Pubmed Monday

Effects of digital learning in anaesthesiology: A systematic review and meta-analysis


Background: Digital methods of instruction have proven to be effective in assisting learning in many fields at various levels. However, none of the meta-analyses have studied the effects of digital learning vs. traditional learning in the field of anaesthesiology.

Objective: We conducted a meta-analysis to review the role of digital learning in anaesthesiology by comparing the effect sizes of the involved studies.

Design: A systematic review and meta-analysis of randomised controlled trials and assessment of the quality of evidence by the Medical Education Research Study Quality Instrument.

Data sources: Educational databases (EBSCOhost and LearnTechLib) and medical databases (PubMed, Embase and Cochrane) were searched from January 1998 to February 2019.

Eligibility criteria: We conducted a search by using key words related to digital learning and anaesthesiology. Articles that compared traditional instruction and digital instruction methods for learners in anaesthesiology were considered.

Results: The 15 studies involved 592 trainees from the field of anaesthesiology. Considering substantial heterogeneity (I2 = 73%), a random-effect model was used. Pooled effect size presented a standardised mean deviation of 0.79, P < 0.001, indicating a statistically significant difference between traditional and digital learning groups, favouring the digital learning group. Results of subgroup analyses showed that using clinical performance to measure learning outcomes exhibited no heterogeneity, digital learning method was more consistent and effective for anaesthetic professionals, and the digital learning method was more effective than traditional learning method in the studies teaching the instructional contents of echocardiography and clinical scenarios.

Conclusion: The current study demonstrated positive effects of digital instruction in the field of anaesthesiology. Training through digital materials may assist professional training between the stages of didactic training and clinical training.

Difficult tracheal intubation in obstetrics


Difficult intubation has been classified into four grades, according to the view obtainable at laryngoscopy. Frequency analysis suggests that, in obstetrics, the main cause of trouble is grade 3, in which the epiglottis can be seen, but not the cords. This group is fairly rare so that a proportion of anaesthetists will not meet the problem in their first few years and may thus be unprepared for it in obstetrics. However the problem can be simulated in routine anaesthesia, so that a drill for managing it can be practised. Laryngoscopy is carried out as usual, then the blade is lowered so that the epiglottis descends and hides the cords. Intubation has to be done blind, using the Macintosh method. This can be helpful as part of the training before starting in the maternity department, supplementing the Aberdeen drill.

Spinal anesthesia for ambulatory surgery: current controversies and concerns


Purpose of review: General anesthesia is a popular choice for ambulatory surgery. Spinal anesthesia is often avoided because of perceived delays due to time required to administer it and prolonged onset, as well as concerns of delayed offset, which may delay recovery and discharge home. However, the reports of improved outcomes in hospitalized patients undergoing total joint arthroplasty have renewed the interest in spinal anesthesia. This review article critically assesses the role of spinal anesthesia in comparison with fast-track general anesthesia for the outpatient setting.

Recent findings: The purported benefits of spinal anesthesia include avoidance of airway manipulation and the adverse effects of drugs used to provide general anesthesia, improved postoperative pain, and reduced postoperative opioid requirements. Improved postoperative outcomes after spinal anesthesia in hospitalized patients may not apply to the outpatient population that tends to be relatively healthier. Also, it is unclear if spinal anesthesia is superior to fast-track general anesthesia techniques, which includes avoidance of benzodiazepine premedication, avoidance of deep anesthesia, use of an opioid-sparing approach, and minimization of neuromuscular blocking agents with appropriate reversal of residual paralysis.

Summary: The benefits of spinal anesthesia in the outpatient setting remain questionable at best. Further studies should seek clarification of these goals and outcomes.

Preoperative sedentary behavior is neither a risk factor for perioperative neurocognitive disorders nor associated with an increase in peripheral inflammation, a prospective observational cohort study


Background Surgical interventions result in a postoperative rise in circulating inflammatory cytokines and high molecular group box protein 1 (HMGB1). Herein, the impact of a sedentary lifestyle and other age-related factors on the development of perioperative neurocognitive disorders (PND) following non-cardiac surgical procedures was assessed in an older (55–75 years-old) surgical population.

Methods Prior to surgery, patients were asked questions regarding their sedentary behavior and daily habits. They also passed the Mini Mental State Examination (MMSE) and their blood circulating interleukin 6 (IL-6) and HMGB1 levels were assayed by ELISA. IL-6 and HMGB1 measurements were repeated respectively 6 and 24 h after surgery. MMSE was re-evaluated 6 weeks and whenever possible 3 months after surgery.

Results Thirty-eight patients were enrolled in the study from January until July 2019. The study identified self-sufficiency, multilinguism, and overall health score on the geriatric depression scale, as protectors against PND. No other demographic (age, sex), environmental (solitary/non-solitary housing, professional and physical activities, smoking, alcohol drinking), comorbidity (antipsychotic drug uptake, diabetic state) and type of surgery (orthopedic, general, genitourinary) influenced the development of PND. Although some factors (surgery type and age) influenced the surgery-induced rise in the circulating IL-6 levels, they did not impact HMGB1.

Conclusion Inflammaging, reflected by the greater increment of surgery-induced IL-6 in patients with advanced age, was present. As trauma-induced release of HMGB1 was not similarly affected by age, we surmise that HMGB1, rather than circulating cytokines, is the key driver of the trauma-induced inflammatory cascade leading to PND.

Peripheral nerve blockade and novel analgesic modalities for ambulatory anesthesia


Purpose of review: Despite peripheral nerve blockade offering analgesic benefits and improving patient satisfaction, it has not been well adopted in ambulatory anesthesia. In this review, we aim to summarize the evidence underlying peripheral nerve blockade, local anesthetic adjuncts, continuous peripheral nerve blockade and novel analgesic modalities, with the objective to provide recommendations on postoperative analgesia optimization after peripheral nerve blockade in an ambulatory setting.

Recent findings: Barriers to the widespread use of peripheral nerve blockade in ambulatory anesthesia could include lack of education and training, and increased anesthetic induction time. Strategies that have demonstrated promise to increase duration of action and attenuate rebound pain phenomenon after peripheral nerve blockade include multimodal analgesia, local anesthetic adjuncts and continuous infusion of local anesthetic. Dexamethasone has been demonstrated to be the most effective local anesthetic adjunct. Continuous peripheral nerve blockade is a reasonable alternative but at the expense of additional costs and logistical reorganization. There is currently insufficient data to promote the ambulatory use of liposomal bupivacaine, cryoanalgesia and percutaneous peripheral nerve stimulation.

Summary: Educational programs and parallel processing may promote peripheral nerve blockade in an ambulatory setting, improving the patient experience in the postoperative period. Intravenous dexamethasone should be considered wherever appropriate as part of a multimodal analgesic strategy to optimize postoperative pain control.

Cardiopulmonary resuscitation in the prone position in the operating room or in the intensive care unit: a systematic review


The prone position is commonly used in certain surgical procedures and to improve oxygenation in mechanically ventilated patients with acute respiratory distress syndrome (ARDS). Cardiorespiratory Arrest (CRA) in this position may be more challenging to treat because care providers trained in conventional CPR may not be familiar with CPR in the prone position. The aim of this systematic review is to provide an overview of current evidence regarding the methodology, efficacy and experience of Cardiopulmonary Resuscitation (CPR) in the prone position, in patients with the airway already secured. The search strategy included PubMed, Scopus and Google Scholar. All studies published up to April 2020 including Cardiorespiratory Arrest or Cardiopulmonary Resuscitation in the prone position were included. Out of the 268 articles located, 52 articles were included: 5 review articles, 8 clinical guidelines in which prone CPR was mentioned, 4 originals, 27 case reports, and 8 editorials or correspondences. Data from reviewed clinical studies confirm that CPR in the prone position is a reasonable alternative to supine CPR when the latter cannot be immediately implemented, and the airway is already secured. Defibrillation in the prone position is also possible. Familiarizing clinicians with CPR and defibrillation in the prone position may improve CPR performance in the prone position.

Education and training in ultrasound-guided regional anaesthesia and pain medicine


Purpose of review: Effective and safe regional anaesthesia and pain medicine procedures require clinicians to learn and master complex theoretical knowledge and motor skills. This review aims to summarize articles relevant to education and training in these skill sets in the previous 2 years.

Recent findings: Twenty-two articles were identified, investigating nine out of the 13 top-ranked research topics in education and training in regional anaesthesia. Research topics addressed by these articles included prerotation simulation, deliberate practice combined with formative assessment tools, validation of assessment tools, three-dimensional-printed models, and knowledge translation from simulation to clinical practice. Emerging concepts investigated for their applications in regional anaesthesia included eye-tracking as a surrogate metric when evaluating proficiency, and elastography aiding visual salience to distinguish appropriate perineural and inappropriate intraneural injections.

Summary: Research into education and training in regional anaesthesia covered multiple and diverse topics. Methodological limitations were noted in several articles, reflecting the difficulties in designing and conducting medical education studies. Nonetheless, the evidence-base continues to mature and innovations provide exciting future possibilities.

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.

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