Welcome to the February Journal Watch. This month we look at Perioperative outcome after regional anaesthesia, examine one novel way of preventing postoperative delirium as well as looking at whether Clopidogrel does increase bleeding in the month after GI surgery as well as much more. This month concludes with an older but useful review on postoperative urinary retention and a leak to the future: systems design to improve intraoperative glucose monitoring. Please contribute interesting articles in the format below to email@example.com
Regional Anaesthesia and Perioperative Outcome
Factors Associated With Risk of Neurologic Complications After Peripheral Nerve Blocks: A Systematic Review.
Anesth Analg 2017;124:645–60)
Randomized controlled studies, case–control studies, cohort studies, retrospective reviews, good quality systematic reviews and case reports/case series reporting neurologic outcomes after PNB were included.
Much of the evidence for risk factors comes from animal models and case reports. Of the human studies, few were designed to test associations between a specific risk factor exposure and neurologic sequelae.
Among the factors investigated in humans, block type, procedure-related paraesthesia, needle design appeared to increase risk.
Intraneural injection, which seems to occur commonly with PNBs, showed an inconsistent direction of association. Only 1 out of 5 studies of deliberate intraneural injection reported an increase in complication rates.
Measures meant to increase precision and reduce complications showed little effect on the incidence of neurologic complications.
Recovery from neurologic injury appears to be worse in patients with pre-existing risk factors.
Effectiveness of Epidural Analgesia, Continuous Surgical Site Analgesia, and Patient-Controlled Analgesic Morphine for Postoperative Pain Management and Hyperalgesia, Rehabilitation, and Health-Related Quality of Life After Open Nephrectomy: A Prospective, Randomized, Controlled Study
Anesth Analg 2017;124:336–45
Sixty patients undergoing open nephrectomy were randomized to be part of epidural analgesia (EA), continuous surgical site analgesia (CSSA), or control groups (patient-controlled analgesic morphine) postoperatively for 72 hours.
CSSA and EA significantly improved postoperative analgesia, reduced postoperative morphine consumption, area of wound hyperalgesia, and accelerated patient rehabilitation after open nephrectomy.
CSSA significantly reduced the severity of residual pain 1 month after surgery and optimized quality-of-life parameters 3 months after surgery.
Link to article: (Full text/abstract)
Main: 020 7535 7700
Direct: 020 7535 7711
Dexmedetomidine for prevention of delirium in elderly patients after non cardiac surgery: a randomised, double blind, placebo controlled trial
Su, Xian; Meng, Zhao-Ting; Wu, Xin-Hai; Cui, Fan; Li, Hong-Liang et al. (2016)
The Lancet vol. 388 (10054) p. 1893-1902
Delirium is a common postoperative complication particularly in the elderly cohort and is associated with worse outcomes, longer ITU stays and distress to patients and their families.
This trial studied using low dose dexmedetomidine infusion (0.1mcg/kg/hr) versus placebo in patients older than 65 years of age admitted to the ITU post operatively. The primary outcome measured was the incidence of delirium. The patients were a mix of both intubated and non intubated patients post operatively. The results showed a significant reduction in delirium incidence in patients who received the sub sedative dose of dexmedetomidine (9% incidence versus 23% in the placebo group). There were no reported adverse effects in the dexmedetomidine group.
Given the plethora of negative studies in the critical care/anaesthesia literature recently, this is surely a good news story. Perhaps the cost of the drug will prohibit these positive findings being translated into everyday clinical practice?
A useful editorial to the above trial was published in October 2016.
Here’s the link.
Randomised clinical trial of postoperative chewing gum versus standard care after colorectal resection
Atkinson C, Penfold CM, Ness AR, Longman RJ, Thomas SJ, Hollingworth W et al
British Journal of Surgery 2016;103(8):962-970
Ileus is a common and troublesome post operative complication. Chewing gum has been proposed to reduce ileus by stimulating gut motility as a form of sham feeding. This trial examines the value of chewing gum post colorectal resection with the primary outcome length of hospital stay. There was no difference reported between the two groups with regard to the primary outcome. There were no difference between the two groups with regard to the secondary outcomes in terms of time to first bowel movement/time to first flatus/time to tolerating oral diet. Of note, there were more deaths in the chewing gum group. No complications that arose were attributed to chewing gum. Previous studies have shown a benefit to chewing gum with respect to earlier return to gut function and motility. One of the theories postulated as to why this trial did not show a difference was that all patients were enrolled in an enhanced recovery programme which may diminish the effects of chewing gum.
Further research required? Or, given that it is a relatively cheap intervention with no reported adverse effects, continue to encourage chewing gum to reduce ileus incidence?
A comprehensive review of haemodynamic monitoring and potential future direction in Anaesthesia this month.
Safety of Continued Clopidogrel Use in the postoperative Course of Gastrointestinal Surgery: A Retrospective Cohort Study.
Reference: Jupiter, D. Fang, X. Adhikari, D. Mehta, H. Riall, T. Annals of Surgery. February 2017 265(2), p 370–378
Headline summary: Use of clopidogrel in the perioperative period is not associated with more bleeding events in the month following surgery.
Theme: Peri-operative bleeding in patients on antiplatelet therapy.
Key words: Pubmed in process
Editorial accompanies mixed methods qualitative study.
Editorial: Lean and the perfect patient experience.
Article. Does Lean healthcare improve patient satisfaction? A mixed-method investigation into primary care.
: Editorial. Blackmore, C. Kaplan, G. BMJ Qual Saf 2017;26:85-86 doi:10.1136/bmjqs-2016-005273. Article. BMJ Qual Saf 2017;26:95-103 doi:10.1136/bmjqs-2015-004290
Headline summary: Lean methods do not improve patient satisfaction as they focus too much on efficiency.
Link: http://qualitysafety.bmj.com/content/26/2/85.full (to the free editorial)
Theme: Lean methods & their applicability in healthcare.
Key words: Editorial. Accreditation; Adverse events, epidemiology and detection; Ambulatory careArticle. Lean management, patient satisfaction, primary care.
Simulation based qualitative research
Title: Information transfer in multidisciplinary operating teams: a simulation-based observational study.
Reference Cumin D, Skilton C, Weller J. BMJ Qual Saf 2017 26(3) 209-216
Headline summary: Formalised communication increases attention and recall of team members. There is still however information that is not communicated. Different team members contribute differentially to the handover process.
Theme: Handover of care
Key words: Checklists, communication, simulation, surgery, teamwork
Quantitative video analysis
Title: Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study
Reference: Korkiakangas T. BMJ Quality and Safety. 26(3) 177-188
Headline summary: This studies the aspects of team behaviour that allow for successful use of the checklist. The important aspects identified were related to the timing of the checklist, the distribution of the theatre personnel and the method used to instigate the checklist. Advice about successful use is given at the end of the article.
Theme: Teamworking with a shared mental model
Key words: Checklists, Communication, patient safety, social sciences, teamwork
Postoperative Urinary Retention: Anesthetic and Perioperative Considerations
Anesthesiology 5 2009, Vol 110, 1139-1157
A Perioperative systems design to improve intraoperative glucose monitoring is associated with a reduction in surgical site infections in a diabetic patient population