Showing papers in "Anaesthesia in 2014"
TL;DR: The structure, physiology and pathology of the endothelial glycocalyx is reviewed, based on a literature search of the past five years, and interventions to protect or repair the glycocalyX are systematically reviewed.
Abstract: The endothelial glycocalyx is an important part of the vascular barrier. The glycocalyx is intimately linked to the homoeostatic functions of the endothelium. Damage to the glycocalyx precedes vascular pathology. In the first part of this paper, we have reviewed the structure, physiology and pathology of the endothelial glycocalyx, based on a literature search of the past five years. In the second part, we have systematically reviewed interventions to protect or repair the glycocalyx. Glycocalyx damage can be caused by hypervolaemia and hyperglycaemia and can be prevented by maintaining a physiological concentration of plasma protein, particularly albumin. Other interventions have been investigated in animal models: these require clinical research before their introduction into medical practice.
335 citations
TL;DR: Based on this narrative synthesis, pre‐operative comprehensive geriatric assessment is likely to have a positive impact on postoperative outcomes in older patients undergoing elective surgery, but further definitive research is required.
Abstract: Comprehensive geriatric assessment is an established clinical approach. It reduces mortality and improves the physical wellbeing of older people in the community or hospitalised for medical reasons. Pre-operative comprehensive geriatric assessment seems a plausible method for reducing adverse postoperative outcomes. The objectives of this systematic review and narrative synthesis are to describe how pre-operative comprehensive geriatric assessment has been used in surgical patients and to examine the impact of comprehensive geriatric assessment on postoperative outcomes in older patients undergoing scheduled surgery. We searched MEDLINE, EMBASE and Web of Science from 1980 to 2013 (week 26). We included five studies: two randomised controlled trials and three before-and-after intervention quasi-experimental studies. Patient populations, interventions and outcome measures varied between studies. Both the randomised trials showed benefit on postoperative outcomes, including medical complications. Two of the before-and-after studies reported a positive impact on postoperative length of stay and other outcomes. The heterogeneity of study methods, populations, interventions and outcomes precluded meta-analysis. Based on this narrative synthesis, pre-operative comprehensive geriatric assessment is likely to have a positive impact on postoperative outcomes in older patients undergoing elective surgery, but further definitive research is required. Clinical services providing pre-operative comprehensive geriatric assessment for older surgical patients should be considered.
247 citations
TL;DR: The introduction of an environmental noise and light reduction programme as a bundle of non‐pharmacological interventions in the intensive care unit was effective in reducing sleep deprivation and delirium, and it is proposed a similar programme should be implemented more widely.
Abstract: Sleep deprivation is common among intensive care patients and may be associated with delirium. We investigated whether the implementation of a bundle of non-pharmacological interventions, consisting of environmental noise and light reduction designed to reduce disturbing patients during the night, was associated with improved sleep and a reduced incidence of delirium. The study was divided into two parts, before and after changing our practice. One hundred and sixty-seven and 171 patients were screened for delirium pre- and post-intervention, respectively. Compliance with the interventions was > 90%. The bundle of interventions led to an increased mean (SD) sleep efficiency index (60.8 (3.5) before vs 75.9 (2.2) after, p = 0.031); reduced mean sound (68.8 (4.2) dB before vs 61.8 (9.1) dB after, p = 0.002) and light levels (594 (88.2) lux before vs 301 (53.5) lux after, p = 0.003); and reduced number of awakenings caused by care activities overnight (11.0 (1.1) before vs 9.0 (1.2) after, p = 0.003). In addition, the introduction of the care bundle led to a reduced incidence of delirium (55/167 (33%) before vs 24/171 (14%) after, p < 0.001), and less time spent in delirium (3.4 (1.4) days before vs 1.2 (0.9) days after, p = 0.021). Increases in sleep efficiency index were associated with a lower odds ratio of developing delirium (OR 0.90, 95% CI 0.84-0.97). The introduction of an environmental noise and light reduction programme as a bundle of non-pharmacological interventions in the intensive care unit was effective in reducing sleep deprivation and delirium, and we propose a similar programme should be implemented more widely.
241 citations
TL;DR: The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri‐operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons.
Abstract: Increasing numbers of elderly patients are undergoing an increasing variety of surgical procedures. There is an age-related decline in physiological reserve, which may be compounded by illness, cognitive decline, frailty and polypharmacy. Compared with younger surgical patients, the elderly are at relatively higher risk of mortality and morbidity after elective and (especially) emergency surgery. Multidisciplinary care improves outcomes for elderly surgical patients. Protocol-driven integrated pathways guide care effectively, but must be individualised to suit each patient. The AAGBI strongly supports an expanded role for senior geriatricians in coordinating peri-operative care for the elderly, with input from senior anaesthetists (consultants/associate specialists) and surgeons. The aims of peri-operative care are to treat elderly patients in a timely, dignified manner, and to optimise rehabilitation by avoiding postoperative complications. Effective peri-operative care improves the likelihood of very elderly surgical patients returning to their same pre-morbid place of residence, and maintains the continuity of their community care when in hospital. Postoperative delirium is common, but underdiagnosed, in elderly surgical patients, and delays rehabilitation. Multimodal intervention strategies are recommended for preventing postoperative delirium. Peri-operative pain is common, but underappreciated, in elderly surgical patients, particularly if they are cognitively impaired. Anaesthetists should administer opioid-sparing analgesia where possible, and follow published guidance on the management of pain in older people. Elderly patients should be assumed to have the mental capacity to make decisions about their treatment. Good communication is essential to this process. If they clearly lack that capacity, proxy information should be sought to determine what treatment, if any, is in the patient's best interests. Anaesthetists must not ration surgical or critical care on the basis of age, but must be involved in discussions about the utility of surgery and/or resuscitation. The evidence base informing peri-operative care for the elderly remains poor. Anaesthetists are strongly encouraged to become involved in national audit projects and outcomes research specifically involving elderly surgical patients.
188 citations
TL;DR: If the National Hip Fracture Database data are accurate, then either there is no difference in 30‐day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not the correct outcome to measure after anaesthesia.
Abstract: Large observational studies of accurate data can provide similar results to more arduous and expensive randomised controlled trials. In 2012, the National Hip Fracture Database extended its dataset to include 'type of anaesthesia' data fields. We analysed 65 535 patient record sets to determine differences in outcome. Type of anaesthesia was recorded in 59 191 (90%) patients. Omitting patients who received both general and spinal anaesthesia or in whom an uncertain type of anaesthesia was recorded, there was no significant difference in either cumulative five-day (2.8% vs 2.8%, p = 0.991) or 30-day (7.0% vs 7.5%, p = 0.053) mortality between 30 130 patients receiving general anaesthesia and 22 999 patients receiving spinal anaesthesia, even when 30-day mortality was adjusted for age and ASA physical status (p = 0.226). Mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030), suggesting excess early mortality related to bone cement implantation syndrome. If these data are accurate, then either there is no difference in 30-day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not the correct outcome to measure after anaesthesia, and therefore future research should focus on differences between general and spinal anaesthesia. These could include more anaesthesia-sensitive outcomes, such as hypotension, pain, postoperative confusion, respiratory infection and mobilisation.
153 citations
TL;DR: There is no clear evidence that exposure to anaesthesia up to the age of 3–4 years is associated with neurocognitive or behavioural deficits, so it can be recommended to keep anaesthesia and surgery as short as possible, to use short‐acting drugs and/or a combination of general anaesthetic and multimodal pain therapy and local or regional anaesthesia, to reduce the overall drug dosage.
Abstract: Various experimental studies in animals have shown that general anaesthetics are potentially toxic to the developing brain. By inducing apoptosis or interfering with neurogenesis, anaesthetic exposure during a critical period of neuronal development can have significant impact on neurocognitive function later in life. It remains controversial whether these experimental results can be transferred to human beings and this is under intensive scientific evaluation. To gain more insight into possible neurotoxic effects on the human brain of infants and small children, a number of retrospective studies have been performed. At present, there is no clear evidence that exposure to anaesthesia up to the age of 3-4 years is associated with neurocognitive or behavioural deficits. Currently, the PANDA, MASK and GAS studies are underway to explore this relationship. Anaesthesia is not an end in itself, but necessary to facilitate surgical procedures. There is evidence that maintaining physiological conditions is important for the overall outcome following anaesthesia and surgery. Until proven otherwise, it can be recommended to keep anaesthesia and surgery as short as possible, to use short-acting drugs and/or a combination of general anaesthesia and multimodal pain therapy including systemic analgesics, and local or regional anaesthesia, to reduce the overall drug dosage.
139 citations
TL;DR: Continuous transversus abdominis plane infusion was non‐inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery and there were no significant differences between the groups for tramadol consumption.
Abstract: Posterior transversus abdominis plane blocks have been reported to be an effective method of providing analgesia after lower abdominal surgery. We compared the efficacy of a novel technique of providing continuous transversus abdominis plane analgesia with epidural analgesia in patients on an enhanced recovery programme following laparoscopic colorectal surgery. A non-inferiority comparison was used. Adult patients undergoing elective laparoscopic colorectal surgery were randomly assigned to receive continuous transversus abdominis plane analgesia (n = 35) vs epidural analgesia (n = 35), in addition to a postoperative analgesic regimen comprising regular paracetamol, regular diclofenac and tramadol as required. Sixty-one patients completed the study. The transversus group received four-quadrant transversus abdominis plane blocks and bilateral posterior transversus abdominis plane catheters that were infused with levobupivacaine 0.25% for 48 h. The epidural group received an infusion of bupivacaine and fentanyl. The primary outcome measure was visual analogue scale pain score on coughing at 24 h after surgery. We found no significant difference in median (IQR [range]) visual analogue scores during coughing at 24 h between the transversus group 2.5 (1.0-3.0 [0-5.5]) and the epidural group 2.5 (1.0-5.0 [0-6.0]). The one-sided 97.5% CI was a 0.0 (∞-1.0) difference in means, establishing non-inferiority. There were no significant differences between the groups for tramadol consumption. Success rate was 28/30 (93%) in the transversus group vs 27/31 (87%) in the epidural group. Continuous transversus abdominis plane infusion was non-inferior to epidural infusion in providing analgesia after laparoscopic colorectal surgery.
123 citations
TL;DR: The aetiology of postoperative delirium and cognitive dysfunction in the elderly with a particular focus on anaesthesia and sedation is reviewed, methods of diagnosing and monitoring postoperative cognitive decline are discussed, and the treatment strategies by which such decline may be prevented are described.
Abstract: Surgery and anaesthesia exert comparatively greater adverse effects on the elderly than on the younger brain, manifest by the higher prevalence of postoperative delirium and cognitive dysfunction. Postoperative delirium and cognitive dysfunction delay rehabilitation, and are associated with increases in morbidity and mortality among elderly surgical patients. We review the aetiology of postoperative delirium and cognitive dysfunction in the elderly with a particular focus on anaesthesia and sedation, discuss methods of diagnosing and monitoring postoperative cognitive decline, and describe the treatment strategies by which such decline may be prevented.
121 citations
TL;DR: In this article, the highly selective α2-adrenergic agonist, dexmedetomidine, attenuates the systemic inflammatory response in patients undergoing aortic cross-clamping.
Abstract: Cardiac surgery with cardiopulmonary bypass is associated with the development of a systemic inflammatory response that can often lead to dysfunction of major organs. We hypothesised that the highly selective α2-adrenergic agonist, dexmedetomidine, attenuates the systemic inflammatory response. Forty-two patients were randomly assigned to receive dexmedetomidine or saline after aortic cross-clamping). The mean (SD) levels of the nuclear protein plasma high-mobility group box 1 increased significantly from 5.1 (2.2) ng ml(-1) during (16.6 (7.3) ng ml(-1) ) and after (14.3 (8.2) ng ml(-1) ) cardiopulmonary bypass in the saline group. In the dexmedetomidine group, the levels increased significantly only during cardiopulmonary bypass (4.0 (1.9) ng ml(-1) baseline vs. 10.8 (2.7) ng ml(-1) ) but not after (7.4 (3.8) ng ml(-1) ). Dexmedetomidine infusion also suppressed the rise in mean (SD) interleukin-6 levels after cardiopulmonary bypass (a rise of 124.5 (72.0) pg ml(-1) vs. 65.3 (30.9) pg ml(-1)). These suppressive effects of dexmedetomidine might be due to the inhibition of nuclear factor kappa B activation and suggest that intra-operative dexmedetomidine may beneficially inhibit inflammatory responses associated with ischaemia-reperfusion injury during cardiopulmonary bypass.
113 citations
TL;DR: The limitations of ‘eyeballing’ patients to quantify frailty are explored, and why the frail older patient, challenged by seemingly minor insults in the postoperative period, may suffer falls or delirium are considered.
Abstract: For most surgeons and many anaesthetists, patient frailty is currently the 'elephant in the (operating) room': it is easy to spot, but is often ignored. In this paper, we discuss different approaches to the measurement of frailty and review the evidence regarding the effect of frailty on peri-operative outcomes. We explore the limitations of 'eyeballing' patients to quantify frailty, and consider why the frail older patient, challenged by seemingly minor insults in the postoperative period, may suffer falls or delirium. Frailty represents a state of increased vulnerability to stressors, and older inpatients are exposed to multiple stressors in the peri-operative setting. Quantifying frailty is likely to increase the precision of peri-operative risk assessment. The Frailty Index derived from Comprehensive Geriatric Assessment is a simple and robust way to quantify frailty, but is yet to be systematically investigated in the pre-operative setting. Furthermore, the optimal care for frail patients and the reversibility of frailty with prehabilitation are fertile areas for future research.
113 citations
TL;DR: The Postoperative Quality of Recovery Scale addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.
Abstract: To date, postoperative quality of recovery lacks a universally accepted definition and assessment technique. Current quality of recovery assessment tools vary in their development, breadth of assessment, validation, use of continuous vs dichotomous outcomes and focus on individual vs group recovery. They have progressed from identifying pure restitution of physiological parameters to multidimensional assessments of postoperative function and patient-focused outcomes. This review focuses on the progression of these tools towards an as yet unreached ideal that would provide multidimensional assessment of recovery over time at the individual and group level. A literature search identified 11 unique recovery assessment tools. The Postoperative Quality of Recovery Scale assesses recovery in multiple domains, including physiological, nociceptive, emotive, activities of daily living, cognition and patient satisfaction. It addresses recovery over time and compares individual patient data with base line, thus describing resumption of capacities and is an acceptable method for identification of individual patient recovery.
TL;DR: Maintenance of anaesthesia using propofol appeared to have no bearing on the incidence of unplanned admission to hospital and was more expensive, but was associated with a decreased incidence of early postoperative nausea and vomiting compared with sevoflurane or desflurane in patients undergoing ambulatory surgery.
Abstract: Summary
With the popularity of ambulatory surgery ever increasing, we carried out a systematic review and meta-analysis to determine whether the type of anaesthesia used had any bearing on patient outcomes. Total intravenous propofol anaesthesia was compared with two of the newer inhalational agents, sevoflurane and desflurane. In total, 18 trials were identified; only trials where nitrous oxide was administered to, or omitted from, both groups were included. A total of 1621 patients were randomly assigned to either propofol (685 patients) or inhalational anaesthesia (936 patients). If surgical causes of unplanned admissions were excluded, there was no difference in unplanned admission to hospital between propofol and inhalational anaesthesia (1.0% vs 2.9%, respectively; p = 0.13). The incidence of postoperative nausea and vomiting was lower with propofol than with inhalational agents (13.8% vs 29.2%, respectively; p < 0.001). However, no difference was noted in post-discharge nausea and vomiting (23.9% vs 20.8%, respectively; p = 0.26). Length of hospital stay was shorter with propofol, but the difference was only 14 min on average. The use of propofol was also more expensive, with a mean (95% CI) difference of £6.72 (£5.13–£8.31 (€8.16 (€6.23−€10.09); $11.29 ($8.62–$13.96))) per patient-anaesthetic episode (p < 0.001). Therefore, based on the published evidence to date, maintenance of anaesthesia using propofol appeared to have no bearing on the incidence of unplanned admission to hospital and was more expensive, but was associated with a decreased incidence of early postoperative nausea and vomiting compared with sevoflurane or desflurane in patients undergoing ambulatory surgery.
TL;DR: A comprehensive search was performed in PubMed, Scopus and Web of Science for cases reporting hypersensitivity reactions to sugammadex and identified 15 cases of hypersensitivity following sugamadex administration, with most of the patients meeting World Anaphylaxis Organization criteria for anaphyl axis.
Abstract: Summary
Sugammadex is a drug used to reverse neuromuscular blockade induced by rocuronium or vecuronium. It has not yet been approved by the Food and Drug Administration in the USA due to concerns regarding hypersensitivity. The objective of this review was to identify similarities in the presentation of hypersensitivity reactions to sugammadex. A comprehensive search was performed in PubMed, Scopus and Web of Science for cases reporting hypersensitivity reactions to sugammadex. In addition, we contacted regulatory agencies and the company marketing the drug for unpublished reports. Reports were included if they were in English, primary investigations, lacked an alternative probable explanation for the reaction and included a comprehensive description of the hypersensitivity. We identified 15 cases of hypersensitivity following sugammadex administration. All cases that reported exact timing (14/15) occurred in 4 min or less. Most of the patients (11/15; 73%) met World Anaphylaxis Organization criteria for anaphylaxis. Awareness must be raised for the possibility of drug-induced hypersensitivity during the critical 5-min period immediately following sugammadex administration.
TL;DR: A retrospective analysis of prospectively collected data from 11 529 patients in whom cardiopulmonary bypass was used from January 2004 to December 2010 found tranexamic acid administration, particularly in doses exceeding 80 mgkg−1, should be weighed against the risk of postoperative seizures.
Abstract: Because of a lack of contemporary data regarding seizures after cardiac surgery, we undertook a retrospective analysis of prospectively collected data from 11 529 patients in whom cardiopulmonary bypass was used from January 2004 to December 2010. A convulsive seizure was defined as a transient episode of disturbed brain function characterised by abnormal involuntary motor movements. Multivariate regression analysis was performed to identify independent predictors of postoperative seizures. A total of 100 (0.9%) patients developed postoperative convulsive seizures. Generalised and focal seizures were identified in 68 and 32 patients, respectively. The median (IQR [range]) time after surgery when the seizure occurred was 7 (6-12 [1-216]) h and 8 (6-11 [4-18]) h, respectively. Epileptiform findings on electroencephalography were seen in 19 patients. Independent predictors of postoperative seizures included age, female sex, redo cardiac surgery, calcification of ascending aorta, congestive heart failure, deep hypothermic circulatory arrest, duration of aortic cross-clamp and tranexamic acid. When tested in a multivariate regression analysis, tranexamic acid was a strong independent predictor of seizures (OR 14.3, 95% CI 5.5-36.7; p < 0.001). Patients with convulsive seizures had 2.5 times higher in-hospital mortality rates and twice the length of hospital stay compared with patients without convulsive seizures. Mean (IQR [range]) length of stay in the intensive care unit was 115 (49-228 [32-481]) h in patients with convulsive seizures compared with 26 (22-69 [14-1080]) h in patients without seizures (p < 0.001). Convulsive seizures are a serious postoperative complication after cardiac surgery. As tranexamic acid is the only modifiable factor, its administration, particularly in doses exceeding 80 mg.kg(-1), should be weighed against the risk of postoperative seizures.
TL;DR: Non‐technical skills are improved when a cognitive aid is present during airway emergencies, and the number of times the cognitive aid was used was associated with higher ANTS scores.
Abstract: Guidelines outlining recommended actions are difficult to implement in the stressful, time-pressured situation of an airway emergency. Cognitive aids such as posters and algorithms improve performance during some anaesthetic emergencies; however, their effects on team behaviours have not been determined. In this study, 64 participants were randomly assigned into control (no cognitive aid) and intervention (cognitive aid provided) groups before a simulated 'can't intubate, can't oxygenate' scenario. Video analysis was undertaken of the non-technical skills and technical performance during the scenarios. All categories had higher Anaesthetists' Non-Technical Skills (ANTS) scores when a cognitive aid was supplied (mean (SD) total ANTS score 10.4 (3.1) vs. 13.2 (2.4), p < 0.001). The number of times the cognitive aid was used was associated with higher ANTS scores (ρ = 0.383, p = 0.002). A trend towards the establishment of an infraglottic airway within 3 min was also noted (control group 55.3% vs. intervention 76.9%, p = 0.076). Non-technical skills are improved when a cognitive aid is present during airway emergencies.
TL;DR: Sublingual ultrasound is a potential tool for predicting a difficult airway in addition to conventional methods, and is suggested to be a more effective tool than current methods.
Abstract: Current methods to assess the airway before tracheal intubation are variable in their ability to predict a difficult airway accurately. We hypothesised that sublingual ultrasound could provide additional information to predict a difficult airway with greater success than current methods. We recruited 110 patients to perform sublingual ultrasound on themselves following brief instruction. Ability to view the hyoid bone on sublingual ultrasound, mouth opening distance, thyromental distance, neck mobility, size of mandible and modified Mallampati classification were recorded and assessed for ability to predict a difficult intubation based on the grade of laryngoscope. Visibility of the hyoid using ultrasound was associated with a laryngoscopic grade of 1-2 (p < 0.0001), and (p < 0.0001) had a positive likelihood ratio of 21.6 and a negative likelihood ratio of 0.28. Each of the other methods had considerably lower positive likelihood ratios and lower sensitivity. Our results suggest that sublingual ultrasound is a potential tool for predicting a difficult airway in addition to conventional methods.
TL;DR: Staffing pressures were perceived as the greatest barrier to early warning systems use, and improved audit, education and training for healthcare professionals were identified as priority areas.
Abstract: The Confidential Enquiries into Maternal Deaths in the UK have recommended obstetric early warning systems for early identification of clinical deterioration to reduce maternal morbidity and mortality. This survey explored early warning systems currently used by maternity units in the UK. An electronic questionnaire was sent to all 205 lead obstetric anaesthetists under the auspices of the Obstetric Anaesthetists' Association, generating 130 (63%) responses. All respondents reported use of an obstetric early warning system, compared with 19% in a similar survey in 2007. Respondents agreed that the six most important physiological parameters to record were respiratory rate, heart rate, temperature, systolic and diastolic blood pressure and oxygen saturation. One hundred and eighteen (91%) lead anaesthetists agreed that early warning systems helped to prevent obstetric morbidity. Staffing pressures were perceived as the greatest barrier to their use, and improved audit, education and training for healthcare professionals were identified as priority areas.
TL;DR: Qualitative reviews suggested the melatonin improved sleep quality and emergence behaviour, and might be capable of reducing oxidative stress and anaesthetic requirements.
Abstract: We systematically reviewed randomised controlled trials of peri-operative melatonin. We included 24 studies of 1794 participants that reported eight peri-operative outcomes: anxiety; analgesia; sleep quality; oxidative stress; emergence behaviour; anaesthetic requirements; steal induction; and safety. Compared with placebo, melatonin reduced the standardised mean difference (95% CI) pre-operative anxiety score by 0.88 (0.44-1.33) and postoperative pain score by 1.06 (0.23-1.88). The magnitude of effect was unreliable due to substantial statistical heterogeneity, with I(2) 87% and 94%, respectively. Qualitative reviews suggested the melatonin improved sleep quality and emergence behaviour, and might be capable of reducing oxidative stress and anaesthetic requirements.
TL;DR: Phenylephrine reduced the risk for hypotension and nausea and vomiting after spinal doses of bupivacaine generally exceeding 8 mg, but there was no evidence that it reduced other maternal or neonatal morbidities.
Abstract: We conducted a systematic review to determine the harm and benefit associated with prophylactic phenylephrine for caesarean section under spinal anaesthesia. We included 21 randomised controlled trials with 1504 women. The relative risk (95% CI) of hypotension with phenylephrine infusion – as defined by authors – before delivery was 0.36 (0.18–0.73) vs placebo, p = 0.004; 0.58 (0.39–0.88) vs an ephedrine infusion, p = 0.009; and 0.73 (0.55–0.96) when added to an ephedrine infusion, p = 0.02. After delivery, the relative risks of hypotension and nausea and vomiting with phenylephrine compared with placebo were 0.37 (0.19–0.71), p = 0.003, and 0.39 (0.17–0.91), p = 0.03, respectively. There was no evidence that hypertension, bradycardia or neonatal endpoints were affected. Phenylephrine reduced the risk for hypotension and nausea and vomiting after spinal doses of bupivacaine generally exceeding 8 mg, but there was no evidence that it reduced other maternal or neonatal morbidities.
TL;DR: A critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: Its role in peri‐operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit.
Abstract: Summary The dye indocyanine green is familiar to anaesthetists, and has been studied for more than half a century for cardiovascular and hepatic function monitoring. It is still, however, not yet in routine clinical use in anaesthesia and critical care, at least in Europe. This review is intended to provide a critical analysis of the available evidence concerning the indications for clinical measurement of indocyanine green elimination as a diagnostic and prognostic tool in two areas: its role in peri-operative liver function monitoring during major hepatic resection and liver transplantation; and its role in critically ill patients on the intensive care unit, where it is used for prediction of mortality, and for assessment of the severity of acute liver failure or that of intra-abdominal hypertension. Although numerous studies have demonstrated that indocyanine green elimination measurements in these patient populations can provide diagnostic or prognostic information to the clinician, ‘hard’ evidence – i.e. high-quality prospective randomised controlled trials – is lacking, and therefore it is not yet time to give a green light for use of indocyanine green in routine clinical practice.
TL;DR: The ultimate aim is to provide a guide through the bewildering array of devices on the market so that clinicians can make informed and accurate choices for their particular hospital environment.
Abstract: Since the adverse consequences of accidental peri-operative hypothermia have been recognised, there has been a rapid expansion in the development of new warming equipment designed to prevent it. This is a review of peri-operative warming devices and a critique of the evidence assessing their performance. Forced-air warming is a common and extensively tested warming modality that outperforms passive insulation and water mattresses, and is at least as effective as resistive heating. More recently developed devices include circulating water garments, which have shown promising results due to their ability to cover large surface areas, and negative pressure devices aimed at improving subcutaneous perfusion for warming. We also discuss the challenge of fluid warming, looking particularly at how devices' performance varies according to flow rate. Our ultimate aim is to provide a guide through the bewildering array of devices on the market so that clinicians can make informed and accurate choices for their particular hospital environment.
TL;DR: Concise guidelines are presented that recommend the method of choice for skin antisepsis before central neuraxial blockade, based on previously published guidelines, laboratory and clinical studies, case reports, and on the known properties of antiseptic agents.
Abstract: Concise guidelines are presented that recommend the method of choice for skin antisepsis before central neuraxial blockade The Working Party specifically considered the concentration of antiseptic agent to use and its method of application The advice presented is based on previously published guidelines, laboratory and clinical studies, case reports, and on the known properties of antiseptic agents
TL;DR: Recommendation for mandatory influenza immunisation of all health care personnel, as well as a systematic review of the evidence and an economic evaluation, is given.
Abstract: vention. Epidemiology and Prevention of Vaccine-Preventable Diseases. In: Atkinson W, Wolfe S, Hamborsky J, Eds, 12th edn. Washington, DC: Public Health Foundation, 2012. 12. Fiore A, Bridges C, Cox N. Seasonal influenza vaccines. Current Topics in Microbiology and Immunology 2009; 333: 43–82. 13. Hayward A, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. British Medical Journal 2006; 333: 1241. 14. Riphagen-Dalhuisen J, Burgerhof J, Frijstein G, et al. Hospital-based cluster randomised controlled trial to assess effects of a multi-faceted programme on influenza vaccine coverage among hospital healthcare workers and nosocomial influenza in the Netherlands, 2009 to 2011. Eurosurveillance 2013; 27: 18: 20512. 15. Potter J, Stott D, Roberts M, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. Journal of Infectious Disease 1997; 175: 1–6. 16. Thomas R, Jefferson T, Lasserson T. Influenza vaccination for healthcare workers who care for people aged 60 or older living in long-term care institutions. Cochrane Database of Systematic Reviews 2013; 7: CD005187. 17. Saxen H, Virtanen M. Randomized, placebo-controlled double blind study on the efficacy of influenza immunization on absenteeism of health care workers. Pediatric Infectious Disease Journal 1999; 18: 79–83. 18. Anikeeva O, Braynack-Mayer A, Rogers W. Requiring influenza vaccination for health care workers. American Journal of Public Health 2009; 99: 22–9. 19. Bernstein H, Starke J. Recommendation for mandatory influenza immunisation of all health care personnel. Pediatrics 2010; 126: 809–15. 20. Caplan A. Time to mandate influenza vaccination in health-care workers. Lancet 2011; 378: 310–1. 21. Burls A, Jordan R, Barton P, et al. Vaccinating healthcare workers against influenza to protect the vulnerable–is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006; 24: 4212–21. 22. Ball S, Walker D, Donahue S, et al. Centres for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel – 201112 influenza season, United States. Morbidity and Mortality Weekly Report 2012; 61(suppl): 65–72. 23. Department of Health and Health Protection Agency. Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England: winter season 2011/12. http://media. dh.gov.uk/network/211/files/2012/ 06/FluVaccine-Uptake_HCWs_acc2.pdf (accessed 18/11/2013). 24. Department of Health and Health Protection Agency. Seasonal influenza vaccine uptake amongst GP patient groups in England: winter season 2011/ 12. http://webarchive.nationalarchives. gov.uk/20130107105354/https://www. wp.dh.gov.uk/immunisation/files/2012/ 06/Flu-vaccine-uptake-GP-patients-2011. 12.pdf (accessed 18/11/2013). 25. Talbot T, Talbot K. Influenza Prevention Update: examining common arguments against influenza vaccination. Journal of the American Medical Association 2013; 309: 881–2. 26. Nair H, Holmes A, Rudan I, Car J. Influenza vaccination in healthcare professionals. British Medical Journal 2012; 344: 2217. 27. Helms C, Polgreen P. Should influenza immunisation be mandatory for healthcare workers? Yes. British Medical Journal 2008; 337: 1026. 28. Babcock H, Gemeinhart N, Jones M, Dunagan C, Woeltje K. Mandatory influenza vaccination of health care workers: translating policy to practice. Clinical Infectious Disease 2010; 50: 459–64. 29. Ottenberg A, Wu J, Poland G, Jabosen R, Koenig B, Tilburt J. Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate. American Journal of Public Health 2011; 101: 212–6. 30. Flegel K. Health care workers must protect patients from influenza by taking the annual vaccine. Canadian Medical Association Journal 2012; 184: 17. 31. Isaacs D, Leask J. Should influenza immunisation be mandatory for healthcare workers? No. British Medical Journal 2008; 337: 1027. 32. Poland G, Ofstead C, Tucker S, Beebe T. Receptivity to mandatory influenza vaccination policies for healthcare workers among registered nurses working on inpatient units. Infection Control and Hospital Epidemiology 2008; 29: 2. 33. The Childrens Hospital of Philadelphia. Why it is important for CHOP to have a mandatory seasonal flu vaccine policy for healthcare workers? 2009. http:// www.chop.edu/news/flu-vaccine-state ment.html (accessed 18/11/2013).
TL;DR: The evidence for the role of bispectral index monitoring, in particular, in guiding anaesthetic management and influencing clinical outcomes, specifically intra‐operative awareness, measures of early recovery, mortality and neurocognitive outcomes are highlighted.
Abstract: Summary
Although the brain is the target organ of general anaesthesia, the utility of intra-operative brain monitoring remains controversial. Ideally, the incorporation of brain monitoring into routine practice would promote the maintenance of an optimal depth of anaesthesia, with an ultimate goal of avoiding the negative outcomes that have been associated with inadequate or excessive anaesthesia. A variety of processed electroencephalogram devices exist, of which the bispectral index is the most widely used, particularly in the research setting. Whether such devices prove to be useful will depend not only on their ability to influence anaesthetic management but also on whether the changes they promote can actually affect clinically important outcomes. This review highlights the evidence for the role of bispectral index monitoring, in particular, in guiding anaesthetic management and influencing clinical outcomes, specifically intra-operative awareness, measures of early recovery, mortality and neurocognitive outcomes.
TL;DR: Although cerebral oxygen desaturation was rare in this population, postoperative cognitive decline was common in both groups, suggesting that factors other than hypoxic neuronal injury are responsible.
Abstract: Coronary artery bypass surgery, performed with or without cardiopulmonary bypass, is frequently followed by postoperative cognitive decline. Near-infrared spectroscopy is commonly used to assess cerebral tissue oxygenation, especially during cardiac surgery. Recent studies have suggested an association between cerebral desaturation and postoperative cognitive dysfunction. We therefore studied cerebral oxygen desaturation, defined as area under the cerebral oxygenation curve 10 min.%, with respect to cognitive performance at 4 days (early) and 3 months (late) postoperatively, compared with baseline, using a computerised cognitive test battery. We included 60 patients, of mean (SD) age 62.8 (9.4) years, scheduled for elective coronary artery bypass grafting, who were randomly allocated to surgery with or without cardiopulmonary bypass. Cerebral desaturation occurred in only three patients and there was no difference in cerebral oxygenation between the two groups at any time. Among patients who received cardiopulmonary bypass, 18 (62%) had early cognitive decline, compared with 16 (53%) in the group without cardiopulmonary bypass (p = 0.50). Three months after surgery, 11 patients (39%) in the cardiopulmonary bypass group displayed cognitive dysfunction, compared with four (14%) in the non-cardiopulmonary bypass group (p = 0.03). The use of cardiopulmonary bypass was identified as an independent risk factor for the development of late cognitive dysfunction (OR 6.4 (95% CI 1.2-33.0) p = 0.027. In conclusion, although cerebral oxygen desaturation was rare in our population, postoperative cognitive decline was common in both groups, suggesting that factors other than hypoxic neuronal injury are responsible.
TL;DR: A novel vasopressor delivery system that automatically administers phenylephrine or ephedrine based on continuous non‐invasive arterial pressure monitoring afforded better control of maternal blood pressure and reduced nausea with no increase in reactive hypertension when compared with manual boluses.
Abstract: Hypotension necessitating vasopressor administration occurs commonly during caesarean section under spinal anaesthesia. We developed a novel vasopressor delivery system that automatically administers phenylephrine or ephedrine based on continuous non-invasive arterial pressure monitoring. A phenylephrine bolus of 50 μg was given at 30-s intervals when systolic blood pressure fell 120% of baseline, with 8/106 (7.5%) in the automated vasopressor group vs 14/107 (13.1%) in the control group, or total dose of vasopressors. The automated vasopressor group had lower median absolute performance error of 8.5% vs control of 9.8% (p = 0.013), and reduced incidence of nausea (1/106 (0.9%) vs 11/107 (10.3%), p = 0.005). Neonatal umbilical cord pH, umbilical lactate and Apgar scores were similar. Hence, our system afforded better control of maternal blood pressure and reduced nausea with no increase in reactive hypertension when compared with manual boluses.
TL;DR: There were no differences between groups in pain scores after surgery, pressure pain thresholds or side‐effects, and the combination of pregabalin and ketamine has a small, beneficial clinical effect.
Abstract: Ketamine and pregabalin each provide postoperative analgesia, although the combination has yet to be evaluated. One hundred and forty-two patients undergoing total hip arthroplasty were randomly assigned to receive ketamine alone, pregabalin alone, ketamine and pregabalin combined, or placebo. Pain scores at rest and on movement, morphine consumption, side-effects, pressure pain thresholds and secondary hyperalgesia were evaluated. Mean (SD) total 48-h morphine use was reduced in patients given ketamine alone (52 (22) mg) and pregabalin alone (44 (20) mg) compared with placebo (77 (36) mg) p < 0.001. Morphine use was further reduced in patients given both ketamine and pregabalin (38 (19) mg) with an interaction between ketamine and pregabalin (ANOVA factorial; p = 0.028). Secondary hyperalgesia was reduced by ketamine. There were no differences between groups in pain scores after surgery, pressure pain thresholds or side-effects. The combination of pregabalin and ketamine has a small, beneficial clinical effect.
TL;DR: Qualitative studies in the anaesthetic setting have been used to define excellence in anaesthesia, explore the reasons behind drug errors, investigate the acquisition of expertise and examine incentives for hand‐hygiene in the operating theatre.
Abstract: Qualitative research methods are a group of techniques designed to allow the researcher to understand phenomena in their natural setting. A wide range is used, including focus groups, interviews, observation, and discourse analysis techniques, which may be used within research approaches such as grounded theory or ethnography. Qualitative studies in the anaesthetic setting have been used to define excellence in anaesthesia, explore the reasons behind drug errors, investigate the acquisition of expertise and examine incentives for hand-hygiene in the operating theatre. Understanding how and why people act the way they do is essential for the advancement of anaesthetic practice, and rigorous, well-designed qualitative research can generate useful data and important insights. Meticulous social scientific methods, transparency, reproducibility and reflexivity are markers of quality in qualitative research. Tools such as the consolidated criteria for reporting qualitative research checklist and the critical appraisal skills programme are available to help authors, reviewers and readers unfamiliar with qualitative research assess its merits.
TL;DR: It is concluded that intranasal dexmedetomidine is effective for sedation in children who do not respond to chloral hydrate and increasing the rescue dose was associated with an increased success rate.
Abstract: Summary
Chloral hydrate is the most commonly used sedative for paediatric diagnostic procedures in China with a success rate of around 80%. Intranasal dexmedetomidine is used for rescue sedation in our centre. This prospective investigation evaluated 213 children aged one month to 10 years who were not adequately sedated following administration of chloral hydrate. Children were randomly assigned to receive rescue intranasal dexmedetomidine at 1 μg.kg−1 (group 1), 1.5 μg.kg−1 (group 2) or 2 μg.kg−1 (group 3). The sedation level was assessed every 10 min using a modified observer's assessment of alertness/sedation scale. Successful rescue sedation in groups 1, 2 and 3 were 56 (83.6%), 66 (89.2%) and 51 (96.2%), respectively. Increasing the rescue dose was associated with an increased success rate with an odds ratio of 4.12 (95% CI 1.13–14.98), p = 0.032. We conclude that intranasal dexmedetomidine is effective for sedation in children who do not respond to chloral hydrate.
TL;DR: Transcutaneous electric acupoint stimulation can significantly improve the quality of recovery and decrease the incidence of anaesthesia‐related side‐effects for patients undergoing ambulatory surgery.
Abstract: Electroacupuncture has been demonstrated to be effective at alleviating pain and postoperative side-effects. Our aim was to investigate whether transcutaneous electric acupoint stimulation, a low-skill alternative to needle-based electroacupuncture, could improve the quality of recovery after ambulatory surgery. Seventy-two women scheduled for cosmetic breast surgery were randomly allocated to transcutaneous electric acupoint stimulation or sham groups. Patients in the transcutaneous electric acupoint stimulation group received 30 min of electrical stimulation at three acupoints located on the hand and forearm before the induction of general anaesthesia. We found significant mean (SD) differences between the transcutaneous electric acupoint stimulation and sham groups in the mean (SD) length of recovery room stay (35.6 (12.9) min vs 48.3 (16.3) min, p = 0.01), time to removal of the laryngeal mask airway (10.2 (2.5) min vs 17.8 (4.4) min, p = 0.01), and time to reorientation of the patient (14.6 (3.2) min vs 26.5 (5.0) min, p = 0.01). Further, postoperative pain scores and the incidence of side-effects were all lower in the transcutaneous electric acupoint stimulation group. In conclusion, transcutaneous electric acupoint stimulation can significantly improve the quality of recovery and decrease the incidence of anaesthesia-related side-effects for patients undergoing ambulatory surgery.