Anesthesia & Co-existing Disease

Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery

The risks from opioid and benzodiazepines may begin even earlier than the perioperative period. This retrospective analysis examined patients that received prescriptions for either in the year before surgery.

They found “opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption.”

It is suggested: “These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.”

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Pediatric Risk Stratification: Patient Comorbidities and Intrinsic Surgical Risk

A retrospective study of the Pediatric NSQIP delineated the impact of intrinsic surgical risk with patient co-morbidities, informing how intrinsic surgical risk can add to mortality prediction.

“Surgical procedures identified by specialty are not independent risk factors for perioperative mortality in pediatric patients. However, in multivariable predictive algorithms, the interaction of patient comorbidities with the intrinsic risk of the surgical procedure strongly predicts 30-day mortality.”

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Frailty in Older Patients Undergoing Emergency Laparotomy

Emergency laparotomy has been the subject of many surveys, notably the NELA audit in the UK, which identified areas for improvement.

This current study examined the specific impact of frailty, which should now be routinely and formally scored in older patients.

The conclusion is in line with so much other evidence documented in this blog:

“A fifth of older adults undergoing emergency laparotomy are frail. The presence of frailty is associated with greater risks of postoperative mortality and morbidity and is independent of age.”

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Antibiotic Prophylaxis and Dental Procedures

Routine antibiotics before dental procedures are only recommended in select circumstances but continue to be over prescribed. This also seems to be an issue in orthopedics where prosthetic joint prophylaxis is prescribed although it was in most cases considered unnecessary.

This study found “More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary”.

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Sugammadex and Postoperative Myasthenic Crisis

This was a database study with its inherent limitations but looked at adults with Myasthenia Gravis undergoing thymectomy and postoperative outcomes, specifically examining the use of Sugammadex.

They found that sugammadex was associated with reductions in postoperative myasthenic crisis and total hospitalization costs and length of stay, but no differences in the secondary outcome of postoperative pneumonia.

They advocate the routine use of Sugammadex in such patients.

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Chronic Post-Surgical Pain after TKR

This was a medical record study that sought to identify the pre-surgical risk factors for chronic post-surgical pain after total knee replacement.

Factors that could predict pain at 5 years in about a third included: fibromyalgia, chronic pain in body parts other than the knee, previous diagnosis of cancer, knee instability, younger age, and presurgical knee pain.

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Malignant Hyperthermia in Pregnancy

A European group issues guidelines for MH in Pregnancy. As always, neuraxial anesthesia is preferred, and guidelines are otherwise similar to the non-obstetric population.

Of note:

  1. The mother is known or suspected to be MH-susceptible (in this case even the fetus may be MH-susceptible)
  2. The fetus may be MH-susceptible but not the mother (because the father of the child is known or suspected to be MH-susceptible).

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SGLT Inhibitors and Diabetic Ketoacidosis

The popularity of SGLT Inhibitors has increased with purported cardiovascular and renal benefits. Issues have arisen however and this consensus addresses the reported cases of normoglycemic diabetic ketoacidosis.

Pertinent to perioperative care, “SGLT inhibitors should be withheld or discontinued prior to any medical procedure (ideally for 3 days), particularly if the patient will be reducing food intake or will not be allowed to eat or drink for some time before and after the procedure.”

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Intraoperative Seizures During Elective Craniotomy

This retrospective study found that the incidence of intraoperative seizures during elective craniotomy with evoked potential monitoring is low. 

The overall incidence of intraoperative seizures was 2.3%. Independent risk factors for intraoperative seizures were seizure history, diagnosis of intracranial tumor, and temporal craniotomy. 

Intraoperative prophylactic anticonvulsant use was protective.

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Propofol and Food Allergies

There is some disquiet about using Propofol in those with allergies. This was a retrospective study of children with immunologically confirmed egg, peanut, soybean or legume allergy and who underwent general anaesthesia.

In 9 out of 10 meeting allergic reaction criteria, valid non‐allergic explanations for the clinical symptoms were found.

The authors conclude that genuine serious allergic reaction to propofol is rare and is not reliably predicted by a history of food allergy.

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