Perioperative Journal Watch September 2016

Welcome to the September 2016 Perioperative Medicine Review newsletter.  This month we have quite a broad church of articles covering perioperative analgesia, utility of bare metal vs. drug eluting stents for coronary artery disease, as well as an interesting examination of the effects of introducing a new electronic medical health records system on patient outcomes in several US hospitals; thankfully no adverse effects were seen.

One article looking at the discrepancy between patient and physician reported functional assessment is of key interest.  Quality, reproducible markers of functional capacity are available and should be used in the planning of care and in risk stratification. This article underlines the importance of quantitative measures of function to support qualitative reporting.

Two particular articles are of interest.  The first, from the authors of the VISION study, the progenitor of a procession of important articles underlining the critical consequences of perioperative myocardial injury.  The authors call for perioperative troponin screening in order to better identify those at highest risk and direct therapeutic interventions to reduce perioperative morbidity where needed.  What is still opaque is which interventions are likely to be of greatest benefit in the perioperative population.  Certainly screening may be the first step, but high quality clinical trials are needed to confirm exactly what to do about perioperative myocardial injury.

The second is an editorial suggesting, somewhat provocatively, that since anaesthesia itself is so very safe nowadays, we, as perioperative physicians, should now hold in our mind the goals of the patient drinking, eating and mobilising (the DREAM from the CHEERS-DREAM campaign) as ideal perioperative outcomes, and the focus of our approach to anaesthesia and the perioperative period.

Please email me at johnwhittle@doctors.org.uk with further ideas and contributions for this newsletter.  I would be vey pleased to include infographics and visual abstracts in future editions.

Significant discrepancies exist between clinician assessment and patient self assessment of functional capacity by validated scoring tools during preoperative evaluation

 

Reference:

Stokes J, Wanderer J, McEvoy M.  Significant discrepancies exist between clinician assessment and patient self assessment of functional capacity by validated scoring tools during preoperative evaluation, Perioperative Medicine (2016) 5:18

 

Headline Summary: 

Patient survey assessing feasibility of pre-operative, patient self-triage regarding functional capacity. There was a significant discrepancy between clinician assessments and patient self-assessments of functional capacity.

 

 

 

Link to article:

https://perioperativemedicinejournal.biomedcentral.com/articles/10.1186/s13741-016-0041-4#Bib1

Theme:

Perioperative medicine

Key words:

Functional capacity, preoperative assessment

Drug-Eluting or Bare-Metal Stents for Coronary Artery Disease

 

Kaare H. Bønaa, M.D., Ph.D., Jan Mannsverk, M.D., Rune Wiseth, M.D., Ph.D., Lars Aaberge, M.D., Ph.D., Yngvar Myreng, M.D et al. Drug-Eluting or Bare-Metal Stents for Coronary Artery Disease. New England Journal of Medicine. 2016, DOI: 10.1056/NEJMoa1607991

Headline Summary:

A multicentre, randomized trial comparing drug-eluting stents and bare-metal stents showed no difference in outcome of death from any cause or nonfatal spontaneous myocardial infarct but a significant reduction in repeat revascularisation with drug eluting stent group. 

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1607991

Theme:

Perioperative medicine

Key words: 

Acute coronary syndrome, postoperative complications

Article Type: 

Original Research

Preoperative paracetamol improves post-cesarean delivery painmanagement: a prospective, randomized, double-blind, placebo-controlled trial.

Ozlem Ozee, Cagla Bali, Oya Yalcin, Pinar Ergenoglu, Nesrin Bozdogan Ozyilkan, sule Akin, Hakan Lalaycim Anis Aribogan. JCA 2016; 33: 51-57

Preoperative use of single-dose intravenous 1g paracetamol was found to be effective in reducing the severity of pain and opioid requirements within 24 hrs after caesarean section.

 

Theme:

Perioperative medicine, Perioperative Analgesia, Pain

Key words: 

Preoperative analgesia ; Caesarean delivery ; General anesthesia, Pain

Article Type: 

Original Research

Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Total Laparoscopic Hysterectomy: A Randomized, Controlled, Observer-Blinded Trial.

Anesthesia & Analgesia. 123(2), August 2016, p 488–492

 

Ghisi, Daniela MD; Fanelli, Andrea MD; Vianello, Federico MD; Gardini, Marco MD; Mensi, Giulio MD; La Colla, Luca MD; Danelli, Giorgio MD

Small RCT with 52 patients; no difference in the consumption of morphine in the first 24 hours between the groups.

Link to article: (Full text/abstract)

http://ovidsp.tx.ovid.com.libproxy.ucl.ac.uk/sp-3.21.1b/ovidweb.cgi?&S=ODFCFPONLKDDPDBGNCIKABFBOHNLAA00&Link+Set=S.sh.22.23.27.32.37.42%7c25%7csl_10

Theme:

Perioperative medicine, Perioperative Analgesia, Pain

Key words: 

Preoperative analgesia ; TAP ; General anesthesia, Pain; Transversus Abdominis Plane

Quality Improvement:

Observational study with difference-in-differences analysis.

Adverse inpatient outcomes during the transition to a new electronic health record system: observational study

BMJ 2016; 354

Barnett Michael L, Mehrotra Ateev, Jena Anupam B.

Headline Summary:

Authors examined adverse safety events and re-admission and mortality rates at 30 days of discharge among patients at 17 US hospitals. The study period was 90 days before and after implementation of the EHR. Data was compared to 399 control hospitals in the same hospital referral region. There was no overall negative effect of implementation of EHR on the outcomes.

There is an accompanying editorial: When hospitals switch to electronic records; Wears, Robert L; BMJ 2016; 354

Link to article:

http://www.bmj.com/content/354/bmj.i3835

Theme:

Quality Improvement

Key words:

EPR, Health records

Special Article:

Perioperative Troponin Screening.

Anesthesia & Analgesia 23(2), August 2016, p 359–360

 

Sessler, Daniel I. MD; Devereaux, P. J. MD, PhD

 

In this article the authors of the influential VISION study argue for troponin screening in surgical in-patients over 45 years for the first 3 post-operative days. Mortality at 30 days in patients with a troponin rise increases 5-fold, and myocardial injury is clinically silent in 65% of cases. NNT to detect myocardial injury in this group is 15.

 

Link to article: (Full text/abstract)

http://ovidsp.tx.ovid.com.libproxy.ucl.ac.uk/sp-3.21.1b/ovidweb.cgi?&S=ODFCFPONLKDDPDBGNCIKABFBOHNLAA00&Link+Set=S.sh.22.23.27.32.37.42%7c11%7csl_10

 

Theme:

 

Patient safety, Cardiology

 

Key Words

 

Cardiac Infarction, MINS, MACE, Cardiac Injury, Cardiology

 

Guidelines

New US guidelines for the management of postoperative pain are referred to in this month’s Analgesia and Analgesia Journal Watch

Anesthesia & Analgesia August 2016 123 (2)

Similarly, guidelines for the screening assessment and management of Adult Patients with Obstructive Sleep Apnea are available in the same journal

Anesthesia & Analgesia 23(2), August 2016, p 263-522

http://ovidsp.tx.ovid.com.libproxy.ucl.ac.uk/sp-3.21.1b/ovidweb.cgi?&S=ODFCFPONLKDDPDBGNCIKABFBOHNLAA00&WebLinkReturn=Full+Text%3dL%7cS.sh.22.23.27.32.37.42.55%7c0%7c00000539-201608000-00011&TOC=S.sh.22.23.27.32.37.42.56%7c1%7c60

Editorial:

Anaesthesia Vol 71, no 9, Sept 2016

Is the pursuit of DREAMing (drinking, eating and mobilising) the ultimate goal of Anaesthesia Anaesanaesthesia?

N. Levy, P. Mills and M. Mythen 1008

Upcoming Conferences:

Improving and Enhancing Perioperative Medicine

Thursday 13 October 2016
Hallam Conference Centre, London

 

Follow this conference on Twitter #perioperative

This second national UK conference, which is aimed at all members of the multidisciplinary perioperative team, focuses on improving and enhancing perioperative medicine with a focus on high risk surgical patients and those with comorbid conditions following the 2015 report by the Royal College of Anaesthetists.

Through national updates , and practical case studies the conference aims to improve the perioperative pathway for these patients, improving patient outcomes and efficiency.

 

http://www.healthcareconferencesuk.co.uk/improving-and-enhancing-perioperative-medicine