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Welsh Anaesthetic Trainees Journal Club

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recovery

Would an internet-based prehabilitation programme be effective?

Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation

BMJ Open 2018;8:e017781. doi:10.1136/ bmjopen-2017-017781

Presented by: Dr G Roberts

Background

Perioperative care is often a fragmented process between disciplines, patients, clinicians and hospitals.  A proof of concept trial had previously demonstrated in gynaecological care that an internet-based peri-operative care platform could potentially empower patients during this period; the aim to enhance post-operative recovery through appropriate self-management strategies, reduce inappropriate recovery behaviour and ultimately enable a quicker return to work.

Design & Setting

  • Three year (2011 to 2014) study sequentially across nine hospitals using a stepped-wedge cluster randomised trial (https://www.bmj.com/content/350/bmj.h391)
  • Eligible hospitals had to perform at least 100 hysterectomies or laparoscopic adnexal surgery. Hospitals served as the control group until the care programme was sequentially implemented.
  • Study design did not allow for blinding, but group allocation was concealed from patient until consent obtained. Data analysts blinded.

Subjects

Over 400 employed women aged between 18 – 65 scheduled for surgery of benign gynaecological disease.

Inclusion

  • Scheduled for hysterectomy (vaginal, laparoscopic or abdominal) and/or laparoscopic adnexal surgery.
  • Aged between 18 – 65.
  • Employed for at least eight hours a week.

Exclusion

  • Severe benign comorbidity or malignancy.
  • Pregnancy
  • Computer or internet illiterate.
  • Insufficient command of Dutch language.

Intervention

Internet-based care programme sequentially rolled out using a multifaceted implementation strategy. Patients were allocated to either the care programme (intervention) or usual care (control).  The care programme included an e-health intervention equipping patients with tailored personalised convalescence advice that had been designed by patients, gynaecologists, GPs and occupational physicians. Post-operatively, the web portal contained an interactive self-assessment tool to monitor recovery.

Outcomes

Primary

  • Sick leave duration until full sustainable return to work (defined as the resumption of own work or other work with equal earnings, for at least four weeks without recurrence of sick leave).

Secondary

  • Functional health status
  • Recovery
  • Self-efficacy
  • Coping
  • Pain

 Results

  • 433 participants recruited from potentially 1591.
  • Data for primary outcome obtained from 401 participants while data for secondary outcomes obtained from 334 participants.
  • 8% of participants in intervention group used the website programme as intended.
  • Median duration until full sustainable return to work was 49 days in intervention group and 62 days in control group.
  • No demonstrable difference in functional health status, self-efficacy and coping.

 Conclusions

The use of internet-based information technology to facilitate a gynaecology patient’s perioperative journey may result in a reduction in post-operative sick days.  It would be worth other surgical specialties adopting and evaluating this method, while identifying those patients who might benefit most from this approach.

Strengths

  • Assessment of both patient and organisation.
  • Intention-to-treat.
  • Sub-group analysis.

Weaknesses

  • Cluster design may have led to recruitment bias.
  • The online platform had a proof of concept but not necessarily validated.
  • Just under a third of eligible patients were recruited, the majority of whom either declined to participate or were not eligible.
  • Due to the eligibility criteria requiring employed women who were computer literate, a high proportion of participants were deemed highly educated – How can conclusions apply across the general population?
  • There was significantly more loss-to-follow up in the intervention group.

Implications

  • There is a potentially large positive bio-psycho-social impact if these results are proved to be reproducible.
  • Reduction in sick days would have a positive socio-economic effect.

 Potential for impact

With more focus and energy being applied to the process of perioperative care by many stakeholders and the increasing use of information technology, this approach may prove to empower patients during their perioperative journey and lead to better recovery profiles.  Care is needed however to ensure that there is more to recovery than simply ‘return to work’.

Shuttle walk or CPET……..survival after oesophageal resection

Poor performance in incremental shuttle walk and cardiopulmonary exercise testing predicts poor overall survival for patients undergoing esophago-gastric resection

European Journal of Surgical Oncology 2018 https://doi.org/10.1016/ j.ejso.2018.01.242

 Presented by: Dr T Green

Background

Patients with oesophageal and gastric cancer have a poor prognosis with an untreated five year survival at time of diagnosis of 20% and an increase to only 40% following treatment.  It can take up to one year for many patients to recover from treatment and regain their preoperative quality of life and many patients will not achieve this.  Careful preoperative assessment is essential to select those who will benefit from surgical treatment.

The Incremental Shuttle Walk Test (ISWT) and Cardiopulmonary Exercise Testing (CPET) can be used to assess the preoperative fitness of patients.  CPET results include the Anaerobic Threshold (AT) and Maximal Oxygen Consumption (VO2 Max).  This study aims to assess the correlation between ISWT and CPET with postoperative survival and postoperative pulmonary complications.

Design & Setting

Observational study of patients undergoing surgery for gastric or oesophageal cancer with or without neoadjuvant chemo-radiotherapy between 2010 and 2014 (presumably at Royal Marsden Hospital / St Mary’s Hospital, London – not stated but based on authors’ affiliations)

Data collected on preoperative clinical stage, postoperative pathological stage, postoperative respiratory complications, all-cause mortality and mortality due to disease recurrence.

Subjects

81 patients assessed through the Perioperative Enhanced Recovery Protocol between 2010 and 2014.  All patients underwent either ISWT or CPET (or both).

Intervention

Observational study – no intervention.

Outcomes

  • Assessment of the utility of the ISWT and CPET for determination of postoperative respiratory complications and mortality.
  • ISWT score of 350m or above.
  • CPET values: AT 11 or above and VO2 Max 14ml/kg/min or above.

Results

  • 73 of 81 patients (90%) had both ISWT and CPET assessment.
  • No correlation between single time point ISWT or CPET results and postoperative respiratory complications.
  • A subset of patients (45) had ISWT both before and after chemoradiotherapy and of these, those who achieved a >10% increase in score were noted to have a reduced incidence of postoperative respiratory complications (19% in those whose ISWT score improved >10% vs 45% in those whose score remained within 10% of their pre-chemoradiotherapy score or whose score reduced by >10%). This did not reach statistical significance (p = 0.08).  There was no correlation between such improvement in ISWT score and overall mortality.
  • All cause mortality and mortality due to disease recurrence correlates strongly (p < 0.001) with ISWT score ≥350m, AT ≥11 and VO2 Max ≥14 (Median survival with ISWT <350m or VO2 Max <14 was 20 months vs >5 years. Median survival with AT <11 21 months vs >5 years.)

Conclusions

ISWT assessment before and after chemotherapy is indicated and a reduction in score indicative of deconditioning, should trigger patient-specific exercise-based intervention.  CPET, being considerably more complicated and expensive, should be reserved for cases with established cardiopulmonary comorbidities.

Strengths

  • Goals and methods clearly defined.
  • Negative results reported.
  • Recognition of limitations of current study.

Weaknesses

  • Observational study therefore no case-control analysis.
  • Small sample size, especially for those undergoing ISWT before and after neoadjuvant chemoradiotherapy leading to underpowered statistical analysis.
  • The concurrent study being performed by the authors assessing the introduction of patient-specific exercise-based prehabilitation appears to have preceded the results of this study and may introduce bias into the analysis and conclusions.

Implications

ISWT may be a cheaper, less complicated method of determining cardiopulmonary fitness prior to surgery for gastric or oesophageal cancer and may be of use in guiding the multidisciplinary team in determining the best course of action for a given patient (surgery or conservative management).

Potential for impact

The use the ISWT, a cheaper, simpler assessment of cardiopulmonary fitness versus CPET is attractive as long as this can reasonably be used to guide treatment options.  The use of CPET still has its place based on the results of this study.

PONV and oral/maxillofacial surgery. Which surgery is worse? Which anaesthetic technique is best?

Postoperative nausea and vomiting after oral and maxillofacial surgery: a prospective study. Dobbeleir M, De Coster J, Coucke W, Politis C.

International Journal of Oral and Maxillofacial Surgery 2018 doi:10.1016/j.ijom.2017.11.018

Presented by: Dr A Phillips

Background

  • Post-operative nausea and vomiting (PONV) is common after general anaesthesia
  • PONV leads to longer hospitalisation, higher costs, lower patient satisfaction
  • Risk scores (e.g. Apfel) exist but limited data on maxillofacial surgery (OMFS) as a risk factor for PONV
  • This study aimed to identify which types of OMFS are more related to PONV

Design & Setting

  • Single centre observational study
  • Participants categorised into bleeding risk based on type of surgery
  • PONV score calculated pre-op and anaesthetic tailored to minimise PONV
  • Anaesthesia non-standardised. Sevoflurane/desflurane/Propofol Target-controlled infusion (TCI) all used and non-standardised anti-emetic use.
  • Online questionnaire completed at day 3 post-op to determine if the patient had PONV

Subjects

  • 308 patients age between 8 to 87 years undergoing general anaesthesia for OMFS
  • Exclusion: cancer cases requiring post-operative high dependency unit care (HDU)

Intervention

  • A variety of maxillofacial surgeries from dental extractions to osteotomy

Outcomes

  • Primary outcome was self-reported post-operative nausea and vomiting questions (multiple choice answers) in the 3 days after surgery via an online questionnaire.

Results

  • 46.1% post-op nausea (PON) and 21.1% post-op vomiting (POV) overall
  • PON statistically significantly higher in the bimaxillary surgery (BIMAX)/ bilateral sagittal split osteotomy (BSSO) groups versus “other minor surgery” and dental extraction groups (P <0.05)
  • Similar pattern between POV groups but no statistical difference between BSSO and “other minor surgery” group

Conclusions

  • Maxillary surgery and BSSO procedures induced significantly more PONV than the other OMFS procedures. These could be included as a parameter in the calculation of the Apfel score.
  • Significantly less PON in anaesthesia maintained with sevoflurance vs. Propofol TCI

Strengths

  • An original study
  • Highlights limitations in pre-operative PONV scores

Weaknesses

  • Observational study
  • Small sample groups
  • Not specified whether elective/emergency surgery
  • No standardisation of anaesthetic or antiemetic use – higher PONV in Propofol TCI group is contrary to widespread evidence – suggests reverse causation
  • Blood loss hypothesised as contributory factor toward PONV – no quantification of blood loss
  • Ingestion of blood hypothesised as contributory factor toward PONV – no mention of the use throat packs
  • Retrospective questionnaires are subject to recall bias

Implications

  • Based on this study, we should consider patients undergoing BSSO/maxillary surgery to be at higher risk of PONV and alter anaesthetic practice accordingly

Potential for impact

  • I don’t think it likely that practice would change based on this article. After all, one of the implications would be to avoid TIVA in those at higher risk of PONV!
  • The article highlights the higher overall risk of PONV in more complex OMFS cases but does little to convince the reader that the surgeries themselves are independent risk factors for PONV.

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.

May 2017

written by Dr C. Williams

Cartoons on facebook: a novel medical education tool. Junhasavasdikul D, Srisangkaew S, Sukhato K, Dellow A. Medical Education 2017;51(5):539-540 doi:10.1111/medu.13312

The popularity of social media is increasing. Cartoons or comics are increasingly being used in medical education. Combining the two seems to make sense and this is what this study aimed to look at. A previous study has shown that using cartoons on a website was associated with an improvement in post-learning test scores of health-care professionals. A prospective trial was carried out using a series of non-animated comic-style cartoons aimed to teach the physiology of breath sounds and their clinical examination. These were published on Facebook in March 2016 and viewers were encouraged to fill in a survey. To date the cartoon has had 30,000 views. More than 90% reported that the cartoons attracted their attention, helped them memorise the content, understand the physiology and improve their approach to conducting a physical examination. The views peaked at 10,000 on the first day, falling to 3000 the next day and then less than 100 views per week.

This study shows that using the popularity of social media for medical education may be successful in reaching a wider audience. It remains to be seen how effective this teaching method is in the long run.

Ventilation with high versus low peep levels during general anaesthesia for open abdominal surgery does not affect postoperative spirometry: a randomised clinical trial. Treschan TA, Schaefer M, Kemper J et al. European Journal of Anaesthesiology 2017;34:1-10 doi:10.1097/EJA.0000000000000626

It is well know that invasive mechanical ventilation during general anaesthesia for surgery causes atelectasis and a reduced long volume. Typically this is due to a cephalic shift of the diaphragm and decreased muscle tone following induction of anaesthesia. For patient undergoing abdominal surgery this is particularly true and the risk of atelectasis increases the closer the incision is to the diaphragm. Intraoperative atelectasis may impair oxygenation. But more importantly, it often continues in the postoperative period and can increase the risk of postoperative pulmonary complications (PPCs). PPCs are known to increase morbidity and mortality and are known to occur in up to 39% of patients.

The reduction in atelectasis and the effect on postoperative respiratory function can probably be modified somewhat by intraoperative ventilation strategies. Protective intraoperative ventilation strategies using low tidal volumes and positive end-expiratory pressure (PEEP) and recruitment manoeuvres are becoming more common place and could prevent the development of PPCs.

The protective role of PEEP has recently been challenged (PROVHILO trial, Lancet 2014; systematic review, Anaesthesiology 2015). This study was a substudy of the PROVHILO trial. It looked at patients having major abdominal surgery and split them into two groups: both groups having low tidal volume ventilation but one group with a PEEP of 12 cmH2O and the other with a PEEP of 2cmH2O. Patients than had their FEV1 and FVC measured every day for 5 days postoperatively. What this study showed was that both groups had approximately a 50% decrease in their spirometry compared to preoperative values. In both groups patients who had worse spirometry function on postoperative day 5 were more likely to develop PPCs.

This study seems to raise more questions about the optimal intraoperative ventilatory strategy. Do high levels of PEEP and recruitment manoeuvres really make as big a difference as we think? Does the ventilation strategy on emergency of anaesthesia influence lung function? Would extending PEEP into the postoperative period or prohibiting the use of 100% oxygen during extubation make a difference?

Optimisation of bodyweight before visceral surgery in obese patients. Bell SW, Warrier SK. British Journal of Surgery 2017 doi:10.1002/bjs.10504

Obesity is an epidemic in the developed world with dramatic rises in the number of people being classed as overweight or obese in the USA. This is a pattern that is replicated across Europe and Australasia. The WHO estimates that 2.8 million people die each year as a result of being obese. We know that life expectancy and quality of life is affected by obesity and it results in many complications including the development of diabetes, cardiovascular disease, musculoskeletal problems and neuromuscular compromise. What can not be ignored is the impact of obesity in the patient presenting for surgery particularly for visceral surgery. Obese patients can be technically challenging from a medical and anaesthetic point of view, a surgical point of view and nursing point of view. They are often challenging to operate on and consequently have compromised outcomes. They are more likely to need critical care, have a longer hospital stay, a prolonged recovery period and often need rehabilitation. In addition to the well known anaesthetic challenges of an obese patient there are surgical challenges to consider. With regards to colorectal surgery there are particular challenges: difficulty in laparoscopic identification of surgical planes, lack of access to critical views, difficulties in vessel visualisation and ligation, and in traditional open surgery difficulty in obtaining appropriate angles for dissection and safe division of the rectum.

Before bariatric surgery the use of very low-energy diets (VLEDs) is common. VLEDs have been shown to reduce total bodyweight, liver fat content and liver volume. The cause a disproportionate reduction n visceral adipose tissue compared to total body mass. Rapid weight loss leads to a reduction in liver volume and makes surgical access to the stomach and oesophageal hiatus easier so improving the technical ease of surgery. Although it is thought that VLEDs may be beneficial in other areas outside bariatric surgery there is very little evidence to support this. For colorectal surgery there has been a focus on preoperative optimisation and prehabilitation. Potentially a reduction in obesity through VLED meal replacement may compliment enhanced recovery programmes. Interventions to reverse some of the negative impact of obesity in the patient undergoing visceral surgery may result in significant benefits. In the field of rectal cancer, the ADIPOSe (Australian Decrease in Intra-Pelvic Obesity for Surgery) trial is looking at the efficacy of VLEDs in the perioperative period. Obesity rates looks set to continue to increase, as do visceral cancers particularly colorectal cancers – the development of which may be linked to obesity. The results of this study will be interesting to see and may result in the acute use of VLEDs for these patients.

Training in intraoperative handover and display of a checklist improve communication during transfer of care. An interventional cohort study of anaesthesia residents and nurse anaesthetists. Julia M, Tronet A, Framer F, Manville V, Fourcase O, Alacoque X, LeManach Y, Kurre MM. European Journal of Anaesthesiology 2017;34:1-6 doi:10.1097/EJA.0000000000000636

Having to handover a patient is common practice in anaesthetics – handover from anaesthetist to anaesthetist, to the recovery team, to the critical care team or to the ward staff are a few examples that spring to mind. How the patient is handed over and the information given is vital. Failure in communication at handover can contribute to morbidity and mortality. With the advent of shift working, having to hand over a patient during the intraoperative period is now not an uncommon occurrence. It has been shown that most preventable adverse events in medicine are because of communication errors and over half of these occur in relation to handover of patient care.

In my anaesthetic training I know of several audits in several different hospitals looking at handover practices from anaesthetists to recovery nurses. Despite our best efforts and training these audits have always shown that we fall below the expected standard. We know from other areas of anaesthetic practice that checklists can be useful and aid in tasks such as this. Handover checklists seem to be an easy way to standardise oral communication and to reduce the loss of information and studies have shown the positive effect of checklists on postoperative handover from anaesthetist to post-anaesthetic care unit nurses.

This study looked at whether intraoperative handover training and display of a checklist would improve communication during intraoperative handover of care. The participants (made up of residents and nurse anaesthetists) were split into two groups – the control group and a group who received handover training and had checklists displayed in the operating theatres. Before training both groups showed similar performances. Over the study period the control group showed no change in performance. In the intervention group, performances improved and this was sustained over a three month period without an increase in handover duration.

As much as checklists are hated by some they do appear to be effective in certain situations. Possibly handover between trainees at shift changes could be improved with their use. As we use more and more technology possibly the development of a smartphone application may further increase adoption be healthcare providers to improve patient safety?

Postoperative pain relief using local infiltration analgesia during open abdominal hysterectomy: a randomised, double-blind study. Acta Anaesthesiologica Scandinavica 2017;61(5):539-548 doi:10.1111/aas.12883

Total abdominal hysterectomy is a relatively common procedure carried out for both benign and malignant conditions of the uterus. In Sweden over 60% of hysterectomies performed each year are carried out via open abdominal surgery. Post-operative pain for the first 24 hours can be severe, particularly during movement and patients often require high doses of rescue analgesia. Pain control is important to promote early mobilisation. Poor pain control is associated with increased morbidity and can evolve into persistent post-surgical pain. There is no universal consensus on the best analgesic technique and evidence can be contradictory. Techniques that may be used range from central neuraxial blocks to peripheral nerve blocks, patient-controlled opioids and multi-modal oral analgesia.

Recently in orthopaedic surgery large volumes of local anaesthetic combined with non-steroidal anti-inflammatory drugs and adrenaline have been successfully used as an analgesic technique. The aim of this study was to see if systematically injected local anaesthesia infiltration compared with placebo can reduce the total rescue analgesic consumption. Patients included were ASA I-III women undergoing total abdominal hysterectomy for a benign uterine lesion. Patients were randomised and both patients and health-care professionals were blinded to the method of analgesia. All patients otherwise had a standard pre-medications, anaesthetic technique and post-operative plan for analgesia. The intervention group received local analgesia infiltration with 300mg of ropivacaine, 30mg ketoralac and 0.5mg of adrenaline. The control group received the same volume of infiltrate of 0.9% saline. The primary outcome was to look at the doses of rescues analgesia and pain scores over the first 24 postoperative hours.

The study found that patients who had local analgesia infiltrated had a lower opioid consumption during the first 24 hours, lower pain scores during the first two post-operative hours and a longer time before they needed a first dose of rescue analgesia. This suggests that local analgesia infiltration may be effective, at least in the short term. The study does have some limitations and ends by concluding that further studies are needed to improve and refine the technique. However, it is a relatively simple and low cost technique that seems to show promise.

Effect of endotracheal tube cuff shape on postoperative sore throat after endotracheal intubation. Chang JE, Kim H, Sung-Hee L, Jung-Man J. Anesthesia & Analgesia 2017 doi:10.1213/ANE.0000000000001933

Having a postoperative sore throat is often seen as a minor and unavoidable compilation that we should not be concerned about. The reported incidence is between 21% and 74% and although a minor complication it can significantly impact on patient satisfaction and postoperative function. There are several factors that mediate the incidence of a postoperative sore throat including: endotracheal tube size, intracuff pressure and duration of intubation. Specifically the area of cuff-trachea contact has been implicated in the development of a postoperative sore throat and hoarseness. Current recommendations are to use high-volume low-pressure cuffs to reduce ischaemic complications due to high endotracheal cuff pressure. But the increased area of cuff-tracheal contact may exacerbate the incidence of a sore throat. An endotracheal tube with a distally tapered cuff has been developed – mainly because it is known that longitudinal folds along the endotracheal tube cuff can lead to aspiration of upper airway secretions and intubation-related pneumonia. A taper-cuff is thought to reduce this.

This study hypothesised that a tapered cuff may reduce the incidence of post-operative sore throat and hoarseness due to the decreased cuff diameter and decreased cuff-trachea contact area. Patient were randomised to be intubated with either a standard endotracheal tube (cylindrical-shaped cuff) or a tube with a tapered cuff. The primary outcome was the incidence of postoperative sore throat. The severity of the sore throat and the presence of hoarseness were secondary outcomes. The patients who were intubated with an endotracheal tube with a tapered cuff had significantly lower incidences and less severe postoperative sore throat.

This may prove to be a relatively easy method of reducing a complication that affects patient outcome after surgery.

Background noise lowers the performance of anaesthesiology residents’ clinical reasoning when measured by script concordance: a prospective randomised crossover volunteer study. Enser M, Moriceau J, Anily J et al. European Journal Aaesthesiology 2017;34:1-7 doi:10.1097/EJA.0000000000000624

Noise is present pretty much everywhere in hospital and more particularly operating theatres and intensive care units. Studies have been done on the negative effects of noise on patients and shown that it indices stress, discomfort and lack of sleep. The most commonly reported health consequence for clinical staff is hearing loss if exposed to high levels of noise. However, noise can impact negatively on the clinical performances of staff causing impaired communication, concentration and even short-term memory loss.

A study has shown that noise can interfere with perception of the pulse oximeter can the anaesthetist’s ability to detect a reduction in oxygen saturation. The WHO recommends that should levels should not exceed 35decibels for continuous sound and should remain below 40 decibels in hospitals at night. Average sound levels in several different studies give noise ranges of 56-71 decibels in operating theatres and 52-59 decibels in intensive care units with peak levels in both above 100 decibels. Residents were given clinical situations to work through with questions about diagnosis, investigation or management which were considered difficult for even experienced anaesthetists. They were given a scenario with pertinent details missing and asked to make a clinical decision. As they did another piece of clinical information was given and so on. The residents were split into two groups and each did one part of the assessment in a quiet environment and the other part in a noisy environment. The noisy environment was recreated using background noise from real emergency situations. Residents were found to have significantly poorer performances in noisy environments than in quiet environments. Junior residents seem to be affected to a greater extent than more senior residents.

Noise can widely affect communication between various personnel in an operating theatre and is a risk factor for medical error. Therefore it should be limited wherever possible. Studies in novice surgeons have also found that they are more likely to make errors when working in a noisy environment. The implementation of awareness campaigns could be a way of raising awareness about this issue. Another option that has been suggested is the adaptation of ‘sterile cockpit rules’ to eradicate non-essential communication during critical phases. However, in reality the silent operating room is rarely a realistic concept. An alternative approach may be for anaesthetists to adapt to working in noisy conditions so that they can function in the invariable loud environments of certain emergency situations.

The Association of Frailty with outcomes and resource use after emergency general surgery: a population-based cohort study. McIsaac D, Moloo H, Bryson G et al. Anaesthesia & Analgesia 2017;124(5):1653-1661 doi:10.1213/ANE.0000000000001960 

Patients over 65 years old have surgery more often than any other age group. We know that a small subset of high risk patients have the highest morbidity and mortality rates (Pearse et al. 2006). Age is an independent risk factor of adverse postoperative outcomes and the likelihood for the patient to need increased resources. In April 2017 we looked at an article describing how frailty is an important condition that should be assessed more commonly. The presence of frailty increases exponentially with age so it is an important area to look at particularly for emergency surgery.

The effect of frailty on outcomes after elective surgery is well documented but there is less work done on the association between frailty and outcome or rescue use after emergency surgery. This study looked at residents in Ontario aged over 65 admitted for emergency surgery. Patients were assessed for frailty and the primary outcome was death within 365 days of surgery. 25.6% of patients (out of a sample size of 77,184 patients) were identified as frail. Death within 1 year of surgery occurred in 33.5% of frail patients as opposed to 19.8% of non frail patients. Not unexpectedly frailty was associated with many other adverse postoperative outcomes, in particular for patients admitted from home a 5 times increased chance of discharge to a rehab or nursing facility.

Perhaps surprisingly the mortality and complication rate were highest in patients having more common and lower absolute risk mortality procedures such as appendicectomy and cholecystectomy. This may be because these procedures are perceived as lower risk and therefore the presence of frailty may not have raised as much concern i.e. a greater willingness to take a higher risk patient to theatre for a smaller procedure. This is similar to the pattern that has been reported for elective surgery. Emergency surgery is very different to elective surgery in that there is not the same length of time to optimise patients. However, it is clear that efforts need to be made to improve risk assessment, care and outcomes for older frail patients in the unique setting of emergency surgery.

Early systolic dysfunction following traumatic brain injury: a cohort study. Krishnamoorthy V, Rowhani-Rahbar A, Gibbons E et al. Critical Care Medicine 2017;45(6):1028-1036 doi:10.1097/CCM.0000000000002404

Previous studies have suggested that traumatic brain injury (TBI) may affect cardiac function. Patients with moderate-severe TBI often have episodes of hypotension early in their hospitalisation which can lead to decreased blood flow to an injured brain. Other studies of non-TBI such as subarachnoid haemorrhage suggest that acute systolic cardiac function may be responsible for the early hypotension seen in catastrophic neurologic processes. A study published in Neurocritical Care Journal in 2011 suggests that the most commonly used vasopressor in this situation is phenylephrine. But fluid therapy and vasopressor selection may be better directed if the cardiac function is known. Patients with moderate-severe TBI were compared with patients with mild TBI. All recruited patients had a transthoracic echocardiogram the day following their injury. For patients with moderate-severe TBI the echo was repeated within 2-4 and 7-9 days of injury. The primary findings of this study are:

  1. Early systolic dysfunction can occur in previously healthy patients following moderate-severe TBI
  2. Systolic function recovers within the week following injury
  3. Younger age and greater TBI severity are independently associated with the development of systolic dysfunction early after TBI
  4. None of the patients with mild TBI had evidence of early systolic dysfunction

This study provides clinically important information. Previously episodes of hypotension in patients with TBI and no other injuries were thought to be due to the physiologic stress of the brain injury, fluid shifts and/or the effect of sedative. Knowledge of early systolic dysfunction may allow a more rationalised approach to fluids and vasopressor use. Prevention of systolic dysfunction by the addition of beta-blockers may be a consideration for the future – beta-blockers have already been associated with a survival benefit in TBI patients (Systematic review and meta-analysis published in Neurocritical care in 2014).

This is a small study but it does throw up some new information. Larger studies are now needed to confirm this and future research needed to looks at the factors associated with cardiac function and TBI and test therapies that may optimise cardiac function.

Chewing gum & PONV

Chewing gum for the treatment of postoperative nausea and vomiting: a pilot randomized controlled trial. Darvall JN, Handscombe M, Leslie K.  British Journal Anaesthesia 2017;118(1):83-89.

Presented by: Dr K James

Background

 Two main areas of  which paper aims of addressing:

  1. Pilot study to test feasibility of a larger Randomised Controlled Trial
  1. Chewing gum may be non-inferior to ondansetron in inhibiting Post Operative Nausea and Vomiting (PONV)
    • Currently no existing study examining the effect of gum chewing on PONV.
    • It is postulated to reduce nausea and vomiting via the ‘sham feeding’ effect linked to vagal stimulation.
    • Meta-analysis (272 patients, 7 RCTs) demonstrated reduced time to first flatus and bowel motion and a non-significant trend towards earlier hospital discharge.
  • Chewing gum may be beneficial in the post operative care setting because:
    • It is a non-pharmacological agent,
    • There are very few side effects
    • It can be self administered

Design & setting

  • Randomized controlled non-inferiority trial to test the hypothesis:

“Chewing gum in the PACU would prove to be non-inferior to ondansetron for the treatment of PONV in female patients after laparoscopic or breast surgery and to test the feasibility of a large multicentre RCT”

  • Non Inferiority defined as a difference between groups of <15% in a per protocol analysis
  • Study was carried out in PACU, Department of Pain and Anaesthesia in Royal Melbourne Hospital,
  • Ethical approval gained 

Subjects

  • Female adult patients
  • ASA I–III
  • Laparoscopic or breast surgery
  • January – June 2016.
  • Written consent was gained from patients
  • Patient/doctor/anaesthetist blinded until patient experienced nausea or vomiting in PACU

 Intervention

  • 155 patients eligible, 53 excluded. Not all reasons for exclusion were disclosed, but a high proportion was due to failure to recruit both anaesthetist and patient.
  • 94 randomized pre-operatively
  • Control arm (n = 46)
    • Received IV anti-emetics on the occurrence of PONV in PACU (current standard of care.)
    • Ondansetron 4mg IV
  • Chewing gum arm (n = 48)
    • Chewing gum administered as first line on occurrence of PONV in PACU
    • Rescue IV anti-emetics available if required.
  • Relief of PONV graded on four point verbal descriptive scale

Outcomes

  • Primary outcome:
    • Full resolution of PONV after either ondansetron or chewing gum.
  • Secondary outcomes:
    • Duration of PACU stay
    • Anti-emetic rescue use
    • Patient acceptability of anti-emetic treatment.
  • Feasibility outcomes:
    • Recruitment rate
    • Protocol compliance
    • Incidence of PONV
    • Ability to chew gum

Results 

The investigators state that:

  • Chewing gum was non-inferior to ondansetron for the treatment of PONV.
    • (Symptoms resolution of 75% and 39% respectively)
  • Non-inferiority statistics demonstrated a p-value of 0.07. (Not significant)
  • No difference in secondary outcomes between groups.
  • Recruitment was satisfactory, protocol acceptable to anaesthetists and nurses, data collection was complete.

Conclusions

On face value, with little critical appraisal of the paper the following conclusions can be made from reading the authors conclusions:

  • Chewing gum was not inferior to ondansetron for treatment of PONV after general anaesthesia for laparoscopic or breast surgery in female patients.
  • Larger multi-centred RCT is feasible

 Strengths

  • Clearly states only a pilot study throughout the report
  • Transparent data collection and data representation
  • Data and results presented thoroughly. Very nice paper to read which looks very appealing.
  • Novel and interesting treatment and solution to PONV

Weaknesses

  • It is only a pilot study, not a RCT (and they had already performed a pilot study for this debate in question)
  • A power calculation was performed, but them not adhered too.
  • They assessed whether PONV was present or absent, its severity was not assessed.
  • There was a variation in medications used intraoperatively which may have effected the results:
    • Additional opioids
    • Reversal agent
    • Intra-op. antiemetics
  • Variation in surgery:
    • Laraoscopic and breast surgery which have two very different profiles of emesis.
  • Peppermint flavour of the chewing gum used may be a confounding factor as it has been reported that peppermint settels the stomach
  • More than 50% of patients of the Chewing Gum group received pharmacological anti emetics. 

Implications and Potential for impact

  • Future RCT could be feasible
  • Interesting study, well presented
  • No conclusions can be drawn about chewing gum as an anti emetic
  • I wont be prescribing Wrigley’s Extra on anaesthetic charts!

Although the paper was written and presented very well, it is trying to find an answer to a problem that does not exist because ondansetron is very well tolerated by most patients, is cheap and not very labour intensive to administer. Conversely, chewing gum, if administered to patients who are too sleepy, could cause harm. The data is analysed in such a way that it is very difficult to follow, and indeed gain any conclusions from.

January 2017

Written by Dr C. Williams

A systematic review of the analgesic efficacy of cannabinoid medications in the management of acute pain. Acta Anaesthesiologica Scandinavica 2017 doi:10.1111/aas.12851

It is becoming increasingly common to find reports or see patients who are convinced that cannabis or cannabinoid medication help with their acute pain. Recently I have spoken to several elderly patients who like to ‘smoke a joint’ every night because it helps with various aches and pains. This systematic review aimed to assess the analgesic efficacy and adverse effects of cannabinoids when used for acute pain. It looked at 7 studies. 5 studies found cannabinoids worked as well as a placebo, 1 study found them to be superior and 1 found them to be inferior.

Sadly for these patients convinced that cannabis is the answer to their pain, this systematic review concluded that cannabinoids were no better than a placebo either by themselves or combined with opioids and 5 of the studies found that adverse effects were more common than with placebo.

Calling the patient’s own name facilitates recovery from general anaesthesia: a randomised double-blind trial. Anaesthesia 2017;72:197-203

‘The cocktail party effect’ describes the effect where one can tune into one voice even in a noisy room, and also how one can immediately detect words of importance such as hearing one’s name in another conversation.

The authors of this study found that after discontinuing the anaesthetic, calling the patient by their name meant that they opened their eyes quicker and the time to i-gel removal was faster. A BIS of 60 was reached in a shorter time and patients spent less time in the post anaesthetic care unit. There are limitations to the study but either way using the patient’s name is an easy method to aid recovery.

But surely out of respect for the patient should we not be doing this anyway?

Editorial: Real-time physiologic monitoring and physician feedback: Are we ready? Canadian Journal of Anaesthesiology 2017;64:239-241

Individual and group data feedback was given to anaesthetists regarding their management of intraoperative temperature monitoring, firstly the percentage of time the patient was hypothermic and secondly the time taken from the start of the case to the first temperature measurement. Giving feedback didn’t change the amount of time the patient was hypothermic however it did reduce the delay in starting to monitor temperature.

The concept of physician feedback as a QI tool is becoming increasingly popular. The authors reason that the reduction shown in the time taken to start temperature monitoring is evidence that providing feedback may contribute to improved perioperative outcomes.

Or is it possible that giving feedback results in the Hawthorne effect – the knowledge of being measured changes behaviour? Does it matter if the goal is to modify current practice? Individualised and group feedback means we need to accept our imperfections to drive improvement. Hospitals will continue to use QI strategies to improve patient care and reduce costs.

As clinicians we need to accept feedback and undergo a cultural shift from ‘shame and blame’ to high-quality continuous improvement focusing on providing the best care for the patient.

Impact of a perioperative quality improvement programme on postoperative pulmonary complications. Anaesthesia 2017;72:317-327

Postoperative pulmonary complications are

  1. common (incidence of between 2-40%)
  2. associated with adverse outcomes (death/increased length of stay/survival)

Enhanced recovery programmes don’t really address this. A team in Manchester developed an ERAS+ programme aimed at reducing pulmonary complications. It incorporated ICOUGH and surgery school (with videos via youtube). In patients undergoing major surgery admitted to critical care postoperatively, pulmonary complications reduced from 19.3% to 10.5% post implementation of ERAS+. One year after ERAS+ was introduced pulmonary complication rate was 8.7%. Patient surveys showed satisfaction with the surgery school. From the data presented it appeared a relatively low-cost programme to set up. Is the new type of peri-operative pathway involving the patients and their families working with multi-professional healthcare teams where we should be heading? On first glance it seems low-cost, effective and well received by patients………

Surgery School focused on:
Nutrition
Breathing
Activity
Oral health
Psychological support
General health
Family support

 

I incentive spirometry
C cough/deep breathing
O oral care
U understanding patient education
G get out of bed
H head of bed elevation

 

Implantation of an Artificial Larynx after Total Laryngectomy. New England Journal of Medicine 2017;376:97-98 doi:10.1056/NEJMc1611966

Total laryngectomy is a lifesaving operation in patients with advanced laryngeal and hypo laryngeal cancer. But it comes with a substantial reduction in the quality of life.  This is a case report of a patient from France who had an artificial larynx implanted in 2015. The artificial larynx consists of a permanent tracheal prothesis with a removable open-ventilation cap that allows continuous passage of air while protecting the patient’s airway from aspiration. This cap allows the patient to breathe and drink fluids. It also opens transiently with coughing to allow secretion expulsion. Over a 16 month follow-up period the patient was able to breathe and expectorate through the upper airways and maintain oxygen saturations on air. He was able to swallow saliva although occasionally aspirated food.

A very short case report and clearly more work may be needed before this becomes a common place procedure but could this be the future for patients needing total laryngectomy?

Anaesthesia and Developing Brains – Implications of the FDA warning. New England Journal of Medicine 2017 doi:10.1056/NEJMp1700196

For a long time there has been a lot of debate about the neurotoxic effects of anaesthetic agents on the neurodevelopment of young children and foetuses. In 2014 an FDA Science Board meeting found that all anaesthetic agents have ‘immediate neuroanatomical consequences and are associated with long-lasting, if not permanent functional effects’.

Clinically this is a little more difficult to interpret. Healthy children rarely undergo repeated or long procedures under general anaesthetic. Brains of premature or children with congenital heart disease may have already been injured by inflammation or chronic hypoxia before having general anaesthetic. More recent studies have shown that a brief single exposure to general anaesthesia is not associated with poorer neurodevelopment outcomes. More results are expected later this year with the conclusion of the Mayo Anesthesia Safety in Kids (MASK) study.

Yet in December 2016 the FDA issued a ‘Drug Safety Communication’ warning 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. Rarely can procedures be safely delayed if indicated during these periods of life. Is the FDA warning wise?

This will already be a time of high stress for parents and families, and there is a risk that the FDA warning may cause delay in procedures that are needed. Parents, patients and doctors must be careful when considering the risk of delaying procedures due to this warning, especially given it states that ‘additional high quality research is needed’. We must be prepared for this question to be asked given that this was covered in the mainstream media and tabloids at the time………

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