POISE study published in The Lancet

The POISE study, (metoprolol versus placebo in high risk surgical patients) has just been published. The key findings were fewer MIs but more deaths. The publication was fast tracked, and it is on the Lancet website only. Should be in a print issue soon. The responses will be interesting to read, especially from cardiologists. This is the largest ever RCT in perioperative patients.

See also the associated editorial by luminaries Fleischer and Poldermans, who have been supporters of perioperative beta-blocker therapy. They still advise cautious use of beta-blockers for tachycardia in at risk patients.

Academic social bookmarking: Online Endnote and more...

When writing papers, academics use Endnote or similar to manage their references. Recently there has been the emergence of online services that not only manage references, but also add in the function of social bookmarking. Social bookmarking is when anyone online can bookmark an interesting webpage and also see what everyone else is marking (eg Del.icio.us and Flickr). This helps to see what other colleagues in the field are reading and leads to discovery of new papers (as well having your references available from any computer anywhere).

Here is a review of the choices available from an article in the Times Higher Education supplement.

The B-unAware Study: Anesthesia Awareness and the Bispectral Index

NEJM March 13. This study reports a comparison of BIS monitoring compared with end-tidal volatile agent monitoring. It found no difference in the incidence of awareness. There is an associated editorial. This finding is in contrast with the B-Aware study that found a 75% reduction in awareness when using BIS monitoring in high risk patients. The study included 1900 patients and was an RCT.

Comments on the methods:
The study's inclusion criteria to be 'at risk of awareness' are very liberal, especially the minor criteria. This was probably not a patient sample that was at significant risk of awareness. Specifically, table 1 shows the following inclusion characteristics: 44% of patients were on beta-blocker, 50% had moderate limited exercise tolerance, and 44% had obesity (each of these are a minor inclusion criteria). This suggests that the study is under-powered to detect a difference by using BIS monitoring as an intervention. The wide inclusion criteria seems to explain how a single hospital quickly completed a study of nearly 2000 patients (in only 14 months).

Depression and its relationship to patient safety

A recent issue of the BMJ has highlighted the strong relationship between depression in RMOs and their six times increase in prescribing errors. This is a new finding, as previously there has been emphasis on system errors. Depression was common in the RMOs in the study (20%). There is also an editorial about the article.
While this research does not specifically deal with anaesthesia, it is likely it applies to impairment of cognitive tasks performed by any doctor that is depressed.
The full article can be viewed at this link. 

Twelve of the Best from 2007

The January issue of Anesthesiology has a special article that presents twelve of the best papers from 2007. Topics include: wound infiltration with diclofenac, a novel local anaesthetic without toxicity, the site of action of general anaesthesia, the causes of maternal death during anaesthesia, the ENIGMA study and others.

NSAIDS and Cardiovascular safety

This comprehensive review published in Circulation gives a good insight into the problem  of cardiovascular risk and the use of COX 2 inhibitors or conventional NSAIDs. I covers the basic pharmacology as well as the clinical use of this important group of drugs. Importantly it looks at the different CVS risk of the conventional NSAIDs. Diclofenac has a high risk (> 2) while naproxen is low risk. More food for thought when prescribing NSAIDs/COX 2 inhibitors for post-op analgesia

Intensive Insulin Therapy: no benefit in severe sepsis

In recent years there has been much interest about the survival benefit from tight glucose control in critically ill patients. This large RCT, published in the NEJM, evaluated the effect of intensive insulin therapy and pentastarch 10% for fluid resusciation (v Ringers lactate solution) in patients with severe sepsis. The study was halted early due to safety. Overall there was no survival benefit. The rate of severe hypoglycaemia was 17% in the insulin group. Pentastach was associated with renal failure compared with Ringers lactate solution.

Update to ANZCA Acute Pain Guideline

December 2007. The Australian and New Zealand College of Anaesthetists (ANZCA) have released  an update to the 2nd edition (2005). It is evidenced based and well written. Highly recommended. It is available online by clicking on the title above.

NEJM editorial on capital punishment by lethal injection

The NEJM reports that the US Supreme court is to rule whether death by lethal injection is unconstitutional because it is 'cruel and unusual'. The journal states that it is the policy the American ASA and AMA that physicians do not participate or advise in capital punishment. The standard three-drug regimen (thiopentone, pancuronium and potassium) has been shown previously to be unreliable in producing unconsciousness. A report from an execution in 2006 said the prisoner called out "It don't work". A video discussion is also available on the NEJM site from the link above.

Meta-analysis of the effect of heart rate achieved by perioperative beta-adrenergic blockade on cardiovascular outcomes

The January issue of the BJA has a meta-analysis of the effect heart rate control from beta-blockers on cardiac outcome. It found no benefit from perioperative beta-blockade on cardiac mortality and morbidity. There was no correlation between heart rate control and cardiac outcome, however there was an increase in drug related adverse effects.

Will the POISE study change periop Beta Blocker use?

This discussion, from the Medscape website, gives an insight into the response that occurred at the AHA meeting in Orlando when the POISE study results where first presented (watch for the full paper in a journal soon). Chief investigator, PJ Devereaux says "I would certainly not recommend it to my mother". Experts in the discussion where divided whether beta blocker should be initiated for at risk patients presenting for high risk surgery. 

Why patients are not customers: the incursion of the business mindset.

Are you a bit dismayed by the encroaching use of business paradigms into healthcare? This opinion piece from Time magazine, explains why 'patients are not customers', and why  'customer satisfaction' is not the same as 'patient well-being'

POISE study results announced

Nov 7 Orlando. The eagerly anticipated POISE study results where presented at the annual meeting  of the American Heart Association. Unexpectedly the results show mixed benefits and risks. In brief, commencing perioperative beta-blockade reduced AMIs, but increased deaths (due to CVA and sepsis). The exact mechanisms behind these findings remain puzzling. In summary, for every 1,000 patients on metoprolol, 15 MIs, 8 new cases of AF and 3 urgent CAGS would be prevented but at the expense of 8 extra deaths, 5 extra strokes and 53 patients with significant hypotension. We await the full paper and the resulting discussion.

Cochrane review of BIS monitoring

This Cochrane review of BIS monitoring during anaesthesia examined the results of twenty studies. It found that BIS guided anaesthesia reduced the dose requirement of anaesthetic drugs, reduced time to extubation and eye opening, and reduced the time to discharge from the PACU. It did not reduce the time to be ready for home readiness. There was a reduction in awareness in high risk patients.

SAFE study: long-term patient outcome

The NEJM has a post-hoc follow-up study of the original SAFE study (albumin v saline for resuscitation of ICU patients). The investigators followed the outcome of the traumatic brain injury subgroup for survival at two years after injury. The saline group had significantly better survival. Overall 71 of 214 patients in the albumin group (33.2%) had died, as compared with 42 of 206 in the saline group (20.4%) (relative risk, 1.63 P=0.003). For severe brain injury (GCS 3-8), 61 of 146 patients in the albumin group (41.8%) died, as compared with 32 of 144 in the saline group (22.2%) (relative risk, 1.88; 95%). This outcome had previously been suspected from the original SAFE study paper. The original SAFE study from 2004 can be read here