Thursday, 1 May 2014

Redesigning Surgical Decision Making for High-risk Patients. NEJM April 2014

This is an interesting perspective on moving towards patient-centred counselling when it comes to offering invasive procedures. Who should help patients weigh the risk / benefit of surgery? Are surgeons inherently biased towards more aggressive treatment? Would a multidisciplinary group serve the patient better?  

Rates and risk factors for prolonged opioid use after major surgery:population based cohort study. BMJ 11 February 2014.

Of the 39 140 opioid naive patients over the age of 66 who had major elective surgery, 1229 (3.1%) of patients continued to use opioids more than 3 months post discharge. This is a smaller rate compared to prolonged opioid use reported in low risk surgery and highlights that opioid dependence is less problematic when prescribed appropriately. Factors associated with prolonged opioid use are discussed. An editorial discussing the role of an anaesthetist in this matter is attached.

Adult obstructive Sleep Apnoea. Lancet 2014; 383: 736-47

This article in the Lancet is for those who crave to know more about OSA….

Aspirin in patients Undergoing Non-cardiac Surgery. NEJM March 2014.

What is the best management of peri-operative aspirin? This international randomised, controlled trial looked at the value of peri-operative aspirin in patients at risk of vascular complication undergoing non-cardiac surgery. Neither the rate of death nor nonfatal myocardial infarction was affected by the use of peri-operative aspirin. There was an increased risk of major bleeding in the aspirin group. In fact, major bleeding was an independent predictor of myocardial infarction. Patients who had received a bare-metal stent (less than 6 weeks) or a drug-eluting stent (less than 1 year) before surgery were excluded.

Wednesday, 26 March 2014

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. anesthesia-analgesia. January 2014 • Volume 118 • Number 1

Since the 2004 NEJM article investigating PONV, there have been several guidelines for the evaluation, prophylaxis, and management of PONV.  This current article takes a more detailed re-evaluation of the subject, taking into consideration additional/newer studies and newer classes of anti-emetics.
The overall recommendations provide an improved and modified risk-scoring system and a few new directions in recommendations for specific pharmacologic therapy.

The utilization of antiemetics is (likely) one of the most common pharmacologic therapies given consistently across our perioperative patient population.  Considering the significant proportion of our patient population, we would be remiss to not familiarize ourselves with these new guidelines. MD

De Vasconcellos K & Sneyd JR. Nitrous oxide: are we still in equipoise? A qualitative review of current controversies. BJA (2013), 111(6): 877-85.

This review article looks at the current position of nitrous oxide in anaesthetic practice, The article compare its relative advantages and disadvantages – the classically known ones which we are all aware of from our primary exams such as diffusion hypoxia, expansion of gas-fille spaces, postoperative nausea and vomiting to more recent concerns with neurotoxicity, wound complications and adverse cardiovascular outcomes. The authors also review recent suggested beneficial effects on the central nervous system, cardiovascular system, reduction of awareness with recall and pain (both acute and chronic) and argue that although nitrous oxide has fallen out of favour in the practice of many anaesthetists, we should re-consider current evidence and any new data (eg. ENIGMA-II) and consider nitrous oxide an option. GK

Myocardial Injury after Noncardiac Surgery. A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes. Anesthesiology, V 120 • No 3. March 2014

This large study showed that myocardial injury after non-cardiac surgery is an independent predictor of 30-day mortality. Myocardial injury (diagnosed by a troponin T peak of 0.03 ng/ml) is relatively common (8% of patients) and mainly occurs in the first 2 days after surgery. 1 in 10 of these patients will die in the next 30 days. This can be easily missed since most patients do not have any ischemic symptoms and do not fit the diagnostic criteria for myocardial infarction. Patients who had a troponin rise from nonischemic etiology such as pulmonary embolism or sepsis were excluded. It is estimated that worldwide around 8 million patients per year may suffer from perioperative myocardial injury.

Preoperative cardiac evaluation and management of patients undergoing elective non cardiac surgery. MJA 199 (10) , 18 November 2013.

Perioperative cardiac complications occur commonly in patients having non-cardiac surgery, resulting in 30-day mortality rates between 15-20%. It has been found that some adverse events are a result of inadequate or incorrect preoperative assessment. This article looks at some of the evidence surrounding the preoperative evaluation and management of cardiac risk in patients undergoing elective non-cardiac surgery.