Pre-operative

Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant

Many differing regimes have been recommended by different organizations as well as those using different direct oral anticoagulants (DOACs) based on their half life and renal function.

A simple regime was employed, largely amounting to interruption of DOACs 1 day before low bleeding procedures or 2 days before high bleeding risk procedures, with an adjustment for moderate renal dysfunction for Dabigatran. Resumption occurred in 1 day with low bleeding risk and 2 – 3 days with higher bleeding risk.

Conclusion: “A simple standardized perioperative management strategy without heparin bridging or measurement of coagulation function was associated with low rates of major bleeding and arterial thromboembolism.“

How this meshes with regional or neuraxial anesthesia guidelines as in ASRA is open to further discussion.

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Music versus midazolam during preoperative nerve block placements

The essential conclusion in this study was the equivalence between music played through noise cancelling headphones and Midazolam.

While previous evidence has suggested the utility of music for awake patients, it should be noted that physician satisfaction was higher than patient satisfaction. And both judged communication to be more impaired in the music group.

Nonetheless sedation has gone s little out of fashion in both anesthesia and ICU with links to delirium in many studies in the elderly and substitution with music may be worth considering.

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Regional anaesthesia is associated with less patient satisfaction

At a time where ultrasound guided regional nerve blockade has exploded in popularity for both extremity and trunk surgery, a caveat appears from this prospective study.

About a third of patients undergoing plexus block for upper extremity surgery reported not being fully satisfied; reasons for dissatisfaction following regional anaesthesia are reported as “insufficient anaesthesia prior to surgery”, and “the discomfort of having a long-lasting insensate extremity postoperatively”.

The authors advocate “stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.”

There appears to be a mismatch between the enthusiasm of regional anesthesia practitioners and patients satisfaction, as well as the current mantra of “shared decision making”.

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Cardiovascular complications with atrial fibrillation and non‐cardiac surgery

This study compared the revised cardiac risk index and three atrial fibrillation thrombo‐embolic risk models for predicting 30‐day cardiovascular events after non‐cardiac surgery in patients with a pre‐operative history of atrial fibrillation.

Such patients had a higher rate of 30 day myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death (29% vs. 13%).

The study found that the revised cardiac risk index was outperformed by other thromboembolic scores – CHADS2 , CHA2DS2‐VASc and R2CHADS2.

However “none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri‐operative risk prediction model.”

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New Index for Preoperative Cardiovascular Evaluation

Another attempt to update or simplify prediction of cardiovascular morbidity and mortality in non-cardiac surgery.

Outcomes were: incidence of 30-day postoperative all-cause mortality, myocardial infarction (MI), or stroke.

This study identified six predictors of primary outcome: age ≥75 years, any history of heart disease, symptoms of angina or dyspnea with regular activities, hemoglobin <12 mg/dl, planned vascular surgery, and emergency surgery.

It is dubbed the Cardiovascular Risk Index (CVRI)

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Complications related to peri‐operative transesophageal echocardiography

Trans-esophageal echocardiography (TEE, TOE) has become a standard monitor for real time cardiac assessment in cardiac and other major surgery and critical care hemodynamic management. However it does have a complication rate.

The Association of Cardiothoracic Anaesthesia and Critical Care carried out a one year prospective audit in cardiac surgery cases in the UK and Ireland. Complications included nine upper gastro‐intestinal perforations and eight upper gastro‐intestinal bleeds. Esophageal stenting, video‐assisted thoracoscopic surgery, gastrostomy, and open surgical repair were listed in the management.

Upper GI injuries are more likely during insertion and lower GI injuries during probe manipulation.

The incidence of peri‐operative TOE‐related complications in the included population was 0.08% and the incidence of death due to a TOE‐related complication was 0.03%.

The implication is that major complications have a 40% risk of death. The authors suggest greater training, use of checklists for safe insertion, and laryngoscope use during insertion, as well as incorporating the risks into consent discussions.

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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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