Anesthesia & Co-existing Disease

Perioperative Peripheral Nerve Injury After General Anesthesia

A review article discusses the incidence, mechanisms, diagnosis and prevention of peripheral nerve injuries during general anesthesia. It is an area still in evolution, as it is found that anesthesia care is appropriate in 90% of cases. Concepts such as ischemia, inflammation, “double crush”, mechanical factors are discussed as well as evoked potential monitoring like SSEP, nerve conduction studies and EMG.

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Clinical Frailty Score and Outcome

Frailty assessment should now be as much a standard as cardiorespiratory evaluation pre-op. No gold standard exists and one qualitative tool is the Clinical Frailty Scale – CFS link

This study on unscheduled surgeries in those over 65 years of age used the CFS as well as other outcome prediction tools.

It found that duration of hospital stay was independently associated with: pre‐operative ASA physical status; surgical severity; peri‐operative E‐POSSUM score; and SORT. Duration of stay was also associated with the CFS, but not independent of these variables.

Future refining of frailty assessment tools may lead to better prediction scales.

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Bicuspid Aortic Valve and Mitral Valve Prolapse

In recent years the guidelines for bacterial endocarditis antibiotic prophylaxis have been drastically curtailed. This Spanish study calls for reconsideration, in that patients with bicuspid aortic valves and mitral valve prolapse had viridans endocarditis with a similar profile to other high risk endocarditis cases.

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Hypertension and Intra-operative Hemodynamics

An observational study fails to link pre-op hypertension to adverse intra-op hemodynamics like hypotension and tachycardia, factors known to increase major adverse cardiovascular morbidity and mortality. It supports AAGBI guidelines and others to continue with elective surgery in patients with blood pressure less than 180/110

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Pre-operative Assessment for Non-Cardiac Surgery

Cardiac assessment is well covered in the AHA guideline, but this European  Society of Anaesthesiology guideline is more comprehensive in looking at areas such as cardiac, respiratory, renal, diabetes, coagulation, medications, anemia, frailty and geriatric, airway, neuromuscular, alcohol and drug misuse. It’s worth comparing your practice…

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(click on PDF article top right for a clear display).

Blood Pressure, Heart Rate and Myocardial Injury

Myocardial Injury after non-cardiac surgery (MINS) was studied and a clear and unsurprising correlation was seen with intra-operative hypotension and tachycardia. Previous studies have demonstrated this as well as the duration of hypotension, and mean arterial pressures less than 65 mm Hg should not be tolerated for more than 5 minutes, especially urgent in older patients and/or cardiovascular disease co-occurrence.  The interval between induction and surgery commencement is particularly noted for such hypotension.

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Heart Disease and Pregnancy Outcome

Morbidty is significant in pregnant women with heart disease, which is now an increasing issue separate from gestational hypertension and pre-eclampsia. This study showed that 16% of pregnant women with heart disease suffered complications – primarily heart failure and arrhythmia. They identified 10 predictors of maternal cardiac complications listed in the link as well as the visually appealing infographic. All would be red flags in an anesthesia setting even in the general population.

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Infographic

 

Polypharmacy and Surgical Outcome

Polypharmacy is a known marker of poorer outcomes in medical patients and this Canadian study seeks to evaluate its role in the surgical population. While it is also associated with postoperative adverse effects, the relationship may be more nuanced in terms of what medications and which patient groups, or whether it is merely a marker for comorbidity, a more likely scenario.

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OSA and Opioid Prescribing

In surgical patients, a retrospective study showed a worrying rate of opioid prescribing (86%) at hospital discharge in patients with known or suspected Obstructive Sleep Apnea (OSA).

Such patients, many of whom are morbidly obese, are at increased risk of respiratory obstruction and depression, and guidelines (such as from the ASA) recommend closer monitoring as well as using multimodal non-opioid analgesia. Where opioid analgesia is required, the Society for Ambulatory Anesthesia advises against ambulatory surgery if pain control cannot be provided with predominantly non-opioid techniques in such patients. Even in-patients with OSA are frequently not properly monitored in high dependency units.

There is still clearly ample room for prescriber education in opioid risk evaluation and mitigation, and OSA patients are at special risk when discharged on opioids (and indeed even as in-patients).

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