Perioperative Journal Watch January 2017

Welcome back to Perioperative Journal Watch and Happy New Year.  We are experimenting with content and style in preparation for choice elements to be included in a regular print publication. This month the format of reporting is varied.  We have presented both expanded abstracts and bullet point headlines.  We would appreciate any feedback as to the style you the reader prefer! Similarly, should you wish to contribute, please email johnwhittle@doctors.org.uk

This month’s content is varied and contains something for all perioperative medicine enthusiasts! Articles cover a range of topics from whether surgical training is suitably patient centred, to the surgical Apgar score and early goal directed mobilisation.   

TriPOM (trainees with an interest in perioperative medicine) is an educational collaborative.  We hope to act as a hub for open access educational materials in perioperative medicine, as well as information about fellowships.  We are currently producing a monthly tutorial (POMTOM) and will be hosting a half day breakout at EBPOM 2017.  If you would like to contribute or know more, then please visit is at tripom.squarespace.com and follow our twitter feed (@triperioperati1)

 

Opinion

Palliative Care and Surgical Training: Are We Being Trained to Be Unprepared?

Wancata: Hinshaw, D: Suwanabol, P. Annals of Surgery, 265 (1); 32-33 January 2017

Headline summary:  Surgical training is focused around technical skills and is procedure not patient centered.

Link: http://ovidsp.uk.ovid.com/sp-3.23.1b/ovidweb.cgi?&S=OKMBPDCPFPHFOJGJFNHKJEEGNDHNAA00&Link+Set=S.sh.5177_1482755555_48.5177_1482755555_60.5177_1482755555_68.5177_1482755555_70.5177_1482755555_73.5177_1482755555_79%7c7%7csl_10

Theme: Palliative care

Key words: Palliative, dying, training

 

Editorials of Interest:

Pre-operative testing guidelines: a NICE try but not enough

Anaesthesia Vol 71, Issue 12, Dec 2016 Pages 1403–1407

K.K Dhatariya, M.D. Wiles

It is interesting how after 13 years, NICE has recently updated the guidance on pre-op testing for adults undergoing elective surgery. Again, is it very variable depending on what the anaesthetist feels necessary to provide optimal perioperative care. We are aware of the complexity of how subjective ASA grading is, therefore the current protocol tends to favour over-testing especially in day-case surgery and young patients. Tests for diabetes and anaemia are frequently done pre -op but appropriate actions not taken to optimise patients until post-operative period.

 

Standardising anaesthesia for hip fracture surgery

Anaesthesia Vol 71, Issue 12, Dec 2016 Pages 1391–1395

S.M White, R Griffiths, I.K Moppett

Anaesthesia Sprint Audit of Practice (ASAP) showed a wide variation in anaesthesia practice for hip fracture as patients present with wide range of pathophysiology. However, all the anaesthetic methods were believed to be the safest of care for that individual patient at the time. Various interest groups have tried to push for a standardised care pathway for hip fracture surgery at national level. Surprisingly, the only professionals within the multidisciplinary team not having standardised practice were anaesthetists. It is about time the anaesthetists conform to a standardised evidence based anaesthesia for hip fracture and move forward for a better outcome report.

 

A Time of Opportunity”: Patient Safety and the Perioperative Surgical Home

 

Garson, Leslie M. MD, MIHM; Vakharia, Shermeen MD, MBA; Edwards, Angela F. MD; Maze, Mervyn MBChB

 

A&A Volume 123(6), December 2016, p 1348–1350

 

The authors argue that the PSH is an opportunity for anaesthetists to advocate for and improve patient safety. The editorial highlights the scale of the challenge, and the need for solutions to systemic problems. It refers to Berwick’s call for organisations to foster a safety culture. It also sets out the argument that validated patient safety measures are required, with data being available to clinicians in a timely fashion. It refers to other papers in the issue, which describe the introduction of patient screening questionnaires and electronic co-ordination of care prior to surgery.

 

Intensive Care:

Intravenous iron or placebo for anaemia in intensive care: the IRONMAN multicentre randomized blinded trial

The IRONMAN investigators,Litton, E., Baker, S. et al Intensive Care Medicine 2016. Doi:10.1007/s00134-016-4465-6

Background:

Both anaemia and allogenic red cell transfusion are common and potentially harmful in patients admitted to the intensive care unit.

The jury is still out on the role that intravenous iron plays in the perioperative setting in the correction of perioperative anaemia-awaiting the PREVENTT trial results.

Design:

Multicentre, randomised, controlled trial

140 patients were enrolled, 70 assigned to IV Iron and 70 to placebo.

Outcomes:

In anaemic patients admitted to the intensive care unit, intravenous iron did not result in a significant lowering of red blood cell transfusion requirement. However, patients who had received intravenous iron had a significantly higher haemoglobin concentration at discharge.

Link

http://link.springer.com/article/10.1007%2Fs00134-016-4465-6

Clinical Physiology

Baseline Pulse Pressure, Acute Kidney Injury, and Mortality After Noncardiac Surgery

 

Oprea, Adriana D. MD; Lombard, Frederick W. MB, ChB, FANZCA; Liu, Wen-Wei MSc; White, William D. MSc; Karhausen, Jörn A. MD; Li, Yi-Ju PhD; Miller, Timothy E. MB, ChB, FRCA; Aronson, Solomon MD, MBA; Gan, Tong J. MD, MHS, FRCA; Fontes, Manuel L. MD; Kertai, Miklos D. MD, PhD

A& A Volume 123(6), December 2016, p 1480–1489

 

Increased pulse pressure (PP) is an important independent predictor of cardiovascular outcome and acute kidney injury (AKI) after cardiac surgery.

 

Baseline BP was measured pre-anaesthetic induction in 9125 adult patients at Duke University Medical Center. Multivariable logistic regression analysis was performed to determine whether baseline PP adjusted for other perioperative risk factors was independently associated with postoperative AKI and 30-day mortality.

 

In the risk-adjusted model for postoperative AKI, elevated baseline PP was associated with higher odds for postoperative AKI, and for mild AKI.

-adjusted odds ratio [OR] for every 20 mm Hg increase in PP, 1.17; 95% confidence interval [CI], 1.10–1.25; P < .0001

 

Elevated PP was not significantly associated with more advanced stages of postoperative AKI or 30-day mortality in these patients.

 

 

Effects of ischaemic conditioning on major clinical outcomes in people undergoing invasive procedures: systematic review and meta-analysis

 

BMJ December 2016

 

The effect of ischaemic conditioning (IC) has been studied in patients having surgery (especially cardiovascular surgery), as well as in patients who require PCIs and secondary stroke prevention. However, few large studies have been conducted, the follow-up of participants was generally short, and the findings were only moderately precise. This review sought to define the effect of IC on outcomes in a variety of settings.

 

It examined 85 trials (13800 patients).

 

Ischaemic conditioning does not reduce mortality, and further research on this outcome is unlikely to be worthwhile.

 

Ischaemic conditioning may reduce myocardial ischaemia, stroke, and acute kidney injury - seen in stroke and PCI groups. However, there was a lack of effect on the composite outcome of major adverse cardiovascular events. And, the beneficial effect on AKI was reduced as AKI severity increased, suggesting that IC may not be effective for more severe and clinically significant cases.

 

Further high quality trials are needed before it has any role in routine clinical practice (there are 61 registered trials of ischaemic conditioning which are recruiting patients).

 

 

 

Preoperative Assessment:

Preoperative Renal Insufficiency: Underreporting and Association with readmission and Major Postoperative Morbidity in an Academic Medical Center

 

Blitz, Jeanna D. MD; Shoham, Marny H. MD; Fang, Yixin PhD; Narine, Venod MD; Mehta, Neeraj MD; Sharma, Beamy S. MD; Shekane, Paul MD; Kendale, Samir MD

Volume 123(6), December 2016, p 1500–1515

 

This retrospective analysis of over 39,000 patients sought to explore the predictive value of a single reduced preoperative eGFR value on adverse patient outcomes in the first 30 days after elective surgery.

 

Patients with reduced eGFR (<60 mL/min/1.73 m2) were identified and categorized by the stages of CKD that correlated with the preoperative eGFR value. Odds of readmission to hospital within 30 days, as well as new diagnosis of AKI, myocardial infarction, and infection, were determined with multivariate logistic regression.

 

Among patients with an eGFR <60, 81.2% did not carry a preoperative diagnosis of CKD.

 

Adjusted odds ratios for readmission (compared with patients with a preoperative eGFR value >=60):

1.48 (99% confidence interval [CI], 1.18–1.87; P < .001) for eGFR 30 to 44

2.06 (99% CI, 1.32–3.23; P < .001) for eGFR <15

 

AKI

2.78 (99% CI, 1.86–4.17; P < .001) for eGFR 45 to 59

3.81 (99% CI, 1.68–8.16; P < .001) for eGFR <15

 

This study highlights that preoperative renal insufficiency may be underreported and appears to be significantly associated with postoperative complications.

 

 

Prediction of Outcome After Emergency High-Risk Intra-abdominal Surgery Using the Surgical Apgar Score

 

Cihoric, Mirjana MD; Toft Tengberg, Line MD, PhD; Bay-Nielsen, Morten MD, PhD; Bang Foss, Nicolai MD, DMsC

A&A Volume 123(6), December 2016, p 1516–1521

 

The Surgical Apgar Score (SAS) is predictive of outcome in elective surgery, but has never been validated exclusively in an emergency setting.

 

The Surgical Apgar Score (SAS) is a simple score on a scale of 0 to 10 calculated from 3 variables collected during the operation: heart rate, mean arterial blood pressure, and estimated blood loss.

 

This was a consecutive prospective single-center cohort study of 355 adults undergoing emergency high-risk abdominal surgery at a Danish teaching hospital.

 

The primary outcome measure was 30-day mortality.

 

Secondary outcome measures were postoperative major complications, defined according to the Clavien-Dindo scale as well as the American College of Surgeons’ National Surgical Quality Improvement Program guidelines, and intensive care unit admission.

 

Cochran–Armitage test for trend was used to evaluate the incidence of both outcomes. Area under the curve was used to demonstrate the scores’ discriminatory power.

 

One hundred eighty-one (51.0%) patients developed minor or no complications.

 

The overall incidence of major complications was 32.7% and the overall death rate was 16.3%.

 

Risk of major complications, death, and intensive care unit admission increased significantly with decreasing SAS (P < .001). The score’s c-statistics were 0.63.

 

The SAS was found to be significantly predictive but weakly discriminative for major complications and death among adults undergoing emergency high-risk abdominal surgery.

 

The authors describe the key differences in this study population and those in which the SAS has been studied in to date (higher rates of pre-op sepsis, higher ASA-PS) and how their use of epidural anaesthesia, GDT and extended stays on the intermediary-care PACU might have diluted the results.

 

Postoperative Outcomes

Who Should Get Extended Thromboprophylaxis After Bariatric Surgery?: A Risk Assessment Tool to Guide Indications for Post-discharge Pharmacoprophylaxis

Reference:  Aminian, A; Andalib, A; Khorgami, Z et al.  Annals of Surgery.  265(1) 143-150

Headline summary: 80% of VTE events occur after discharge in bariatric patients.  Risk factors that place patients in a high risk group include; congestive heart failure, paraplegia, dyspnoea at rest and reoperation. 

Link: http://ovidsp.uk.ovid.com/sp-3.23.1b/ovidweb.cgi?&S=OKMBPDCPFPHFOJGJFNHKJEEGNDHNAA00&Link+Set=S.sh.5177_1482755555_48.5177_1482755555_60.5177_1482755555_68.5177_1482755555_70.5177_1482755555_73.5177_1482755555_79.5177_1482755555_85.5177_1482755555_91.5177_1482755555_97.5177_1482755555_103.5177_1482755555_109.5177_1482755555_115.5177_1482755555_121%7c24%7csl_10

Theme: Bariatric Surgery      

Key words: Venous thrombo- prophylaxis

 

 

 

 

Impact of Enhanced Recovery After Surgery and Fast Track Surgery Pathways on Healthcare-associated Infections: Results From a Systematic Review and Meta-analysis

Reference: Grant, M; Yang, D; Wu, C; Makary, M; Wick, E.  Annals of Surgery, 265(1) 68-79.  January 2017.

 

Headline summary: Fast track surgery and enhanced recovery programmes reduce health care associated infections. 

Link: http://ovidsp.uk.ovid.com/sp-3.23.1b/ovidweb.cgi?&S=OKMBPDCPFPHFOJGJFNHKJEEGNDHNAA00&Link+Set=S.sh.5177_1482755555_48.5177_1482755555_60.5177_1482755555_68.5177_1482755555_70.5177_1482755555_73.5177_1482755555_79.5177_1482755555_85.5177_1482755555_91.5177_1482755555_97%7c14%7csl_10

 

Theme: ERAS, Post op infections

Key words:  ERAS, FTS, HAIs

 

 

Are patient-reported outcomes correlated with clinical outcomes after surgery?

Waljee J, Ghaferi A, Cassidy et al.  Ann Surg 2016;264:682-689

Headline: In bariatric patients, patient reported outcomes are not related to complications but are related to procedural effectiveness (weight loss).

 

Abstract only (available through NHS Athens) http://journals.lww.com/annalsofsurgery/Abstract/2016/10000/Are_Patient_reported_Outcomes_Correlated_With.17.aspx

Theme:  Patient reported outcomes

Keywords:  bariatric surgery, patient-reported outcomes, quality of life

 

Prospective Randomised Controlled Trial of Liberal Vs Restricted Perioperative Fluid Management in Patients Undergoing Pancreatectomy

 

Reference: Grant F, Brennan M, Allen P et al. Ann Surg 2016;264:591-598

 

Headline: In Pancreatectomy liberal (12mls/kg) and restrictive (6mls/kg) fluid regimens have statistically insignificant differences in Grade 3 complications and length of stay.

 

Link: Abstract only (available through NHS Athens) http://journals.lww.com/annalsofsurgery/Abstract/2016/10000/Prospective_Randomized_Controlled_Trial_of_Liberal.6.aspx

Theme: Perioperative fluid management of major non-cardiac surgery

 

Key words: fluid management, Pancreatectomy, randomised controlled trial

 

 

Troponin Elevation After Colorectal Surgery

Gorgun E, Lan B, Aydinli H et al. Ann Surg 2016;264:605-611

 

Headline: 4% of patients developed a Troponin rise after colorectal surgery.  Of those 20% died, but mainly not of cardiac causes. Approximately half of these patients had a cardiology consult. 

 

Link: Abstract only (available through NHS Athens) http://journals.lww.com/annalsofsurgery/Abstract/2016/10000/Troponin_Elevation_After_Colorectal_Surgery_.8.aspx

Theme:  Cardiac complications post op

Key words:  colorectal surgery, postoperative mortality, Troponin Elevation

Quality Improvement:

Combining Systems and Teamwork Approaches to Enhance the Effectiveness of Safety Improvement Interventions in Surgery: The Safer Delivery of Surgical Services (S3) Program

Reference: McCulloch, P;  Morgan, L; New, S; et al. Annals of Surgery, 265(1), 90-96.  January 2017. 

Headline summary: Combined teamwork training, systems redesign and lean quality improvement is more effective than any one single approach in isolation. 

Link: http://ovidsp.uk.ovid.com/sp-3.23.1b/ovidweb.cgi?&S=OKMBPDCPFPHFOJGJFNHKJEEGNDHNAA00&Link+Set=S.sh.5177_1482755555_48.5177_1482755555_60.5177_1482755555_68.5177_1482755555_70.5177_1482755555_73.5177_1482755555_79.5177_1482755555_85.5177_1482755555_91.5177_1482755555_97.5177_1482755555_103%7c16%7csl_10

Theme: Quality Improvement, Safety

Key words:  TTT, Lean QI, systems

The problem with red, amber, green: the need to avoid distraction by random variation in organizational performance measures.

 

Reference: Anhøj JHellesøe AB.

 

Headline summary:  Compares two common performance indicators (red, amber, green charts vs run charts).  Falls in favor of run charts as a superior method of analyzing performance data. 

Link: http://qualitysafety.bmj.com/content/26/1/81.full

Theme: Process control

Key words: Control charts, run charts; Quality improvement; Quality measurement; Statistical process control

 

Other interesting stories:

Epidural Local Anesthetics Versus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting, and Pain After Abdominal Surgery: A Cochrane Review

Guay, Joanne MD; Nishimori, Mina MD; Kopp, Sandra L. MD

A&A Volume 123(6), December 2016, p 1591–1602

 

The aim of this review was to compare the effects of postoperative epidural analgesia with local anesthetics to postoperative systemic or epidural opioids after abdominal surgery.

 

An epidural containing a local anesthetic, with or without the addition of an opioid, accelerates the return of the gastrointestinal transit (high quality of evidence). An epidural containing a local anesthetic with an opioid decreases pain after an abdominal surgery (moderate quality of evidence). An epidural containing a local anesthetic does not affect the incidence of vomiting or anastomotic leak (low quality of evidence). For open surgery, an epidural containing a local anesthetic would reduce the length of hospital stay (very low quality of evidence).

 

Cognitive decline in the elderly after surgery and anaesthesia: results from the Oxford Project to Investigate Memory and Ageing (OPTIMA) cohort.

Anaesthesia Vol 71, Issue 10, October 2016

D Patel, A.D. Lunn, A.D. Smith, Lehmann and Dorrington

The OPTIMA database was examined in order to ascertain the time-course of cognitive decline with age following anaesthesia and surgery (1988-2008) with follow up extended to 2012.

Cognitive decline was more rapid in people who on recruitment were older, male, had worse cognition and carried the E4 allele of apoliprotein. Cognitive decline appears to accelerate after surgery in elderly individuals already diagnosed with cognitive impairment, but not in other elderly patients.

 

This Paper has been covered as part of a Journal Club at https://journalblog.co.uk/

 

 

Combination of 5-HT3 Antagonist and Dexamethasone Is Superior to 5-HT3 Antagonist Alone for PONV Prophylaxis After Laparoscopic Surgeries: A Meta-analysis

 

Som, Anirban MD; Bhattacharjee, Sulagna MD, DNB; Maitra, Souvik MD, DNB; Arora, Mahesh K MD; Baidya, Dalim Kumar MD

 

A&A Volume 123(6), December 2016, p 1418–1426

 

Data from 17 RCTs (1402 patients) were included [no statistical heterogeneity (I2 = 0) among studies].

 

The combination of dexamethasone and a 5-HT3 receptor antagonist is more effective in preventing PONV than the 5-HT3 antagonist alone.

 

-odds ratio 0.38, 95% confidence interval [CI] 0.27–0.54; number needed to treat = 6.6

 

The need for rescue antiemetic is also decreased in patients receiving the combination.

-odds ratio 0.21, 99% CI 0.10–0.46; number needed to treat = 6

 

Patients in the combination group complained of less pain after 24 hours (Weighted Mean Difference -0.67, 99% CI -1.27 to -0.08).

 

Data was insufficient to detect any significant difference in incidence of adverse effects.

 

 

 

 

Featured article:

Early goal directed mobilisation in the surgical intensive care unit: a randomised controlled trial

Reference Schaller S, Anstey M, Blobner M, Edrich T, Grabitz S, Ilse Gradwohl M et el Lancet 2016;388(10052):1377-1388

Expanded abstract

Background:

Immobilisation predicts adverse outcomes in patients in the surgical intensive care unit. Disuse atrophy and functional decline are common. Attempts to mobilise patients early after surgery in the intensive care unit are frequently restricted.

This multicentre study (5 hospitals) randomly assigned 200 patients to receive standard treatment(n=96) or the intervention (n=104);the intervention being the use of early goal directed mobilisation using a validated surgical intensive care unit optimal mobilisation score (SOMS).

Design:

Randomised controlled trial

Results:

The intervention group had improved mobilisation level(p<0.0001), reduced length of stay in the intensive care unit (p=0.0054) and improved functional mobility at discharge (p=0.0002).

Link:

http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)31637-3/fulltext

Accompanying comment:

http://thelancet.com/journals/lancet/article/PIIS0140-6736(16)31745-7/fulltext