Psychological Factors and Surgical Outcome

Anaesthesia publishes this interesting discussion of what is a somewhat heterogeneous literature on how psychology and mental health may impact surgical recovery and outcome. It discusses how anxiety and catastrophizing impacts pain, and how depression may predict longer term pain and recovery trajectory. Attitudinal factors, particularly self‐efficacy, a positive outlook and patient‐perceived control have been associated with earlier functional recovery.

The authors discuss how education, stress control, behavioural training, and multimodal prehabilitation including exercise can improve functional recovery, although traditional surgery outcome gains may not be as apparent from available literature.

There is a need for further study and for now it is suggested that “it may be that a stratified approach is required, targeting patients with abnormal mood and low self‐efficacy for prehabilitation”.

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Elderly and Frail Patient Pre-op Optimization

Anaesthesia provides this focus on the important issue of frail and elderly patients presenting for surgery. Beyond basic medical assessment, it emphasizes assessment of non-traditional aspects now clearly linked to worse outcomes, like frailty, balance and gait, nutritional status, cognitive issues, mental health, functional status, medications and polypharmacy, social and family supports.

Pre‐operative comprehensive geriatric assessment is now enshrined in many programs, reference being made to programs at Guy’s and St Thomas’, Nottingham, Duke and Michigan.

Review of several Frailty assessment tools is provided, including the Fried Scale, Rockwood Index, Clinical Frailty Score, and Edmonton Scale.

Nutritional assessment and optimization are discussed, as well as current opinion on the prevention and management of delirium and post-operative cognitive dysfunction.

The importance of (often absent) advance directives and proxy decision makers is stressed, and the need to involve patients and families in shared decision making that goes beyond simple surgical risk, but encompassing patient-centred outcomes such as functional decline, loss of independence and the subsequent care burden

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Prophylactic Platelet Transfusion in ICU

Platelet transfusion in critical care is frequently employed to decrease the risk of bleeding despite questionable efficacy. This study found that such a practice was associated with increased red cell transfusion, fewer ICU free days, fewer hospital free days, and less improvement in SOFA scores.

They conclude: “Prophylactic administration of platelets in the critically ill was not associated with improved clinical outcomes, though residual confounding may exist”.

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Steroid Use after Cardiac Arrest

Studies have investigated adrenal insufficiency after cardiac arrest and tend to suggest benefits for the use of steroids.

In this retrospective observational study, post-arrest steroid use during hospitalization was associated with better survival to hospital discharge and 1-year survival.

Clearly the findings mandate randomized controlled studies to confirm such benefits.

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Medical and Health News Weekly

Lower sleeping times and fragmented sleep are independently associated with an increased risk of subclinical multiterritory atherosclerosis link

1 in 5 develop persisting back pain, various back pain trajectories described along with disability, depression, comorbidities and opioid/antidepressant use link

Vitamin D in elderly may be safe but bone mineral density did not improve link

1 in 10 US adults have a food allergy, although 1 in 5 believed themselves to have one link

Inappropriate antibiotics used in at least 1 in 4 link

More plants and less meat recommended again link

How to help the 30% of youths who develop anxiety link

Odds of dying from opioid overdose now surpass motor vehicle rates in US link

Anaerobically prepared fecal microbiota transplantation may be effective in treating ulcerative colitis, but further research is needed to assess longer-term efficacy and safety link

Anti-vaxxers a leading threat to health link

Platelet-Transfusion Thresholds in Neonates

In preterm (<34 weeks) infants with severe thrombocytopenia, two thresholds for platelet transfusion were compared. Those randomly assigned to receive platelet transfusions at a platelet-count threshold of 50,000 per cubic millimeter had a significantly higher rate of death or major bleeding within 28 days compared to 25,000 per cubic millimeter. The accompanying New England journal editorial puts it: less is more.

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Intra-Aortic Balloon Pumps

Intra-aortic balloon pumps have been used empirically for decades for cardiogenic shock in acute myocardial infarction and this study again finds no mortality benefit. They conclude: “IABP has no effect on all-cause mortality at 6-year long-term follow-up. Mortality is still very high, with two thirds of patients with cardiogenic shock dying despite contemporary treatment with revascularization therapy”.

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The study and its implications are discussed further in an accompanying editorial link

Pain Management for Ambulatory Arthroscopic ACL Reconstruction

Multimodal, and especially opioid-free, analgesic techniques are now the norm in enhancing recovery in ambulatory surgery such as knee anterior cruciate ligament reconstruction. Femoral nerve block, adductor canal block, and local instillation analgesia are variously employed and this guideline from the Society for Ambulatory Anesthesia sought to determine the optimal balance of technique with risks. “Based on the evidence available, local instillation analgesia provides the best balance of analgesic efficacy and associated risks”. Where not employed they provide a weaker recommendation for adductor canal or femoral nerve block.

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Preoperative Cardiac Optimization

Another Anaesthesia review discusses the approach to preoperative cardiac risk stratification, hypertension, heart failure, murmurs, beta-blockers and other medication management, and implantable electronic cardiac devices.

Also discussed is the role of preoperative investigation such as EKG, CXR, and Echocardiography, as well as serial monitoring of Troponins and BNP. Some evidence for exercise therapy as a preoperative cardiac prehabilitation is reviewed.

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