in being able to encourage and support individuals to stay in the training system further down the timeline.

Earlier studies looking at foundation programme trainees and trainees at later stages of their careers found few differences in preferences suggesting that medical career preferences and values are usually formed prior to leaving medical school. This study focused on final year medical students with the objective to look at how medical students trade off different training position attributes when they choose their first training position. The study presented students with characteristics of training positions and choices of scenarios with a range of conditions. The aim was to looks at how much extra must a training position offer to compensate individuals for ‘poor’ rather than ‘excellent’ working conditions? This study revealed that the presence of good working conditions was the most influential characteristic of a training position.

Importantly this study was carried out well before the junior doctor contract issues and ensuing strikes. The conflict revolves around changes to working conditions which will result in the loss of pay for unsocial (weekend/evening/night) hours and requires the same number of doctors to cover longer rotas. The government are targeting the very job characteristic that is most valued by medical students. The ramifications of this conflict on medical workforce planning remain to be seen.

Alfentanil and rocuronium: an alternative to suxamethonium during rapid-sequence induction and tracheal intubation. Abou-Arab MH. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12877

A PhD dissertation abstract looking at the use of alfentanil and rocuronium for rapid-sequence induction (RSI). Traditionally, RSI uses a combination of thiopentone and suxamethonium. Rocuronium is now considered a suitable alternative to suxamethonium. However, it still has a slower onset of action. Opioids are now an integral part of a standard anaesthetic induction. Due its very rapid onset of action alfentanil may be a suitable drug to use in conjunction with rocuronium during a RSI.

The goal of this study was to look at the efficacy of alfentanil  and the dose needed to achieve optimal conditions for tracheal intubation, avoid the release of stress hormones and significant arterial blood pressure changes when used in conjunction with thiopentone and rocuronium. The results suggest that alfentanil with rocuronium represents an excellent alternative to suxamethonium during RSI. The full results and discussion are not yet available for will be interesting to see.

Non-technical skills of surgical trainees and experienced surgeons. Gostlow H, Marlow N, Thomas M, Hewett P, Kiermeier A, Babidge W, Altree M, Pena G, Maddern G. British Journal of Surgery 2017 doi:10.1002/bjs.10493

To ensure patient safety and to be a competent surgeon, or for that matter a doctor of any specialty, requires effective non-technical skills as well as technical expertise. Recently the Royal Australasian College of Surgeons introduced a curriculum incorporating non-technical skills that they considered essential for a competent surgeon. This study aimed to compare the non-technical skills of experienced surgeons who completed their training before the introduction of the new curriculum with the non-technical skills of more recent trainees. Surgeons were divided into subgroups according to their years of experience. They then undertook a simulated scenario designed to challenge their non-technical skills – the closure of an emergency trauma laparotomy – sounds simple but in true simulation style the patient soon deteriorated and haemorrhaged needing a blood transfusion, except the patient was a Jehovah’s Witness. There were also a whole host of other stressors such as distractions, interruptions and other factors relating to communication. The scenarios were video-recorded and assessed using the Non-Technical Skills for Surgeons (NOTSS) scoring system.

When comparing junior versus senior trainees, senior trainees generally achieved higher scores with some exceptions: situational awareness, gathering information, leadership and supporting others. But when comparing junior trainees to experienced surgeons the senior experienced surgeons achieved lower scores for all the NOTTS elements. Overall, there was an increase in the mean NOTTS score as trainees progressed towards fellowship. The scores peaked at or shortly after fellowship and then decreased linearly over time. This may not represent a true deterioration in skills with more experience. Some hypotheses include that more senior surgeons are used to working in clinical situations where they make the final clinical decision and also they may be used to making their decisions implicitly. The NOTTS score relies on surgeons explicitly articulating their thought processes. This generally comes naturally to trainees as they usually work alongside a supervisor where they need to explain their clinical reasoning.

What this study makes clear is that training in non-technical skills is required at all levels of training, including past the fellowship and beyond.

Journal Club: 28th March 2017

Myocardial injury after Noncardiac Surgery. A large, international, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors and 30-day Outcomes

Anesthesiology 2014; 120:564-78

Presented by Dr S. Tufail

 Background

  • Most studies focus on perioperative myocardial INFARCTION
  • Patients sustain myocardial injury in the perioperative period which will not satisfy criteria for myocardial infarction
  • These patients have a poor prognosis
  • Timely & appropriate intervention could potentially improve outcome
  • Proposed definition of myocardial injury after non-cardiac surgery (MINS)
    • Myocardial injury caused by ischaemic (that may or may not result in necrosis), has prognostic relevance and occurs during or within 30 days after non-cardiac surgery.
    • Does not include injury due to non-ischaemic etiology

 Primary Objective:

  • Inform the diagnostic criteria of MINS

Secondary Objectives:

  • Determine characteristics, predictors & 30 day outcomes of MINS

 Design and Setting

  • Used VISION data
  • VISION: The Vascular events In noncardiac Surgery patIents cOhort evaluatioN
    • Large (ongoing) international prospective cohort study
  • Evaluating complications post non cardiac surgery
  • Previous publication showed Troponin in the first 3 days after surgery were independent predictors of 30 day mortality

MINS Study

  • Analyzed VISION data
  • Evaluated troponin elevations until day 30 after surgery
  • Excluded non-ischemic troponin elevations
  • Adjusted for perioperative complications
  • VISION: First 15,000 patients had event rates three times higher than expected. Had enough data for MINS objectives

 Subjects

  • Eligible patients for VISION study:
    • Non cardiac surgery
    • Aged 45 years or older
    • General or regional anaesthesia
    • Elective or urgent/emergency surgery
    • Day or night
    • Weekday/weekend
    • 15,065 patients

 Intervention

  • Patients interviewed, examined & charts reviewed for potential pre-operative predictors of major perioperative complications
  • 4th generation Troponin T (TnT)
    • 6-12 hours post op
    • 1st day, 2nd day & 3rd day
  • TnT 0.04ng/ml or greater, lab threshold for abnormal at time study began
  • If TnT greater than/equal to 0.04ng/ml, assessed patients for ischemic symptoms & ECG
  • If patients developed ischemic symptoms during first 30 days, physicians encouraged to obtain TnT & ECG.

Outcomes

  • Primary Outcome:
    • Mortality at 30 days post op (Cause of death also reported
  • Secondary Outcomes:
    • Patients evaluated throughout hospital stay by research staff
    • Contacted patients 30 days post op-if patient or NOK indicated an event, patient’s notes were reviewed

Adjudicators:

  • Evaluated all patients with an elevated TnT (1st 30 days)
  • Presence of any ischemic features (? Myocardial infarction)
  • ? Non ischemic reason for raised TnT
  • Check myocardial injury occurred during or after surgery (ie. Not pre-op)
  • Their decisions used in statistical analysis

Statistical Analysis

  • Primary objective: MINS diagnostic criteria
  • Cox proportional hazards model
  • Dependent variable: Death up to 30 days after non-cardiac surgery
  • Independent variables
    • 9 pre-op characteristics (VISION stats)
    • 6 time-dependent perioperative adverse complications
    • Potential MINS diagnostic criteria

Potential MINS diagnostic criteria

  • Peak TnT ≥ 0.04ng/ml with one or more ischemic feature
    • If this- repeat analysis with exploration of impact of each individual ischemic feature on 30 day mortality to decide which to include in MINS diagnostic criteria
  • Peak TnT ≥ 0.04ng/ml without an ischemic feature
    • If this- planned to repeat MINS diagnostic criteria COX proportional hazard model with two more diagnostic criteria
    • TnT 0.02ng/ml & TnT 0.03ng/ml, without knowledge of ischemic features.
    • Reference group (TnT ≤ 0.01ng/ml)
  • After establishing MINS diagnostic criteria, determined the incidence & 95% CI of patients fulfilling these criteria
  • Patients who developed MINS determine incidence of each individual ischemic feature
  • Compared cardiovascular outcomes at 30 days for patients who did and did not suffer MINS (Fischer exact test)

Sample Size

  • Model to determine diagnostic criteria of MINS
  • Evaluated 19 variables
  • Required 228 deaths in the study

Results

  • Model to determine diagnostic criteria of MINS
  • Evaluated 19 variables
  • Required 228 deaths in the study
  • TnT ≥ 0.04ng/ml with one or more ischemic feature
  • TnT ≥ 0.04ng/ml with no ischemic feature
  • TnT ≥ 0.03ng/ml

ALL independently predicted 30 day mortality

  • Diagnostic criteria for MINS (Primary objective):
    • Any peak TnT of ≥ 0.03ng/ml that was judged as resulting from myocardial ischaemia
  • Total of 1200 patients (8%, 95% CI 7.5-8.4) fulfilled the MINS criteria
  • 1% of MINS events occurred within the first two days after surgery
  • 2% of patients suffering MINS did NOT experience ischemic symptoms
  • 9% with MINS did not have an ischemic ECG
  • 8% would have fulfilled definition of myocardial infarction
  • 12 independent predictors of MINS

Prognostic impact of MINS:

  • Increased risk of non-fatal cardiac arrest, heart failure and stroke
  • 30 day mortality rate:
    • 8% in patients who suffered MINS
    • 1% no MINS (OR 10.07; P<0.001)

Predictors of mortality among patients suffering MINS

  • Age ≥75 years
  • ST elevation/new LBBB
  • Anterior ischemic ECG

Discussion

  • MINS diagnostic criteria established
  • MINS was common (8%)
  • Associated with substantial mortality & CVS complications at 30 days
  • Populations-attributable risk suggests MINS explains 34% of deaths that occur during the first 30 days post op
  • 1 in 10 patients with MINS died within 30 days

Strengths

  • Large study
  • Prospective
  • Good follow up ( 99.7%)
  • Same Troponin assay

Weaknesses

  • Only measured TnT until day 3
  • Can only apply TnT threshold for that one assay
  • Did not assess for ischemic features with TnT 0.03ng/ml
  • May have missed non-ischemic reasons for raised TnT
  • A LOT of stats

Implications

  • Should we assess patients for MINS post op?
  • No established effective treatment
  • However, prognosis may be modifiable e.g. aspirin & statins
  • Need for clinical trials to establish strategies to prevent and treat MINS
  • Majority of MINS would go undetected without TnT measurement post op

Potential for Impact

  • ? Ensure modifiable CVS risk factors optimised pre-op
  • ? Increased vigilance in high risk patients
  • Realistically not going to routinely measure TnT post op in all patients
  • Should TnT be added to blood post op if being done anyway?

 

Journal Club: 1st March 2017

Children and parental anxiolysis in paediatric ambulatory surgery: a randomized controlled study comparing 0.3mg kg-1 midazolam to tablet computer based interactive distraction.

British Journal of Anaesthesia 2017;118(2):247-253

doi:10.1093/bja/aew436

Presented by Dr R. Morris-Clarke

Background

  • Having an operation is a stressful time for both parents and children
  • Induction of anaesthesia and parent separation creates fear and anxiety
  • May lead to post operative adverse behavioral changes
  • Midazolam and distraction techniques pre-operatively are common place
  • Premedication associated with unwanted side effects
  • Distraction techniques time consuming but cost effective
  • Previous study – children aged 1-11 given a computer tablet for distraction and showed an effective decrease anxiety

Design and Setting

  • Children’s Hospital of the University of Lyon, France
  • Patients admitted to the ambulatory surgical ward – elective
  • 16th May 2013 – 25th March 2014
  • Informed written consent from Parents and assent for children ages 7+
  • Patients randomized via computer programme to:
    • Midazolam 0.3mg/kg PO or PR 20-30 mins prior to anaesthesia
    • IPAD 20 mins prior to anaesthesia
  • Groups kept separate from each other
  • Primary aim – compare the impact of midazolam vs IPAD at mask induction (time 3)
  • Other aims
  • Anxiety measured on arrival to ward (time 1) at separation from parents (time 2) and once back on ward (time 4)
  • Also recorded post operative behavioral changes at home and parent’s overall satisfaction
  • Child anxiety measured by modified Yale pre-anxiety score (mYPAS)
  • 27 items incl. activity, arousal, vocalization, use of parents, emotional state
  • >30 defined anxiety; >40 high anxiety
  • Parent anxiety – State trait anxiety inventory (STAI), higher scores indicate high anxiety
  • Post hospital behavior questionnaire

Subjects

  1. Children aged 4-10 years
  2. ASA 1-3

Exclusions:

  • Pre-operative behavioural disturbances
  • Psychiatric medication
  • Previous history of multiple surgeries (>3)

Interventions

  • Patients assessed on ward (time 1)
  • Patients assessed with parents on arrival to surgical waiting area (time 2)
  • At Gas induction (time 3)
    • Allowed to carry on playing with IPAD
    • Anaesthesia maintained with sevoflurane
    • GA+/- LA
    • Kept in recovery until no PONV, fully awake, low pain scores
  • Assessed again back on ward (time 4)
  • At home assessments made over the phone at day 1, 7, 14

Outcomes

  • Primary outcome difference between the two group mYPAS scores at gas induction
  • For a power 80% and p<0.05 – 53 patients need in each arm
  • Qualitative and quantitative data was collected and analyzed according to normal distribution fishers exact/x2 test or Wilcoxon nonparametric test as appropriate
  • Statistical analysis was conducted using SAS

Results

  • 118 patients recruited and randomized
  • 60 in IPAD group
  • 58 in Midazolam
    • 3 not included (2 did not receive midazolam and 1 had no mYPAS data)
  • Time 3 (main aim – at gas induction) showed no difference between the two groups
  • 5 vs 41.8
  • Time 2 (assessment of patients in surgical wiaitng area) no difference STAI or mPAS
  • Overall mean mYPAS score less in IPAD group
  • Parents and nurses more satisfied with IPAD
  • Only 40% response rate postoperatively

Conclusions

  • No significant difference to anxiety levels in both groups – either equally good or equally bad. (not previous score of high anxiety was 40 and both groups achieved a mean greater than that.
  • Parents and nurses more satisfied with IPAD – they reported if felt more normal than seeing a semiconscious child
  • Previous trials that had shown a difference between the two did not use a psychiatrist to measure the scores and used different child ages – interpretation bias and someone not accustomed to the questionnaire creating the scores.
  • Low response rate post-operative meant no further conclusions could be drawn

Suggested problems by the authors:

  1. Kids wanted a tablet when they got home
  2. Underpowered
  3. Elective cases only
  4. Low dose of midazolam

Strengths

  • ‘Fun’ study that has the potential to benefit patients via non-pharmacological methods
  • Use of several common statistical tests
  • Prospective randomized trial

Weaknesses

  • No control group i.e. with no intervention
  • iPad 20 minutes before anaesthesia – could the child be bored of it by then?
  • ‘One size fits all’ approach – ipad is a distraction technique but one technique may not suit every child.
  • Why was this published in the BJA and not a French journal. Yet it is being reported in the mainstream media as a positive outcome?
  • How were patients selected? This is not stated. 118 patients of the period of 10 months at a children’s hospital seems a low number.
  • Not blinded – difficult to do.
  • Based on 1 previous positive study
  • Various types of surgery used which may cause different anxiety for different reasons other than anaethesia i.e. cosmetic pinnaplasty
  • Both equally effective or equally ineffective? Who can tell in the end.

Implications/Potential for impact

  • In the elective setting is midazolam appropriate? Post operative drowsiness delaying discharge times.
  • The study implied that the use was normal – everyone?
  • Lead on to further studies regarding distraction versus medication
  • Ultimately will vary anesthetist to anaesthetist and patient to patient

 

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