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Welsh Anaesthetic Trainees Journal Club

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colorectal cancer

February 2018

Written by Dr. C. Williams

Comparison of 4 cardiac risk calculators in predicting postoperative cardiac complications after non cardiac operations. Cohn S, Ros NF. The American Journal of Cardiology 2017 doi:10.1016/j.amjcard.2017.09.031

Identifying patients who are at high-risk of perioperative complications is something that we are still trying to refine. There are many risk calculators available to try to identify all kinds of risk – ranging from cardiovascular risk, risk of acute kidney injury, risk of post-operative cognitive dysfunction, risk of mortality and so on. Trying to work out which is the best risk calculator to use can seem like trying to negotiate your way through a minefield.

We know that cardiovascular complications after non cardiac surgery are an important cause of postoperative morbidity and mortality. One can use different risk calculators and get different estimates of the patients risk but which is the most reliable risk predictor? This is a question this paper tries to answer by looking at 4 different cardiac risk calculators.

Trying to identify high risk patients is not a new phenomenon – the first cardiac risk index was published by Goldman et al. in 1977. This was followed in 1999 by Lee at al publishing the revised cardiac risk index (RCRI). In 2013 Davies et al. improved prediction using a 5 factor reconstructed RCRI (R-RCRI). The 2014 ACC/AHA guidelines on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery recommended using the RCRI or two newer tools created from the National Surgical Quality Improvement Program (NSQIP) database – namely the myocardial infarction or cardiac arrest (MICA) calculator or the American College of Surgeons surgical risk calculator (ACS-SRC).

Essentially this paper found that all 4 risk calculators performed well at defining low and elevated risk groups but tended to slightly underestimate cardiac events. There are two salient points made:

  1. The definitions for outcomes and timeframes used to develop the risk calculators are different therefore a valid direct comparison of outcomes is not possible
  2. If the risk calculators are used in a manner different from the way derived they do not perform as well

Ultimately risk calculators give an estimate of risk – it is not a black/white answer as to whether that patient will develop that particular complication. What they are useful for is to facilitate shared decision making discussions with patients and enable them to make an informed decision regarding their treatment choice.

Postoperative ERAS interventions have the greatest impact on optimal recovery: Experience with implementation of EAS across multiple hospitals. Aarts M, Rotstein O, Pearsall E metal on behalf of the iERAS group. Annals of Surgery 2018 doi:10.1097/SLA.0000000000002632 

ERAS (Enhanced recovery after surgery) pathways use evidence-based practices to minimise perioperative stress and promote early recovery. These multimodal care pathways incorporate multiple interventions within the preoperative, intraoperative and postoperative course of the patient’s perioperative journey. Multiple papers have been published which demonstrate that ERAS benefits patients when compared to standard care and show a decreased rate of complications, accelerated recovery and earlier discharge from hospital.

But while ERAS has been shown to be effective at improving outcomes, it can be difficult to implement not least because it requires a sustained collaborative effort from members of a multidisciplinary team. This paper aims to determine which component of ERAS has the largest impact on recovery for patients undergoing colorectal surgery and also to look at the relative benefits of ERAS in laparoscopic versus open surgery.

Of the 2876 patients studied only 20.1% had care that was compliant with all phases of the pathway. The poorest compliance was for the postoperative interventions yet these were the interventions most strongly associated with an optimal recovery. Compliance with ERAS was associated with improved outcomes regardless of whether surgery was open or laparoscopic. However, the impact of ERAS compliance was significantly greater in patients having open surgery.

In addition to the ERAS components two other potentially modifiable factors were found to significantly impact on patient outcomes namely operative technique and preoperative haemoglobin levels.

Maybe it is time to go back and reassess how ERAS is implemented. My view as an anaesthetist is that it seems that more emphasis is placed on the preoperative and intraoperative parts of the pathway – the question is whether this is because that is what happens or because those are the parts of the pathway that anaesthetists are more involved with? There is plenty of emerging evidence that postoperative care is as important as other parts of the pathway and if the results of this study are valid then it would seem that postoperative interventions make the most difference to patient outcomes. Once again this paper adds to the increasing body of evidence that as anaesthetists it may have come to the time that we need to step up to the mark and pay more attention to postoperative care. After all, why take so much care making sure our patients are as pre-optimised as possible and given the best intraoperative care if we do not follow this through to the postoperative phase?

Preoperative geriatric assessment and tailored interventions in frail older patients with colorectal cancer: a randomised controlled trial. Ommundsen N, Wyller TB, Nesbakken A et al. Colorectal Disease 2018 doi:10.111/codi.13785

The role of comprehensive geriatric assessment for older patients undergoing surgery is much discussed in the literature at the moment. Geriatric assessment and input has already been shown to make a difference and improve functional status in hip fracture patients. This paper aimed to looks at whether a preoperative geriatric assessment can identify older patients at risk of developing postoperative complications after surgery for colorectal cancer. Patients over the age of 65 years scheduled for elective colorectal cancer surgery and fulfilling criteria for frailty were randomised to either a preoperative geriatric assessment and a tailored intervention (based on the assessment) or usual care.

The findings of this paper were that a geriatric assessment and tailored intervention made no difference to the rate of complications or to the secondary endpoints of median length of stay, discharge to own home, need for readmittance or reoperation within 30 days or 30 day and 3 month mortality.

In my opinion there are significant limitations to the data in this study – despite running for a long period of time (2011 – 2014) only 122 patients were recruited and consequently the study is probably underpowered (acknowledged by the authors). Also, the optimal time from intervention to surgery was hypothesised to be 3 weeks – which seems a short time period for an intervention to make a significant difference to outcome. Furthermore the authors go on to detail that the actual time for pre optimisation was a median of 6 days. Additional evidence is needed to be able to draw conclusions as to the effectiveness of geriatric assessment on patient outcomes particularly given that geriatric input has been shown to be efficient in other surgical settings.

Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes? A systematic review and meta-analysis. Chong MA, Wang Y, Berbenetz NM, McConchie I. European Journal of Anaesthesiology 2018;35:1-15 doi:10.1097/EJA.0000000000000778 

There is much debate about the effectiveness of perioperative goal-directed haemodynamic and fluid therapy. The seminal study by Shoemaker et al published in 1988 demonstrated that patients receiving preoperative haemodynamic optimisation titrated to goals of end organ blood flow had improved outcomes. Since then there have been multiple randomised controlled trials looking at this. In my personal experience many anaesthetists have quite polarised views on the efficacy of goal directed therapy.

The authors carried out a systematic review and meta analysis of 95 randomised controlled trials where goal directed therapy was studied defined as fluid and/or vasopressor therapy titrated to haemodynamic goals. The findings of this comprehensive review demonstrate that goal directed therapy modestly improves mortality in non-trauma and non pregnant adult surgical patients. The authors suggest that based on the articles included for analysis, the numbers suggest tat for every 1000 patients treated with goal directed therapy, 18 deaths would be prevented.

However, the quality of evidence was low to very low with much clinical heterogeneity among the goal-directed therapy devices and protocols. This is likely to be an area of continuing interest for perioperative research and further well designed and adequately powered trials are needed. Hopefully the OPTIMISE-II and FLO-ELA trials may answer some of the questions surrounding goal directed therapy.

Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. New GA, Ayyash R, Danjoux GR. Anaesthesia 2018 doi:10.1111/anae.14177

Pre-operative exercise has been much debated over the past few years. There have been several systematic reviews on the effects of pre-operative exercise with sufficient clinical trial data to support pre-operative exercise training as being safe and efficacious. But how exactly can one translate the evidence from clinical trials into clinical practice. This paper aims to provide practical and evidence-based guidelines on how to deliver pre-operative exercise training to patients awaiting major, non cardiac surgery.

Chronic physical inactivity accelerates age-associated declines in maximal aerobic capacity and functional fitness which consequently places individuals at increased risk of complications when undergoing major or complex surgery.

There are ten key recommendations which cover patient selection for exercise training in surgical patients, integration of exercise training into multi-nodal prehabilitation programmes and advice on exercise prescription factors and follow-up. This guideline also touches on the fact that successful implementation of rehabilitations programmes may prove challenging. A range of institutionalised cultural and attitudinal barriers exist that could affect pre-operative initiatives to a varying degree. System-related barriers include lack of educational opportunities highlighting the benefits of exercise, insufficient infrastructure and concerns about the feasibility of delivery and cost effectiveness of potential programmes. Several barriers to implementation are highlighted – the main ones being resistance to change from patients and staff and lack of funding or support from management.

Although the authors acknowledge that further research is needed to identify the optimal exercise prescription, this is a much needed clinical guidelines. Hopefully it will result in perioperative teams being able to incorporate pre-operative exercise training for patients into their routine practice.

Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. Jones PM, Cherry RA, Allen BN et al. The Journal of the American Medical Association 2018;319(2):143-153 doi:10.1001/jama.2017.20040

This article looked at over 313000 patients to look at whether handing over of care from one anaesthetist to another during surgery is associated with a worse outcome. Given the shift work that many anaesthetists (particularly trainees) now work, handing over of care during surgery cannot always be avoided. Handovers may be temporary (initial clinician hands over care to another clinician for a break and then returns) or complete (care is completely handed over to another clinician). Handover is a potentially vulnerable time for the patient because all information required must be transferred between clinicians in a busy environment with many distractions. If crucial details are missed the patient may be at risk of an adverse event. The alternative theory is that a rested clinician taking over care from a fatigued clinician may improve the quality of care and reduce adverse events.

Complete intraoperative handover of care compared with no handover of care was associated with a higher risk of all-cause death, hospital readmission and major postoperative complications over 30 days (44% versus 29%). Intraoperative handovers were also associated with an increase in intensive care admissions and a longer hospital stay.

This is a topic which raises many questions. The authors note that in Canada the number of complete handovers of care is increasing each year. Fatigue and the effects that it has on performance at work is also much debated at the moment.* Knowing that fatigue exacerbates many human limitations, some departments have implemented policies of restricted duty hours for medical staff. It is likely that these policies have an impact on the number of handovers of care.

Given the increase in adverse events observed in this study, the public health implications are concerning. The most prudent approach would be to minimise unnecessary anaesthetic handovers. However the factor of fatigue cannot be ignored. At some point fatigue will have a measurable and detrimental effect on clinicians and handovers in this case would be reasonable. But the question of how to determine when the risk of a fatigued clinician exceeds the potential risk of a complete handover is not one that can currently be answered.

(*July 2017A national survey of the effects of fatigue on trainees in anaesthesia in the UK.  McClelland L, Holland J, Lomas J-P, Redfern N, Plunkett E. Anaesthesia 2017 doi:10.1111/anae.13965)

October 2017

Written by Dr C. Williams

Caffeine accelerates recovery from general anesthesia via multiple pathways. Fong R, Khokhar S, Chowdhury A et al. Journal of Neurophysiology 2017;118:1591-1597 doi:10.1152/jn.00393.2017

Currently there is no method to accelerate emergence from general anaesthsia. Patient’s wake when they clear the anaesthetic from their systems. Drugs that had the ability to reverse the coma-like state induced by general anaesthetic agents would likely have considerable utility in clinical settings. In 1975 it was shown that direct intraventricular application of a membrane permeant cAMP analog could accelerate recovery from a variety of anaesthetic and sedative agents.

In 2014 the authors of this study demonstrated that drugs that increase intracellular cAMP dramatically accelerated emergence from anaesthesia. Three intravenous agents that increase cAMP levels were tested – forskolin, theophylline and caffeine – caffeine was shown to accelerate emergence time when anaesthesia was maintained with isoflurane 2%. This study aimed to determine whether caffeine had the same effect at higher anaesthetic concentrations. In this study, rats were anaesthetised for 60 minutes with end-tidal isoflurane levels of 3%. Ten minutes before anaesthesia was terminated the rats were injected with either saline (as a control) or a solution containing caffeine. Recovery time was taken as the time the rat was removed from the anaesthesia chamber, placed on its back on a table to the time it could stand with 4 paws on the table. This study appeared to show that caffeine accelerates emergence from anaesthesia even at high levels of isoflurane. The dose of caffeine was increased by 25mg/kg – starting at 25mg/kg and increasing to 75mg/kg. Caffeine at 75mg/kg produced a 55% reduction in emergence time

Caffeine inhibits phosphodiesterase which prevents the breakdown of cAMP. It also acts as an antagonist at all adenosine receptors. Blockade of the A adenosine receptor mediates caffeine’s arousal effects. Caffeine is already the most psychoactively used drug – in the USA more than 90% of adults use it daily. It is already used clinically either to treat neonatal apnoeas or for certain types of headache and is readily available.

However, this is a small study – no more than 9 rats were studied. There are also questions as to whether this study could be transferred to humans. Also the question as to whether a drug to accelerate emergence is necessary must be raised. It is tempting to speculate about other possible benefits of caffeine. Caffeine is known to have cognitive benefits – hence the reason it is one of the most widely used ‘drugs’. Anaesthetics can impair the cognitive abilities of patients, particularly the elderly, for significant periods of time. If caffeine was shown to accelerate cognitive recovery then it may play a significant role in postoperative recovery. To explore this theory would require extensive research.

Preoperative fluid retention increases blood loss during major open abdominal surgery. Hahn RG, Bahaman H, Nilsson L. Perioperative Medicine 2017;6:12 doi:10.1186/s13741-017-0068-1

Fluid management is an essential component in the management of major abdominal surgery. There is a marked variation in how the kidneys excrete or conserve fluid both in everyday life and preoperatively. Urine analysis can give a measure of the kidney’s state of fluid retention. It is known that a high concentration of urinary waste products is associated with a longer half-life of crystalloid fluid, a greater need for fluid optimisation, more complications after hip fracture surgery and a higher 30-day mortality in acute geriatric care. Little is known about how preoperative fluid retention affects intraoperative fluid balance. The aim of this study was to explore the relationship between preoperative dehydration and fluid requirements during major abdominal surgery with the hypothesis that fluid retention, indicating dehydration would mean more fluid is needed intra-operatively.

Patients undergoing elective open major abdominal surgery had their urine analysed for colour, specific weight, osmolality and creatinine concentration to calculate a fluid retention index. The fluid balance was obtained as the sum of infused fluid (crystalloid, colloid or blood products), minus the blood loss and excreted urine. Fluid retention was found in 37% of patients. It was associated with a significantly higher blood loss, a higher haemorrhage rate and a greater need for intravenous fluids. Despite the larger blood loss, the total fluid balance remained positive after surgery in dehydrated patients.

Preoperative dehydration is associated with higher fluid requirements intra-operatively but also a greater blood loss and a more positive fluid balance. These effects were most apparent in gynaecological and urological surgery. The results from this study would suggest that more fluid should be given to patients found to have concentrated urine preoperatively. More studies are needed to determine if this would improve patient outcome.

Paravertebral block does not reduce cancer recurrence, but is related to higher overall survival in lung cancer surgery: a retrospective cohort study. Lee EK, Ahn HJ, Zo J, Kim K, Jung DM, Park JH. Anaesthesia and Analgesia. 2017 doi:10.1213/ANE.0000000000002342 

Evidence is continuing to emerge about how postoperative analgesic methods have an impact on long-term prognosis after cancer surgery. Opioids trigger immune suppression by impairing innate immunity, altering antigen presentation and predominately favouring pro tumour cytokines. If a patient’s innate immunity is suppressed during the postoperative period there is the potential that remnant malignant cells or micro metastases may grow, establish and spread early after surgery.

Regional anaesthesia can reduce the need for opioids. Using this simple well known fact, it stands to reason that one would expect a lower cancer recurrence and higher survival if regional analgesic techniques were used instead of opioids. This was a large retrospective cohort study aiming to look at precisely this. They hypothesised that thoracic epidural or paravertebral catheters rather than intravenous opioids (via a PCA) as the postoperative analgesic method would be associated with better outcomes in patients undergoing lung cancer surgery.

The notes of 1729 patients undergoing open thoracotomy for primary non-small-cell lung cancer were reviewed. Patients either had a fentanyl PCA, a thoracic epidural with ropivacaine/hydromorphone solution or paravertebral catheter with ropivacaine infusion. Patients had what was then described as a ‘balanced’ anaesthetic  including opioids – either fentanyl boluses or remifentanil infusion. All patients had the same post-operative analgesic protocol for the next 2-3 weeks which was oral analgesics and/or fentanyl patch.

Recurrence rates were similar in all three groups and cancer recurrence was the cause of death in over 80% of the patients in each of the three groups. There was a statistically significant higher overall survival rate in the patients who received paravertebral catheters as the method of post-operative analgesia. Other variables were also related to overall survival including age, male sex, cancer stage, transfusion and duration and extent of surgery.

Unfortunately this study still does not help to answer the questions surrounding the role of anaesthetic techniques on cancer recurrence.

Regional anaesthesia and analgesia in cancer care: is it time to break the bad news? Sekandarzad MW, van Zundert A, Doornebal CW, Hollmann MW. Current opinion in anaesthesiology 2017;30(5):606-612 doi:10.1097/ACO.0000000000000492

The perioperative period is increasingly being recognised as a narrow but crucial window in cancer treatment. As the above paper hypothesises, regional anaesthesia has been proposed to reduce the incidence of cancer recurrence after surgery. There is a separate body of evidence suggesting that perioperative regional anaesthesia may be associated with a survival benefit in cancer patients.

The truth is that existing literature presents conflicting and inconclusive results about the impact of regional anaesthesia on cancer recurrence in patients undergoing surgery. Data is predominantly based on retrospective studies. with as many studies suggesting regional techniques have a positive outcome on cancer recurrence as those that suggest the opposite. The results from meta-analyses and systematic reviews are equally as conflicting. Conflicting results may be due to confounding factors including tumour-specific factors (such as type, grade and lymph invasion) which many studies do not take into account.

It seems unlikely that regional anaesthesia techniques either alone or in combination with modification of other perioperative factors can give clinically meaningful immune-protective effects when powerful chemotherapeutic agents appear to play a small role in cancer survival (contributing to 2% of the 5-year survival in adults). Additionally there is little convincing evidence that opioids promote cancer recurrence or facilitate the development of metastatic disease.

This review article critically refutes the concept that regional anaesthesia as a single modality in the complex oncological setting if cancer surgery can give positive cancer outcomes. The results of ongoing RCTs designed to investigate the link between regional anaesthesia and its ability to reduce cancer recurrence are eagerly awaited although it is unclear as to whether any clear results will be produced. Proving the efficacy of a single intervention (regional anaesthesia) in the multifactorial perioperative oncological setting will be challenging. What is clear is that a reducing postoperative pain and if possible preventing the progression to persistent post surgical pain, even at the expense of no difference in relation to reduced cancer recurrence, is still a goal to aim for.

European guidelines on perioperative venous thromboembolism prophylaxis: Surgery in the elderly. Kozek-Langenecker S, Fenger-Eriksen C, Thienpont E, Barauskas G, for the ESA VTE Guidelines Task Force. European Journal of Anaesthesiology 2017;34:1-7 doi: 10.1097/EJA.0000000000000705

The risk of venous thromboembolism (VTE) is higher in elderly patients particularly those aged over 70 years and elderly patients with co-morbidities. Large population-based epidemiological studies globally show that VTE predominantly occurs in the elderly and rarely occurs prior to late adolescence. But with an increased VTE risk comes an increased risk of bleeding. Therefore it is important to address this issue and ensure that there is appropriate risk stratification, correction of modifiable risks and sustained perioperative thromboprophylaxis.

Limited physiological reserves of older patients make them more vulnerable to postoperative stress and illness including VTE. Factors that have been associated in various studies with deep vein thrombosis and pulmonary emboli in there elderly include: congestive cardiac failure, pulmonary circulation disorders, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy, anaemia and coagulopathies.

Recommendations for VTE prophylaxis in the elderly are typically extrapolated from non-age specific VTE prophylaxis trials therefore timing and dosing of pharmacoprophylaxis are adopted from the non-aged population.

The general recommendations include:

  • Age over 70 is a risk factor for postoperative VTE
  • In elderly patients identify risk factors and correct if possible
  • Avoid bilateral knee replacements in elderly or frail patients
  • Timing and dosing of pharmacological VTE prophylaxis as in the non-aged population
  • In elderly patients with rena failure, low-dose un-fractionated heparin may be used or weight-adjusted dosing of LMWH
  • Careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation
  • Multi-faceted interventions for VTE prophylaxis in elderly and frail patients including pneumatic compression devices, LMWH (and/or direct oral anti-coagulants after knee or hip replacement)

Risk factors for postoperative ileus after colorectal cancer surgery. Rybakov EG, Shelygin YA, Khomyakov EA, Zarodniuk IV. Colorectal Disease 2017 doi:10.1111/codi.13888

Postoperative ileus is a temporary dysfunction of the gastrointestinal tract in response to surgical intervention. It is a common complication of abdominal surgery and most frequently developed after extensive colorectal operations. It causes significant financial and resource burden on healthcare institutions. The reduction in the incidence of ileus has therefore been placed as one of the top five priorities by the association of coloproctology of Great Britain and Ireland. Treatment is mainly symptomatic as there are no effective pharmacologic agents to treat it, therefore ileus prophylaxis based on the knowledge of potential risk factors is important.

300 patients having elective surgery for colorectal cancer were included. All patients had routine multimodal anaesthesia, a thoracic epidural (with a ropivacaine infusion) and the principles of enhanced recovery were followed: minimal preoperative starvation, no mechanical bowel preparation, no routine use of nasogastric tubes, maintenance of normothermia and minimisation of intraoperative infusions.

Ileus developed in 13% of the patients studied. After multivariate analysis four independent risk factors were identified: a BMI or 26 or over, previous abdominal surgery, the presence of extensive organ adhesions and the administration of opioids in the postoperative period. Importantly due to the fact that every patient in the study had an epidural with a plain ropivacaine infusion only a small proportion (10.7%) required opioids postoperatively. Yet a negative impact of opioids was demonstrated even at this small proportion.

It will never be possible to omit opioids in all patients but actively trying to use techniques that are opioid sparing may be a potential method in which anaesthetists can contribute to reducing the rates of postoperative ileus. This is however a retrospective and relatively small sized study therefore results should be interpreted with some caution.

The impact of fatigue on the non-technical skills performance of critical care air ambulance clinicians. Myers JA, Powell DMC, Adlington S, Sim D, Psirides A, Hathway K, Haney MF. Acts Anaesthesiologica Scandinavia 2017. doi:10.1111/aas.12994

Fatigue and how it affects performance is highly topical at the moment, particularly in anaesthetics following on from the publication of a national survey of the effects of fatigue on trainees in anaesthesia in the UK (Anaesthsia 2017;72:1069-1077) which was reviewed in July’s journal watch.*

This study looked at critical care doctors who are involved in air transfer of patients. The critical care air transport setting is dynamic and challenging and even a small performance decrement has the potential to affect clinical care and patient safety. Fatigue is presumed to negatively influence patient and clinician safety although the precise relationship is not entirely clear. It is also possible that sleep deprived clinicians may not recognise the extent to which their performance is impaired.

Nineteen physicians undertook two different simulated air ambulance missions, once while rested and once when fatigued. Performance was assessed by blinded observers based on expected behaviour in four non-technical skills domains: teamwork, situational awareness, task management and decision making. Participants also rated their own performances. They also completed a psychomotor vigilance task and a cognitive function test.

The physician’s non-technical skills were significantly better across all categories of skills and cognitive tests when rested. Clinicians completed relatively routine air transfer scenarios at levels of fatigue they routinely experience during usual clinical practice (e.g. towards the end of a night shift). Clinician’s also demonstrated limited awareness of their one degraded performance when fatigued. Self-ratings of performance showed no difference between fatigued and non-fatigued performance, in direct contrast to the rating provided by blinded observers.

This study highlights the importance of fatigue and how it can adversely affect performance. There is currently no good policy on recognising and managing the impact of fatigue in the NHS. Hopefully as awareness increases this will be addressed for all healthcare professionals, not only for the impact it has on patient safety but also the long term health impacts of chronic fatigue.

*A national survey of the effects of fatigue on trainees in anaesthesia in the UK. McClelland L, Holland J, Lomas J-P, Redfern N, Plunkett E. Anaesthesia 2017 doi:10.1111/anae.13965

Complications and unplanned admissions in non-operating room procedures. Leslie K, Kave B. Current opinion in Anaesthesiology 2017 doi:10.1097/ACO.0000000000000519 (13)

Increasing numbers of increasingly complex diagnostic and therapeutic procedures are being performed in areas remote from the operating theatre suite. This review aims to look at complications and unplanned admissions in patients requiring anaesthetic care for endoscopy, bronchoscopy and radiology procedures.

For endoscopy large analyses of databases show a low incidence of complications and unplanned admissions. In outpatients the incidence of cardiopulmonary complications was 0.9% – significant predictors included age over 60 years, higher ASA status and inpatient versus outpatient treatment.  Reviews of bronchoscopy seem to show that moderate sedation is tolerated well in these patients. Studies looking at procedures in radiology found that unplanned admissions were more likely to be due to pain, haemorrhage or infection as opposed to a sedation related problem.

Obstructive sleep apnoea has been associated with worse outcomes after procedures in the operating theatre. Studies have shown that OSA in patients having endoscopy or colonoscopy was not associated with any significant increase in cardiovascular or respiratory complications – the authors do make a note that caution should be applied in interpreting this due to poor methodological quality of the studies.

Overall, sedation seems to be associated with a low rate of complications – although some studies suggest more complications during deep propofol-based sedation rather than lighter benzodiazepine sedations. As anaesthetists we would like to think that if we provide the sedation as opposed to it being provided by a non-anaesthetist then it would be safer and have fewer complications. However, studies appear to suggest that sedation provided by anaesthetists is associated with more complications than if given by non-anaesthetists. The reasons for this are not explored but could be related to the fact that anaesthetists may provide sedation for higher risk patients and may provide a deeper level of sedation than non-anaesthetists. Clearly further randomised trials are required to define the optimum sedation drugs, sedation depth and the sedation provider.

September 2017

Written by Dr C. Williams

The incidence and characteristics of 3-month mortality after intraoperative cardiac arrest in adults. Hur M, Lee H-C, Lee KH et al. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12955

Intraoperative cardiac arrest (IOCA) is thankfully a relatively uncommon event. In 2002 a study in the US reported rates of IOCA as high as 19.7 per 10,000 anaesthetic events. However more recent studies have given rates of 27-43 per 100,000. In contrast to most other in-hospital or out-of-hospital cardiac arrests IOCA generally occur in monitored patients and resuscitation is started immediately. Nevertheless IOCA is generally associated with poor clinical outcomes and a high in-hospital mortality rate (approximately 66%).

The majority of studies looking at IOCA have focused on the characteristics of the arrest or the optimal management. Very few studies have looked at clinical outcomes after IOCA. This study was conducted in Japan and looked at the records of almost 240,000 adult patients who underwent a surgical procedure under general anaesthetic from January 2005 to December 2014. 101 patients who suffered IOCA were identified but after exclusions 50 records were looked at. Excluded were brain dead organ donors and patients on cardiopulmonary bypass or ECMO. The primary outcome was 3-month mortality after IOCA.

The rate of IOCA in this study was 21 per 100,000 patients. Nineteen patients died in the operating room and a further 12 died within 3 months (mortality 62%). Three survivors had unfavourable neurological outcomes at 3 months. IOCA occurred most commonly during the maintenance phase of anaesthesia, followed by pre-induction. The most common initial cardiac rhythm seen was VF/VT. The most common cause of IOCA was pre-operative patient complications (42%), followed by surgical complications (36%) then anaesthetics related events (14%). In immediate non-survivors of IOCA, the incidences of emergency surgery, out of hours operating, pre-operative patient complications, need for intra or post arrest transfusion, were all higher. These patients also had higher total doses of adrenaline and a longer duration of cardiac compressions.

Although the overall incidence of IOCA has decreased, the outcomes remain largely unchanged compared to previous studies. It appears that IOCA in patients being operated on out-of hours results in a higher immediate mortality although not a higher unfavourable outcome in survivors. The exact cause for this is difficult to ascertain, mainly due to the fact that the number of IOCA are thankfully very small meaning that the numbers of patients included in the analysis for this study was only 50. Various other factors appear to be implicated as risk factors for immediate mortality after IOCA but no definite conclusions can be made. The ultimate conclusion is that a large-scale study into IOCA and risk factors associated with 3-month mortality is needed.

Postoperative complications in individuals aged 70 and over undergoing elective surgery for colorectal cancer. Colorectal disease 2017 doi:10.1111/codi.13821

Almost 60% of colorectal cancer cases are diagnosed in patients aged over 65-years. For non-metastatic disease surgery is the best management. In more advanced stages, surgery may be indicated for symptom relief such as obstruction, perforation or bleeding. It is known that elderly patients undergoing major surgery are higher risk. This study identified 190 patients between 2009-2015 undergoing colorectal resection aged over 70 years of age. Medical and surgical postoperative complications were reviewed and outcomes analysed comparing length of stay, critical care admission, 30-day readmission rates, 30-day and 1-year mortality.

97.9% of the patients were classified as ASA III or above with 60.5% assessed as fitting the criteria for frailty on geriatric preassessment. Medical postoperative complications occurred in 40.5% of patients whereas surgical postoperative complications occurred in 17.9%. The most common medical complication was infection with urinary tract infection, lower respiratory tract infections and catheter related sepsis being top of the list. The next most common category of medical complications was transient confusion or altered mental function. The most common surgical postoperative complications were surgical site infections and the need for reoperation.

The complications were classified using the Clavien-Dindo (CD) Classification system into CD grade 2 and CD grade 3 (more severe). CD grade 2 complications occurred in almost 40% and grade 3 in just over 10%. Unsurprisingly the more severe the complication the longer the postoperative length of stay – CD grade 2 resulted in a 114% increased postoperative length of stay, CD grade 3 by 162%. CD grade 2 complications did not significantly alter readmission or mortality (at 30 days or 1 year). However, grade 3 complications were associated with an increase in 1-year mortality rates. A complication of CD grade 2 or above increased the need for critical care admission.

Comparison of the results from this study to others looking at postoperative complications are difficult because many studies do not specify the definitions used for complications or derive data from ICD-9 coding. However, it is clear that complications can have a significant impact on the perioperative surgical course. Medical complications are more common therefore surgeons should have medical expertise concerning the most common medical postoperative complications. For vulnerable, multimorbid older patients collaboration with other medical specialties and a multi-disciplinary approach is of paramount importance to provide the best overall care for this group of patients.

Impact of reversal strategies on the incidence of postoperative residual paralysis after rocuronium relaxation without neuromuscular monitoring: a partially randomised placebo controlled trial. Nemes R, Fülesdi B, Pongrácz A et al. European Journal of Anaesthesiology 2017;34(9):609-616 doi:10.1097/EJA.0000000000000585 

There has been many recent papers looking at postoperative residual paralysis and the impact it has on postoperative recovery. The evidence indicated that there is a significant incidence of residual paralysis particularly when neuromuscular function is not monitored. Many anaesthetists argue that they can ensure adequate recovery of neuromuscular function without the need for a nerve stimulator and without having to give neostigmine. There has also been some concern about the use of neostigmine due to its undesirable muscarinic side-effects and its limited ability to reverse even a moderate neuromuscular block. Sugammadex is now well established as an alternative to neostigmine for the reversal of a neuromuscular block by encapsulation of the steroidal neuromuscular blockers. The cost of sugammadex compared to neostigmine is significant meaning that in several institutions its use is closely controlled. Studies published studying the reversal of rocuronium with sugammadex did not find any postoperative residual neuromuscular block in the first 60 minutes compared to a significant proportion of patients given neostigmine.

This was a partially randomised, placebo controlled, double-blind study aiming to investigate the incidence of postoperative residual neuromuscular block using acceleromyography after spontaneous recovery of rocuronium-induced block, compared to administration of sugammadex, neostigmine or a placebo. Patients undergoing surgery were given a general anaesthetic with propfol, fentanyl, sevoflurance and rocuronium. Neuromuscular block was measured by acceleromyography. If the anaesthetist deemed that pharmacological reversal was needed the patient was then randomly allocated to receive sugammadex (2mg/kg), neostigmine (0.05mg/kg) or a placebo. In recovery an independent anaesthetist blinded to the treatment given then reassessed the neuromuscular function using acceleromyography. The main outcome measure was a train-of-four measurement of less than 0.9 on arrival in recovery.

The results indicated that pharmacological reversal was more effective than spontaneous recovery of a neuromuscular block. No agent was 100% effective but there were less incidences of a residual block in patients given sugammadex than those given neostigmine. What was highlighted by this study was that the residual block in patients allowed to spontaneously recovery and those deemed to need pharmacological reversal but randomised to receive a placebo was no different. This would indicate that clinically estimating who should need reversal or not may not be the best method. Studies have indicated that the incidence of a clinically relevant residual block by anaesthetists is less than 1%. This study demonstrated a significant residual postoperative neuromuscular weakness requiring rescue treatment in 8.8% of patients. Although it could be argued that the higher rates may have been detected due to a higher level of monitoring and awareness during the study, this highlights the risk of unmonitored muscle relaxant use.

There are limitations to this study the main ones being very small groups of patients and only rocuronium was studied. Yet overall, this study serves as a reminder that neuromuscular blocks should be monitored and reversed adequately. Other studies have shown that inadequate reversal is implicated in the development of respiratory postoperative complications. The incidence of a residual block after sugammadex was significantly lower than neostigmine. The sharp reality in todays NHS is that the cost of sugammadex is a limiting factor and as such it should maybe be reserved for patients at particular risk of undesirable effects of a residual neuromuscular block.

Angiotensin II for the treatment of vasodilatory shock. Khanna A, English S, Wang X et al for the ATHOS-3 Investigators. New England Journal of Medicine 2017;377:419-430 doi:10.1056/NEJMoa1704154

Vasodilatory shock, the most common type of shock, is characterised by peripheral vasodilation and reduced blood pressure despite preserved cardiac output. Patients with severe vasodilation who have hypotension despite the use of high doses of vasopressors have a poor prognosis with a 30-day all cause mortality of over 50%. This was a randomised, double-blind, placebo controlled phase 3 trial to determine whether the addition of angiotensin II to background vasopressors would improve blood pressure in patients with catecholamine-resistant vasodilatory shock.

Vasodilatory shock requires prompt treatment to ensure organ perfusion through the reestablishment of adequate blood pressure while the underlying cause of the shock is identified and treatment. Vasopressors are used when intravenous fluid resuscitation alone fails to restore blood pressure.

Treatment available for patients with catecholamine-resistant vasodilatory shock are limited and the available treatments often have associated side-effects. Options include glucocorticoids, vasopressin, methylene blue and high-volume hemofiltration. New therapies have so far proved to be disappointing. The nitric oxide inhibitor 546C88 increased blood pressure in patients with septic shock but was associated with more frequent cardiovascular side-effects and increased mortality at 28-days.

In the ATHOS-3 trial (Angiotensin II for the Treatment of High-Output Shock) the primary endpoint was the response of mean arterial blood pressure (MAP) at hour 3 with a response either being a MAP >75mmHg or an increase above baseline of at least 10mmHg without an increase in vasopressor dose. Patients were included if they had vasodilatory shock unresponsive to fluid resuscitation (defined as at least 25ml/kg of body weight over the previous 24 hours) and high dose vasopressors (defined as 0.2mcg/kg/min of noradrenaline or equivalent). Patients were randomly assigned to either receive synthetic human angiotensin II or saline placebo. Significantly more patients given angiotensin II met the primary end-point criteria. In fact, for those given angiotensin II the MAP increased rapidly and the dose of both angiotensin II and vasopressors were able to be reduced. The rate of adverse events (specifically tachyarrhythmias, distal ischaemia, ventricular tachycardia and atrial fibrillation) were similar in the both the angiotensin II and the placebo groups.

The study had a relatively small sample size so the possibility of clinically important side-effects related to angiotensin II cannot be excluded. Also follow-up was only for 28-days so either beneficial or harmful long-term effects of angiotensin II therapy cannot be excluded. Larger trials of longer duration are needed to answer these questions and to directly compare angiotensin II with other vasopressors.

ICU admission after surgery: who benefits? Ghaffar S, Pearse R, Gillies M. Current opinion in critical care 2017;23(5):424-429 doi:10.1097/MCC.0000000000000448

The number of operations performed each year continues to grow and combined with an aging population, more and more procedures are performed on patients who previously may not have been considered for surgery. The last decade has also witnessed an increased recognition of the importance of and improvements in perioperative care. Overall mortality rates after surgery are low at 0.5% but complication rates are higher with the global figure suggested to be approximately 16% with complications being associated with an increase in mortality.

The incidence of adverse events will obviously vary by surgery, institution, region and nation. Differences in the process of care are often given as a cause in particular the access to critical care beds. Admission to ICU has been a standard after certain types of surgery for many years, however, ICU resources particularly in the UK are limited and expensive. Having the ability to identify those patients that would benefit the most from critical care admission is a major issue for those delivering perioperative care. The ability and need to identify high-risk patients, develop pathways to signpost to the most appropriate postoperative care placement and methods to allow as early detection as possible of the deteriorating patient are all vital to improve outcomes and best utilise finite resources.

Evidence from large epidemiological studies suggest that for many patients undergoing major elective surgery routine ICU admission may not provide any additional benefit and may contribute to an increase length of hospitalisation and cost. The evidence also suggests that for patients undergoing major emergency surgery where there is insufficient time to optimise comorbidities or where there is any other major physiological derangement are best managed in a critical care setting.

A study published in 2013 found that ICU bed provision and rate of admission did not correlate with overall mortality. In fact, countries that had the lowest mortality rates after surgery also had the lowest rates of ICU admission. An explanation for this could be the use of alternatives to ICU admission in some of the best performing European countries. Patients recovering from major elective noncardiac surgery require prompt and effective treatment of pain, hypothermia, cardiorespiratory compromise, fluid imbalance combined with early mobilisation and enteral nutrition. The main way that ICU provides a benefit in these scenarios is the access to high quality nursing care. This can be delivered in less intensive environments such as post anaesthetic care units or specialist wards. In this way patients will still receive a higher level of nursing care along with early identification of deterioration and rapid access to relevant services such as critical care outreach.

Another consideration is that of the use of ‘fast-track’ pathways in cardiac surgery for low to moderate risk patients. They have been established for many years and appear to be safe and shorten the ICU stay without increasing complication rates. Maybe this is an area that needs further exploration for noncardiac major elective surgery.

Clearly the benefits of ICU admission for many types of major surgery remain uncertain. Identifying the patients most at risk of death and complications following surgery remains the major challenge for perioperative care. As pointed out in this review, future research should focus on how postoperative care can best be structured to provide patient optimum care within the available resources.

Risk factors for peripheral nerve injuries following neuraxial labour analgesia: a nested case-control study. Haller G, Pichon I, Gay F-O, Savoldelli G. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12951

Neuraxial anaesthesia is the most common method for either labour analgesia or anaesthesia for delivery. Post-partum lower extremity motor and sensory dysfunctions occur in between 0.1-9.2% of deliveries and are a well known complication in obstetrics. Usually these symptoms are transient and resolve spontaneously within a year. For a small minority the damage is permanent. While the damage is easily identified the causation may be more difficult. Anecdotally and personal experience is that any type of neurological problem tends to be blamed on the neuraxial anaesthesia. Although most published data indicates that these complications are related to compression of the nerve roots, plexus and peripheral nerves due to obstetric factors (femoral nerve, lateral femoral cutaneous nerve, obturator nerve, pudendal nerve and common peroneal nerve). There are other studies that associate non-obstetric-related factors with peripheral nerve injuries mainly radiculopathies or catheter injuries.

The most feared but fortunately rare complication of neruaxial anaesthesia is an injury to the central nervous system. This paper quotes the rate as 1:145,000 to 1:240,000. This is comparable to the 2009 Royal College of Anaesthetists NAP3 report that quotes the cases of permanent harm relating to central neuraxial block in obstetrics as 1:80,000 to 1:320,000.

This study collected data from almost 20,000 obstetric patients having neuraxial procedures in the Maternity Department of Geneva University Hospital, a tertiary referral centre where over 80% of deliveries are performed under neuraxial anaesthesia. 19 patients (0.96%) were found to have peripheral nerve injuries. According to neurologists 15 of these cases were likely related to compression or tractions by the baby’s head or obstetric manoeuvres/instrumentation. In four cases a nerve root injury due to the Tuohy needle were suspected. Other risk factors for nerve injury included a gestational age >41weeks, late initiation of neuraxial anaesthesia, repeated anaesthetic procedures, assisted delivery with forceps and a newborn birth weight of >3.5kg.

This paper highlights that although patient and anaesthetic factors contribute to peripheral nerve injuries, obstetric related factors are the most prominent risk. Thankfully overall motor and sensory dysfcuntions following delivery and neuraxial anaesthesia are rare and typically self-limiting. Despite this fact the risk of nerve injury by a Tuohy needle or catheter insertion should not be minimised particularly as symptoms can persist for a long length of time and have a significant impact on the patient’s quality of life.

Early definitive treatment rate as a quality indicator of care in acute gallstone pancreatitis. Green R, Charman S, Palser T. British Journal of Surgery 2017 doi:10.1002/bjs.10578

The incidence of acute pancreatitis is rising with it now being one of the most common intra-abdominal emergency conditions. The most common aetiology is gallstones with them being implicated in 35 – 40% of pancreatitis cases. The available evidence and current guidelines recommend that patients with mild gallstone pancreatitis should have definitive treatment of their gallstones during the same hospital admission or within two weeks of discharge. Definitive treatment is namely a cholecystectomy or if unfit for surgery an endoscopic sphincterotomy. Adherence to these recommendations improves patient outcomes and reduces hospital length of stay and the risk of further episodes of pancreatitis. Compliance with guidelines is variable. This study aimed to examine variation in patients receiving early definitive treatment for gallstones following an episode of acute gallstone pancreatitis and determine its validity as an indicator of quality of care.

Using information from the Hospital Episode Statistics database just over 19,500 patients were identified. Of the patients only 6733 received early definitive treatment within two weeks of discharge. In total 28.5% received treatment during their admission and a further 6% had treatment within two weeks of discharge. In the 1-year follow up 23.9% of patients had one or more emergency admissions for gallstone pancreatitis related complications. 33.8% were readmitted within 2 weeks with the remaining 66.2% of readmissions occurring after the point at which the patient should have had early definitive treatment. Early treatment was associated with a 39% reduction in readmissions.

This study seems to support the idea that early definitive treatment for gallstone pancreatitis is associated with improved patient outcome. As well as improving patient morbidity and mortality the reduction in readmission rates with early treatment is associated with potential cost savings. This issue was touched on in the August journal watch.* This study provides further evidence to suggest that maybe surgeons and anaesthetists alike should take ‘hot’ cholecystectomies seriously.

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

How to better identify patients at high risk of postoperative complications? Talmor D, Kelly B. Current opinion in critical care 2017;23(5):417-423 doi:10.1097/MCC.0000000000000445 

As already discussed more patients are presenting for surgery at a later age with more co-morbidities. The challenge is how to identify the patients most at risk of postoperative complications. The aim of preoperative risk assessment is to help identify patients at increased risk of complications and allow appropriate postoperative management to be planned, ultimately to lead to improved patient outcomes.

There are a multitude of prediction scoring systems that can be used – covering them all in this short synopsis is impossible. However, most prediction scores predict postoperative mortality with, at best, moderate accuracy. Score incorporating surgery-specific and intraoperative events may improve the accuracy of traditional scores. The more ‘traditional’ risk factors of increased ASA score, emergency surgery, intraoperative blood loss and haemodynamic instability are consistently associated with increased mortality using most scoring systems.

Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk factors are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative haemodynamic instability, blood loss, the extent of the surgical incision and the volume of resection in prioritising patient admission to higher levels of postoperative care.

Ultimately the prediction of postoperative complications remains difficult. Independent risk factors for worse outcomes include increasing age, frailty, chronic renal failure and poor cardio-respiratory reserve despite having at best only moderate discriminatory value. Many anaesthetists still appear to feel that risk scoring is a waste of time. It is an area that is developing but at the moment the risk scoring systems we have are the best that are currently available. There is no doubt that they only give predictions and no matter how good a scoring system is, it will never and can never be 100% accurate. But in a healthcare system where resources and critical care beds not infinite they can be useful in trying to prioritise which patients need higher levels of care postoperatively.

 

Can CPET predict in-hospital morbidity?

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery.

British Journal of Surgery. West MA, Asher R et al. 2017;103: 744–752

Presented by Dr L. Emmett

Background

  • Major colorectal surgery carries substantial morbidity and mortality – 30 day mortality of 2.9%
  • Risk stratification permits collaborative decision making, optimisation and effective utilisation of hospital resources
  • CPET is an objective measure of physical fitness under stress, mimicking surgery
  • This study aimed to assess the predictive value of selected CPET variables and their association with in-hospital morbidity in major elective colorectal surgery

Methods

  • 6 UK hospitals recruited consecutive adult patients over a 3 year period

Inclusion criteria

  • Major elective colorectal surgery

Exclusion criteria

  • Emergency surgery
  • Neoadjuvant chemotherapy
  • Lower limb dysfunction
  • Inability to consent
  • Inflammatory bowel disease
  • Distant metastases

 

  • CPET was conducted according to American Thoracic Society and American College of Chest Physician guidelines
  • Standard protocols used for all patients – observations recorded were heart rate, 12 lead ECG, blood pressure and pulse oximetry. Ventilation and gas exchange were monitored using a metabolic cart
  • In-hospital morbidity was measured at 5 days post op using an objective scoring system, Dindo score and post op 30 day mortality were also recorded

Primary aim

  • Compare the postoperative morbidity score and the V02 at lactate threshold and peak exercise

Secondary aims

  • To compare multi variable relationship between patient demographics, CPET variables and post operative in hospital morbidity

Intervention

  • Statistical analysis of CPET variables matched with POMS tool
  • 425 patients to be recruited to demonstrate that these variables were better than chance at risk prediction

Results

  • 7% had postoperative complications
  • VO2 lactate threshold <11.1ml/kg/min and VO2 peak threshold <18.2ml/kg/min were associated with a statistically significant increase in post operative complications
  • BMI >27 and open procedures (rather than laparoscopic) associated with increased complications

Conclusions

  • There was a statistically significant increase in postoperative morbidity in those patients with a lower VO2 at lactate threshold, VO2 at peak, and O2 pulse at lactate threshold

Strengths

  • Conclusion matches primary aim
  • More evidence that CPET testing is valuable, potentially selecting appropriate patients and risk stratifying
  • Potential for increasing CPET provision, funding and awareness
  • No adverse effects
  • Strong statistical significant observed
  • In keeping with findings from other studies

Weaknesses

  • No new knowledge, only backing up existing evidence
  • Unblinded study, CPET data used in clinical management
  • Centre to centre variations in findings
  • CPET isn’t the whole story!

Implications and Potential for Impact

  • Further increasing evidence base
  • Increase provision of CPET services
  • Stimulate further research in high risk patients
  • Asks questions about utilisation with other risk scoring systems

 

August 2017

Written by: Dr C. Williams

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In practice the implications of these changes are:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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.

 

Oral or intravenous iron?

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

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 hepatobiliary 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.

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