Pre-operative

Preoperative Erythropoietin And Transfusion in Surgical Patients

Erythropoietic-stimulating agents such as erythropoietin find wide usage in cancer chemotherapy-related as well as kidney disease anemia, but concerns continue as to their thromboembolic risks.

This systematic review and meta-analysis found a significant reduction in perioperative allogeneic blood transfusions, also confirmed among the subset of patients undergoing cardiac and orthopedic surgery. They found no significant increase in risk of thromboembolic complications with preoperative erythropoietin administration.

Dosing and timeframes in less heterogeneous populations may be needed but the results are encouraging.

link

WHO Surgical Safety Checklist & Mortality

A large population cohort study in a surgical setting in Scotland finds a remarkable 36% relative decrease in perioperative mortality since implementation of the WHO Surgical Safety Checklist.

No such trend in improvement was observed in the non‐surgical cohort. While causality is always difficult to prove, no other baseline demographics changed to explain the results. Most importantly, “This study provides further evidence that the success of checklist implementation is more pronounced when it is supported by a cohesive and wider approach to patient safety”, and also stresses the importance of “creating a culture of communication and teamwork that supports patient safety”.

Full text

Cardiopulmonary exercise testing

Cardiopulmonary Exercise Testing (CPET) is increasingly used to assess risk and optimize planning before major surgery. Deficiencies in the CPET-derived variables anaerobic threshold, peak oxygen consumption, and ventilatory efficiency for carbon dioxide are associated with poor postoperative outcomes.

This educational article seeks to enlighten on the interpretation of the ‘nine-panel plot’ and enhance understanding of the results:

Article link

Incentive Spirometry after CABG

The ubiquitous incentive spirometer for breathing exercise after surgery has often been questioned as lacking evidence. Many prehabilitation programs use structured deep breathing as well as inspiratory muscle strength training, along with aerobic and resistance training. Australian choosing wisely physiotherapy guidelines recommended against incentive spirometry ( link ).

This was a single center randomized trial in coronary artery bypass surgery which aimed to improve adherence by incorporating hourly reminder bells. The results were quite impressive in improved Incentive Spirometer use adherence, atelectasis severity, early postoperative fevers, noninvasive positive pressure ventilation use, intensive care unit length of stay by a day, and 6-month mortality rates.

“Incentive spirometers can be clinically effective, but perhaps only when adherence is high”. Further studies are recommended on incentive spirometry without reminders. As a relatively small trial, further larger studies with balanced patient populations are essential.

link

Prevention & Management of Accidental Awareness

Awareness under general anesthesia is still encountered in situations not that rare. The Royal College of Anaesthetists and Association of Anaesthetists have issued this guidance on the topic, incorporating NAP5 evidence.

Discussion on approach to consent, anesthesia management, monitoring, and how efforts to minimize awareness takes place in the document. Special emphasis on the prudent use of neuromuscular blocking agents occurs.

Full text

Guidelines for day‐case surgery 2019

Day case surgery continues to proliferate and is intended to be the method of choice in the majority of surgeries. It’s self-evident meaning should not be confused with 23-hour stay in the US.

This updated free paper from the Association of Anaesthetists in Britain/Ireland provides an excellent overview of the practice of ambulatory surgery.

Topics include the need for organization, leadership and governance involving physicians and non-physicians in pre-admission clinics, and selection of patients. Discussion around specific issues like obesity and obstructive sleep apnea occurs. Spinal anesthesia need not be a barrier. ‘Fitness for a procedure should relate to the patient’s functional status as determined at pre‐anaesthetic assessment, and not by ASA physical status, age or body mass index’.

Multimodal analgesia techniques including regional nerve blocks should be the norm.

full text

Preoperative predictors of poor acute postoperative pain control

A systematic review and meta-analysis sought to identify preoperative factors that could predict poor postoperative pain control. Some new links were found, and others that might have been suspected did not show association.

In brief, factors predicting poor postoperative pain control were: younger age, female sex, smoking, history of depressive or anxiety symptoms, sleep difficulties, higher BMI, presence of preoperative pain, and use of preoperative analgesia.

Sleep difficulty and depression showed the strongest association.

Pain catastrophizing, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control.

Hopefully outcomes can be improved by individualized targeting of pain-predictive factors.

Full text

Patient centred ACS NSQIP Risk

The American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator is one of the major tools employed preoperatively as a risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. ( link ).

This study involved patients, who commonly underestimate their risk. Nearly 90% of participants desire to review their ACS Calculator report before future surgical consents. High-risk patients were 3 times more likely to underestimate their risk of any complication, death, serious complications or discharge to a nursing/rehabilitation unit. After reviewing their calculated risks, 70% stated that they would consider participating in prehabilitation to decrease perioperative risk, and nearly 40% would delay their surgery to do so.

The practice of involving patients may not only help in providing realistic expectations but motivate them to optimize modifiable risk factors and participate in the growing field of preoperative optimization or prehabilitation.

link

Chewing Gum and Anesthesia

There has been debate about whether patients should be disallowed to chew gum before anesthesia and the risk of aspiration.

This correspondence and cross references suggest that in healthy volunteers gum chewing was not associated with increased gastric fluid volume measured 2 h after the oral intake of 250 ml of water.

Future studies incorporating gastric ultrasound in clinical patients may lead to a more liberal view, and the potential of chewing gum to even improve gastrointestinal recovery in ERAS protocols.

link

Intravenous Acetaminophen Before Pelvic Organ Prolapse Repair

This randomized study from the “green journal” compared preoperative intravenous acetaminophen 1g with placebo in women undergoing either laparoscopic or vaginal prolapse repair.

The findings were that “preoperative IV acetaminophen did not reduce pain scores or opioid use and had no effect on patient satisfaction or QOL. Routine use of preemptive IV acetaminophen alone is not supported by this study”.

This joins other studies showing little gain from intravenous acetaminophen.

link