Pubmed Monday

Double standard: why electrocardiogram is standard care while electroencephalogram is not?


Purpose of review Major adverse cardiovascular and cerebrovascular events (MACCE) significantly affect the surgical outcomes. Electrocardiogram (ECG) has been a standard intraoperative monitor for 30 years. Electroencephalogram (EEG) can provide valuable information about the anesthetized state and guide anesthesia management during surgery. Whether EEG should be a standard intraoperative monitor is discussed in this review.

Recent findings Deep anesthesia has been associated with postoperative delirium, especially in elderly patients. Intraoperative EEG monitoring has been demonstrated to reduce total anesthesia drug use during general anesthesia and postoperative delirium.

Summary Unlike ECG monitoring, the EEG under general anesthesia has not been designated as a standard monitor by anesthesiologist societies around the world. The processed EEG technology has been commercially available for more than 25 years and EEG technology has significantly facilitated its intraoperative use. It is time to consider EEG as a standard anesthesia monitor during surgery.

Cognitive decline after carotid endarterectomy: Systematic review and meta-analysis


Background: Postoperative cognitive decline (pCD) occurs frequently (6 to 30%) after carotid endarterectomy (CEA), although there are no exact estimates and risk factors are still unclear.

Objective: The objective of this study was to determine pCD incidence and risk factors in CEA patients.

Design: We performed a systematic review and meta-analysis of both randomised and nonrandomised trials following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Data sources: We searched Cochrane, PubMed/Medline and Embase databases from the date of database inception to 1 December 2018.

Eligibility criteria: We selected longitudinal studies including CEA patients with both pre-operative and postoperative cognitive assessments. Primary outcome was pCD incidence, differentiating delayed neurocognitive recovery (dNCR) and postoperative neurocognitive disorder (pNCD). dNCR and pNCD incidences were expressed as proportions of cases on total CEA sample and pooled as weighted estimates from proportions. Postoperative delirium was excluded from the study design. Secondary outcomes were patient-related (i.e. age, sex, diabetes, hypertension, contralateral stenosis, pre-operative symptoms, dyslipidaemia and statin use) and procedure-related (i.e. hyperperfusion, cross-clamping duration and shunting placement) risk factors for pCD. We estimated odds ratios (ORs) and mean differences through a random effects model by using STATA 13.1 and RevMan 5.3.

Results: Our search identified 5311 publications and 60 studies met inclusion criteria reporting a total of 4823 CEA patients. dNCR and pNCD incidence were 20.5% [95% confidence interval (CI), 17.1 to 24.0] and 14.1% (95% CI, 9.5 to 18.6), respectively. pCD risk was higher in patients experiencing hyperperfusion during surgery (OR, 35.68; 95% CI, 16.64 to 76.51; P < 0.00001; I = 0%), whereas dNCR risk was lower in patients taking statins before surgery (OR, 0.56; 95% CI, 0.41 to 0.77; P = 0.0004; I = 19%). Sensitivity analysis revealed that longer cross-clamping duration was a predictor for dNCR (mean difference, 5.25 min; 95% CI, 0.87 to 9.63; P = 0.02; I = 49%).

Conclusion: We found high incidences of dNCR (20.5%) and pNCD (14.1%) after CEA. Hyperperfusion seems to be a risk factor for pCD, whereas the use of statins is associated with a lower risk of dNCR. An increased cross-clamping duration could be a risk factor for dNCR.

Preeclampsia and the anaesthesiologist: current management


Purpose of review: Preeclampsia remains an important cause of maternal and neonatal morbidity and mortality. Recent interest in angiogenic biomarkers as a prognostic indicator is reviewed, together with analgesic, anaesthetic and critical-care management of the preeclamptic patient.

Recent findings: There has been recent interest in the angiogenic biomarkers placental growth factor and soluble fms-like tyrosine kinase-1 in establishing the diagnosis of preeclampsia and guiding its management. Neuraxial blocks are recommended for both labour and operative delivery if not contraindicated by thrombocytopenia or coagulopathy, although a safe lower limit for platelet numbers has not been established. For spinal hypotension phenylephrine is noninferior to ephedrine in preeclamptic parturients and may offer some benefits. When general anaesthesia is required, efforts must be made to blunt the hypertensive response to laryngoscopy and intubation. Transthoracic echocardiography has emerged as useful technique to monitor maternal haemodynamics in preeclampsia.

Summary: Improvements in the diagnosis of preeclampsia may lead to better outcomes for mothers and babies. Peripartum care requires a multidisciplinary team approach with many preeclamptic women receiving neuraxial analgesia or anaesthesia. Women with severe preeclampsia may require critical-care support and this should meet the same standards afforded to other acutely unwell patients.

Organ donation: from diagnosis to transplant


Purpose of review Organ transplantation has largely expanded over the last decades and despite several improvements have been made in the complex process occurring between the identification of organ donors and organ transplant, there is still a chronic inability to meet the needs of patients. Consequently, the optimization of the transplant process through its different steps is crucial, and the role of the intensivists is fundamental as it requires clinical, managerial and communication skills to avoid the loss of potential donors. The purpose of this review is to provide an update on the transplant process from the early identification of the donor, to transplant. The two main pathways of organ donation will be discussed: donation after death by neurologic criteria and the donation after cardiac death (DCD).

Recent findings Recent evidence demonstrates that appropriate intensive care management is fundamental to increase organ availability for transplantation. The expansion of pool donation requires a strong legal framework supporting ethical and organizational considerations in each country, together with the implementation of physicians’ technical expertise and communication skills for family involvement and satisfaction. New evidence is available regarding organ donor's management and pathway. The importance of checklists is gaining particular interest according to recent literature. Recent clinical trials including the use of naloxone, simvastatin and goal directed hemodynamic therapies were not able to demonstrate a clear benefit in improving quality and number of transplanted organs. Ethical concerns about DCD are recently being raised, and these will be discussed focusing on the differences of outcome between controlled and uncontrolled procedure.

Summary The major change in the process of organ donation has been to implement parallel DCD and donation after brain death pathways. However, more research is needed for improving quality and number of transplanted organs.

Guideline on anaesthesia and sedation in breastfeeding women 2020: Guideline from the Association of Anaesthetists


Breastfeeding has many health benefits for the mother and infant. Women who are breastfeeding may require anaesthesia or sedation. Concerns regarding the passage of drugs into breast milk may lead to inconsistent advice from professionals. This can sometimes result in the interruption of feeding for 24 hours or longer after anaesthesia, or expressing and discarding ('pumping and dumping') breast milk; this may contribute to early cessation of breastfeeding. However, there are data regarding the transfer of most anaesthetic drugs into breast milk. We advise that breastfeeding is acceptable to continue after anaesthesia and should be supported as soon as the woman is alert and able to feed, without the need to discard breast milk. We provide evidence-based information on the pharmacokinetics of drugs commonly used during anaesthesia so that professionals can undertake a risk-benefit discussion with the woman. We advise the development of local policies that aid logistical planning and guide staff to facilitate breastfeeding during the woman's hospital stay.

Keywords: adverse effects; anaesthesia; breast feeding; general; pre-operative assessment; regional; surgery.

Anesthesia and the brain after concussion


Purpose of review: To provide an overview of acute and chronic repeated concussion. We address epidemiology, pathophysiology, anesthetic utilization, and provide some broad-based care recommendations.

Recent findings: Acute concussion is associated with altered cerebral hemodynamics. These aberrations can persist despite resolution of signs and symptoms. Multiple repeated concussions can cause chronic traumatic encephalopathy, a disorder associated with pathologic findings similar to some organic dementias. Anesthetic utilization is common following concussion, especially soon after injury, a time when the brain may be most vulnerable to secondary injury.

Summary: Brain physiology may be abnormal following concussion and these abnormalities may persist despite resolutions of clinical manifestations. Those with recent concussion or chronic repeated concussion may be susceptible to secondary injury in the perioperative period. Clinicians should suspect concussion in any patient with recent trauma and strive to maintain cerebral homeostasis in the perianesthetic period.

Postoperative delirium: why, what, and how to confront it at your institution


Purpose of review: The current article reviews the importance of postoperative delirium (POD), focusing on the older surgical population, and summarizes the best-practice guidelines about POD prevention and treatment which have been published within the last several years. We also describe our local experience with implementing a perioperative delirium risk stratification and prevention pathway, and review implementation science principles which others may find useful as they move toward risk stratification and prevention in their own institutions.

Recent findings: There are few areas of consensus, backed by strong experimental data, in POD best-practice guidelines. Most guidelines recommend preoperative cognitive screening, nonpharmacologic delirium prevention measures, and avoidance of deliriogenic medications. The field of implementation science offers strategies for closing the evidence-practice gap, which we supplement with lessons learned from our own experience implementing a perioperative delirium risk stratification and prevention pathway.

Summary: POD continues to be a serious perioperative complication commonly experienced by older adults. Growing appreciation of its prognostic implications and evidence behind multidisciplinary, collaborative, and focused prevention strategies rooted in implementation science have prompted several major groups to issue consensus guidelines. Adopting best practices POD risk stratification and prevention pathways will improve perioperative care for older adults.

Haematoma, abscess or meningitis after neuraxial anaesthesia in the USA and the Netherlands: A closed claims analysis


Background: Severe complications after neuraxial anaesthesia are rare but potentially devastating.

Objective: We aimed to identify characteristics and preventable causes of haematoma, abscess or meningitis after neuraxial anaesthesia.

Design: Observational study, closed claims analysis.

Setting: Closed anaesthesia malpractice claims from the USA and the Netherlands were examined from 2007 until 2017.

Patients: Claims of patients with haematoma (n = 41), abscess (n = 18) or meningitis (n = 14) associated with neuraxial anaesthesia for labour, acute and chronic pain that initiated and closed between 2007 and 2017 were included. There were no exclusions.

Main outcome measures: We analysed potential preventable causes in patient-related, neuraxial procedure-related, treatment-related and legal characteristics of these complications.

Results: Patients experiencing spinal haematoma were predominantly above 60 years of age and using antihaemostatic medication, whereas patients with abscess or meningitis were middle-aged, relatively healthy and more often involved in emergency interventions. Potential preventable causes of unfavourable sequelae constituted errors in timing/prescription of antihaemostatic medication (10 claims, 14%), unsterile procedures (n = 10, 14%) and delay in diagnosis/treatment of the complication (n = 18, 25%). The number of claims resulting in payment was similar between countries (USA n = 15, 38% vs. the Netherlands n = 17, 52%; P = 0.25). The median indemnity payment, which the patient received varied widely between the USA (&OV0556;285 488, n = 14) and the Netherlands (&OV0556;31 031, n = 17) (P = 0.004). However, the considerable differences in legal systems and administration of expenses between countries may make meaningful comparison of indemnity payments inappropriate.

Conclusions: Claims of spinal haematoma were often related to errors in antihaemostatic medication and delay in diagnosis and/or treatment. Spinal abscess claims were related to emergency interventions and lack of sterility. We wish to highlight these potential preventable causes, both when performing the neuraxial procedure and during postprocedural care of patients.

Maternal morbidity: how to reduce it


Purpose of review Internationally there has been increased interest in maternal morbidity; both as a strategy to reduce maternal deaths and also because of the significant impact on a woman’s life as a result of suffering from maternal morbidity. The present review will evaluate the current knowledge of, and strategies to reduce maternal morbidity.

Recent findings The study of maternal morbidity and how to reduce it has been hampered for many years by the lack of a standard approach to measurement and evaluation. The World Health Organization has attempted to standardize the approach to maternal morbidity with the development of a new definition that recognizes the multiple dimensions of maternal morbidity, including external factors such as socioeconomic factors. This approach will assist with a more accurate evaluation of maternal morbidity. Maternal morbidity arises from many and varied causes. Many of these are amenable to quality improvement with an associated reduction in maternal morbidity.

Summary There have been significant advances in the understanding of maternal morbidity: incidence causes and management. Future research should aim to establish accurate rates for maternal morbidity and further develop ways for healthcare professionals, including anaesthesia care providers, to reduce it.

Interventional radiology for the obstetric patient


Purpose of review To discuss the recent results of the use of interventional radiology modalities treating postpartum hemorrhage (PPH).

Recent findings PPH still is a leading cause of maternal morbidity and mortality. An important risk factor for the development of PPH is the placenta accreta spectrum. In patients with placenta accreta, we can use prophylactic balloon occlusion of the common or internal iliac artery or abdominal aorta to prevent PPH. Balloon occlusion of the abdominal aorta seems to ensure better results than balloon occlusion of the iliac artery in terms of blood loss, transfusion rate and hysterectomy rate reduction with a minimal risk of complications. To treat PPH uterine artery embolization can be effective and potentially fertility-sparing, while having a low complication rate.

Summary The use of aortic balloon occlusion catheters for the prevention of PPH and uterine artery embolization for the treatment of PPH are well tolerated and feasible options for patients with placenta accreta spectrum.

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