Pubmed Monday

Recommendations for standards of monitoring during anaesthesia and recovery 2021

Abstract

This guideline updates and replaces the 5th edition of the Standards of Monitoring published in 2015. The aim of this document is to provide guidance on the minimum standards for monitoring of any patient undergoing anaesthesia or sedation under the care of an anaesthetist. The recommendations are primarily aimed at anaesthetists practising in the UK and Ireland, but it is recognised that these guidelines may also be of use in other areas of the world. Minimum standards for monitoring patients during anaesthesia and in the recovery phase are included. There is also guidance on monitoring patients undergoing sedation and during transfer. There are new sections specifically discussing capnography, sedation and regional anaesthesia. In addition, the indications for processed electroencephalogram and neuromuscular monitoring have been updated.

Expert consensus on peri-operative myocardial injury screening in noncardiac surgery: A literature review

Abstract

Peri-operative myocardial injury, detected by dynamic and elevated cardiac troponin (cTn) concentrations, is a common complication of noncardiac surgery that is strongly associated with 30-day mortality. Although active screening for peri-operative myocardial injury has been suggested in recent guidelines, clinical implementation remains tentative due to a lack of examples on how to tackle such an interdisciplinary project at a local level. Moreover, consensus on which assay and cTn cut-off values should be used has not yet been reached, and guidance on whom to screen is lacking. In this article, we aim to summarise local examples of successfully implemented cTn screening practices and review the current literature in order to provide information and suggestions for patient selection, organisation of a screening programme, caveats and a potential management pathway.

Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery

Abstract

Background: Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive.

Methods: In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion.

Results: Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P = 0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P = 0.08).

Conclusions: Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.).

Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis

Abstract

Study objective: To evaluate the efficacy of perioperative dexmedetomidine (DEX) administration for preventing delirium in adults after non-cardiac surgery.

Design: Systematic review and meta-analysis of randomized controlled trials (RCTs).

Interventions: Perioperative administration of DEX to prevent delirium in adults following non-cardiac surgery.

Measurements: The incidence of postoperative delirium (POD).

Methods: The databases of PubMed, Embase and Cochrane Central Register were searched from inception to Mar 4, 2021 for all available RCTs that assessed DEX for POD in adults after non-cardiac surgery. Risk ratio (RR) with a 95% confidence interval (CI) was calculated for dichotomous data. Standardized mean difference (SMD) was calculated for continuous data. Risk of bias was assessed using the second version of the Cochrane risk-of-bias tool for RCTs (RoB 2.0), and the level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.

Main results: Thirteen studies, including the meta-analysis with a total of 4015 patients (DEX group: 2050 patients; placebo group: 1965 patients), showed that DEX significantly reduced the incidence of POD in adults after non-cardiac surgery compared with control group (RR: 0.60; 95%CI: 0.46 to 0.77, P = 0.0001, I2 = 55%, GRADE = moderate). Meanwhile, there was a statistical difference by the subgroup analysis between the mean age ≥ 65 years group and the mean age <65 years group. There were no statistical differences in length of hospital stay following surgery (SMD: -0.36; 95%CI: -0.80 to 0.07, P = 0.1, I2 = 97%, GRADE = low) and all-cause mortality rate (RR:0.57; 95%CI: 0.25 to 1.28, P < 0.17, I2 = 0%, GRADE = moderate) compared with placebo group. However, Meta-analysis showed that DEX administration significantly resulted in intraoperative bradycardia when compared with placebo group (RR: 1.39; 95%CI: 1.14 to 1.69, P = 0.0009, I2 = 0%, GRADE = high), and as well as intraoperative hypotension (RR: 1.25; 95%CI: 1.11 to 1.42, P = 0.0004, I2 = 0%, GRADE = high).

Conclusion: This systematic review and meta-analysis suggests that perioperative administration of DEX could significantly reduce the incidence of POD in patients elder than 65 years following non-cardiac surgery. However, there was no definite evidence that perioperative DEX could reduce the incidence of POD in patients younger than 65 years of age after non-cardiac surgery. In addition, perioperative DEX administration was associated with an elevated risk of bradycardia and hypotension.

Persistent postoperative opioid use in Europe A systematic review

Abstract

BACKGROUND In the United States, postoperative opioid prescriptions have been implicated in the so-called ‘opioid epidemic’. In Europe, the extent of overprescribing or misuse of opioids is not known.

OBJECTIVES To describe the proportion of persistent postoperative opioid use in adults (>18 years) in European countries.

DESIGN Systematic review of the published data.

DATA SOURCES We searched the electronic literature databases MEDLINE (Ovid), Embase (Ovid), PubMed/MEDLINE and Scopus.

ELIGIBILITY CRITERIA Studies describing opioid use in adult patients (>18 years) at least 3 months after surgery.

RESULTS One thousand three hundred and seven studies were found, and 12 studies were included in this review. The rate of opioid use after 3 to 6 months was extracted from the studies and categorised by the type of surgery. Nine studies investigated opioid use after total hip or total knee arthroplasties (THA and TKA) and reported opioid user rates between 7.9 and 41% after 3 months. In all the included studies, a proportion between 2 and 41% of patients were opioid users 3 months after surgery. The level of evidence varied from high to very low.

CONCLUSION To describe persistent opioid use in relation to specific countries or types of surgery is not possible. Because of the wide ranges observed, we can neither confirm nor rule out a possible public health problem linked to the persistent use of opioids in Europe.

Second victim support structures in anaesthesia: a cross-sectional survey in Belgian anaesthesiologists

Abstract

Background: Anaesthesiologists are prone to patient safety situations after which second victim symptoms can occur. In international literature, a majority of these second victims indicated that they were emotionally affected in the aftermath of a patient safety incident (PSI) and received little institutional support after these events.

Objective: To study the current second victim support structures in anaesthesia departments in Belgium.

Methods: An observational cross-sectional survey. Belgian anaesthesiologists and anaesthesiologists in training were contacted through e-mail from May 27th until 15 July 2020.

Results: In total, 456 participants completed the online survey. 73.7% (n = 336) of the participants encountered a PSI during the last year of their medical practice. 80.9% (n = 368) of respondents answered that they do discuss incidents with their colleagues. 18.0% (n = 82) discussed all incidents. 19.3% (n = 88) admitted that these incidents are never discussed in their department. 15.4% of participants (n = 70) experienced or thought that the culture is negative during these PSI discussions. 17.3% (n = 79) scored the culture neutral. Anaesthesiologists who encountered a PSI in the last years scored the support of their anaesthesia department a mean score of 1.59 (ranging from -10 to +10). A significant correlation (P < 0.05) was found between the culture during the morbidity and mortality meetings, the support after the incidents and the perceived quality of the anaesthesia department.

Conclusion: Of the participating anaesthesiologist in Belgium, 80.9% discussed some PSIs and 18.0% discussed all PSIs as a normal part of their staff functioning with an experienced positive or neutral culture during these meetings in 84.6%. Psychological safety within the anaesthesiology departments is globally good; however, it could and should be optimized. This optimization process warrants further investigations in the future.

Hemodynamic support in septic shock

Abstract

Purpose of review The current article reviews recent findings on the monitoring and hemodynamic support of septic shock patients.

Recent findings The ultimate goal of hemodynamic resuscitation is to restore tissue oxygenation. A multimodal approach combining global and regional markers of tissue hypoxia seems appropriate to guide resuscitation. Several multicenter clinical trials have provided evidence against an aggressive fluid resuscitation strategy. Fluid administration should be personalized and based on the evidence of fluid responsiveness. Dynamic indices have proven to be highly predictive of responsiveness. Recent data suggest that balanced crystalloids may be associated with less renal failure. When fluid therapy is insufficient, a multimode approach with different types of vasopressors has been suggested as an initial approach. Dobutamine remains the firs inotropic option in patients with persistent hypotension and decrease ventricular systolic function. Calcium sensitizer and phosphodiesterase inhibitors may be considered, but evidence is still limited. Veno-arterial extracorporeal membrane oxygenation may be considered in selected unresponsive patients, particularly with myocardial depression, and in a highly experienced center.

Summary Resuscitation should be personalized and based on global and regional markers of tissue hypoxia as well as the fluid responsiveness indices. The beneficial effect of multimode approach with different types of vasopressors, remains to be determined.

Minimizing postoperative pulmonary complications in thoracic surgery patients

Abstract

Purpose of review: Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

Recent findings: There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

Summary: The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Septic shock: a microcirculation disease

Abstract

Purpose of review The aim of this study was to discuss the implication of microvascular dysfunction in septic shock.

Recent findings Resuscitation of sepsis has focused on systemic haemodynamics and, more recently, on peripheral perfusion indices. However, central microvascular perfusion is altered in sepsis and these alterations often persist despite normalization of various macro haemodynamic resuscitative goals. Endothelial dysfunction is a key element in sepsis pathophysiology. It is responsible for the sepsis-induced hypotension. In addition, endothelial dysfunction is also implicated involved in the activation of inflammation and coagulation processes leading to amplification of the septic response and development of organ dysfunction. It also promotes an increase in permeability, mostly at venular side, and impairs microvascular perfusion and hence tissue oxygenation.

Microvascular alterations are characterized by heterogeneity in blood flow distribution, with adequately perfused areas in close vicinity to not perfused areas, thus characterizing the distributive nature of septic shock. Such microvascular alterations have profound implications, as these are associated with organ dysfunction and unfavourable outcomes. Also, the response to therapy is highly variable and cannot be predicted by systemic hemodynamic assessment and hence cannot be detected by classical haemodynamic tools.

Summary Microcirculation is a key element in the pathophysiology of sepsis. Even if microcirculation-targeted therapy is not yet ready for the prime time, understanding the processes implicated in microvascular dysfunction is important to prevent chasing systemic hemodynamic variables when this does not contribute to improve tissue perfusion.

Pectoral nerve blocks for breast surgery A meta-analysis

Abstract

BACKGROUND Pectoral nerve blocks (PECS block) might be an interesting new regional anaesthetic technique in patients undergoing breast surgery.

OBJECTIVE The aim of this meta-analysis was to investigate postoperative pain outcomes and adverse events of a PECS block compared with no treatment, sham treatment or other regional anaesthetic techniques in women undergoing breast surgery.

DESIGN We performed a systematic review of randomised controlled trials (RCT) with meta-analysis and risk of bias assessment.

DATA SOURCES The databases MEDLINE, CENTRAL (until December 2019) and clinicaltrials.gov were systematically searched.

ELIGIBILITY CRITERIA All RCTs investigating the efficacy and adverse events of PECS compared with sham treatment, no treatment or other regional anaesthetic techniques in women undergoing breast surgery with general anaesthesia were included.

RESULTS A total of 24 RCTs (1565 patients) were included. PECS (compared with no treatment) block might reduce pain at rest [mean difference −1.14, 95% confidence interval (CI), −2.1 to −0.18, moderate quality evidence] but we are uncertain regarding the effect on pain during movement at 24 h after surgery (mean difference −1.79, 95% CI, −3.5 to −0.08, very low-quality evidence). We are also uncertain about the effect of PECS block on pain at rest at 24 h compared with sham block (mean difference −0.83, 95% CI, −1.80 to 0.14) or compared with paravertebral block (PVB) (mean difference −0.18, 95% CI, −1.0 to 0.65), both with very low-quality evidence. PECS block may have no effect on pain on movement at 24 h after surgery compared with PVB block (mean difference −0.56, 95% CI, −1.53 to 0.41, low-quality evidence). Block-related complications were generally poorly reported.

CONCLUSION There is moderate quality evidence that PECS block compared with no treatment reduces postoperative pain intensity at rest. The observed results were less pronounced if patients received a sham block. Furthermore, PECS blocks might be equally effective as PVBs. Due to mostly low-quality or very low-quality evidence level, further research is warranted.

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