Anesthesiology: July 2017 Podcast

New Issue of Anesthesiology
m_cover

Image source: Anesthesiology

On the cover:
Management of perioperative fluid impacts gastrointestinal function. In this issue of Anesthesiology, Gómez-Izquierdo et al. randomized patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program to receive intraoperative goaldirected fluid therapy or fluid therapy based on traditional principles and assessed the impact on postoperative ileus. Intraoperative goal-directed fluid therapy did not reduce postoperative ileus, suggesting that previously demonstrated benefits might have been offset by advancements in perioperative care.

Perioperative Venous Thromboembolism: A Review.

Venous thromboembolism (VTE) is a significant problem in the perioperative period, increasing patient morbidity, mortality, and health care costs. It is also considered the most preventable of the major postoperative complications | Anesthesia & Analgesia

B0008083 Blood clot in a vein

Image source: Annie Cavanagh – Wellcome Images // CC BY-NC-ND 4.0

Despite widespread adoption of prophylaxis guidelines, it appears that morbidity from the disease has not substantially changed within the past 2 decades. It is becoming clear that current prophylaxis efforts are not sufficient. Using more potent anticoagulants may decrease the incidence of VTE, but increase the risk for bleeding and infection. Much has been learned about the pathophysiology of venous thrombogenesis in recent years.

Beyond the “traditional coagulation cascade,” which anticoagulants modulate, there is a growing appreciation for the roles of tissue factor, monocytes, neutrophils, neutrophil extracellular traps, microvesicles, and platelets in thrombus initiation and propagation. These recent studies explain to some degree why aspirin appears to be remarkably effective in preventing thrombus propagation. Endothelial dysfunction, traditionally thought of as a risk factor for arterial thrombosis, plays an important role within the cusps of venous valves, a unique environment where the majority of venous thrombi originate. This suggests a role for newer treatment modalities such as statins. Not all patients have an equal likelihood of experiencing a VTE, even when undergoing high-risk procedures, and better tools are required to accurately predict VTE risk. Only then will we be able to effectively individualize prophylaxis by balancing the risks for VTE against the risks associated with treatment.

Given the different cell types and pathways involved in thrombogenesis, it is likely that multimodal treatment regimens will be more effective, enabling the use of lower and safer doses of hemostatic modulating therapies such as anticoagulants, antithrombotics, and antiplatelet medications.

Full reference: Gordon, R. & Lombard, F. Perioperative Venous Thromboembolism: A Review. Anesthesia & Analgesia: Published online: 20 June 2017

The potential for big data analytics to enhance our knowledge of the complex regional pain syndromes

In an era of expanding costs and declining reimbursement, the healthcare industry has dramatically expanded the collection of demographic and clinical data to facilitate billing efficiency and maintain financial solvency | Journal of Clinical Anesthesia

ball-63527_960_720

Electronic health data collection has primarily emphasized the capture of diagnostic coding, medication delivery, laboratory utilization, and procedural interventions to support third party reimbursement claims, improve efficiency, and provide transparency. Although much of the electronic stored data was never directly intended to answer clinical questions, or guide clinical care, the use of data analytics has created opportunities to winnow through the vast data collections and pull out useful insights into previously unrecognized patterns of common and uncommon medical disorders

Full reference: Burgess, F. & Fragoza, K. (2017) Fishing for answers in an ocean of data: The potential for big data analytics to enhance our knowledge of the complex regional pain syndromes. Journal of Clinical Anesthesia. Volume 40. pp. 117–118

Confronting the Perioperative Pain Paradox

Pain medications, especially opioids, have understandably undergone intense scrutiny due to recent public concern over prescription drug abuse, as well as the known side effects of opioids limiting enhanced recovery programs | Anesthesiology News

eight-2045292_960_720.jpg

The problem with eliminating opioid use is that major surgery comes with major pain, and opioids are effective at treating major pain. Furthermore, when opioids are finally introduced after attempting to avoid their use, it is usually done “emergently”—only after the patient is in extreme, inconsolable pain that disrupts recovery. This will likely lead to giving patients larger doses and increasing the risk for adverse events that we are all trying to avoid.

Note that severe acute pain is a risk factor for the development of chronic pain, sleep disturbances, changes in mood and behavior (especially in children), poor wound healing and delayed recovery. This avoidance of opioids in the face of intense pain due to their potential short- and long-term negative effects has created, what I call, the “perioperative pain paradox.”

Full reference: Answine, J.F. (2017) Confronting the Perioperative Pain Paradox. Anesthesiology News. Published online: 15 June 2017

A survey of UK peri-operative medicine: pre-operative care

A.-M. Bougeard et al.  A survey of UK peri-operative medicine: pre-operative care. Anaesthesia.  published online 14th June 2017.

Summary
The majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115).

They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%).

Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%) had clinics for high-risk surgical patients. However, 80 (93%) expressed a desire for support and training in shared decision-making.

We asked about management of pre-operative anaemia, and identified that 69 (80%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively.

A need for peri-operative support in managing frailty and cognitive impairment was identified, as few (24%) respondents indicated that they had access to specific interventions.

Respondents were asked to rank their ‘top five’ priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction ; and primary care collaboration.

We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

Nurses’ experiences of pain management for people with advanced dementia approaching the end of life

Pain management in end-stage dementia is a fundamental aspect of end-of-life care; however, it is unclear what challenges and facilitators nurses experience in practice, whether these differ across care settings, and whether training needs to be tailored to the context of care | Journal of Clinical Nursing

hands-2257419_960_720.jpg

Aims and objectives: To explore hospice, acute care and nursing home nurses’ experiences of pain management for people with advanced dementia in the final month of life. To identify the challenges, facilitators and practice areas requiring further support.

 

Conclusions: Achieving pain management in practice was highly challenging. A number of barriers were identified; however, the manner and extent to which these impacted on nurses differed across hospice, nursing home and acute care settings. Needs-based training to support and promote practice development in pain management in end-stage dementia is required.

Relevance to clinical practice: Nurses considered pain management fundamental to end-of-life care provision; however, nurses working in acute care and nursing home settings may be undersupported and under-resourced to adequately manage pain in people dying with advanced dementia. Nurse-to-nurse mentoring and ongoing needs-assessed interactive case-based learning could help promote practice development in this area. Nurses require continuing professional development in pharmacology.

Full reference: De Witt Jansen, B. et al. Nurses’ experiences of pain management for people with advanced dementia approaching the end of life: a qualitative study. Journal of Clinical Nursing. 26,(9-10) pp. 1234–1244

Improving communication during anaesthesia care transition in the operating room

Jullia, Marion et al. Training in intraoperative handover and display of a checklist improve communication during transfer of care: An interventional cohort study of anaesthesia residents and nurse anaesthetists. European Journal of Anaesthesiology: July 2017 – Volume 34 – Issue 7 – p 471–476

BACKGROUND: Handovers during anaesthesia are common, and failures in communication may lead to morbidity and mortality.

OBJECTIVES: We hypothesised that intraoperative handover training and display of a checklist would improve communication during anaesthesia care transition in the operating room.

DESIGN: Interventional cohort study.

SETTING: Single-centre tertiary care university hospital.

PARTICIPANTS: A total of 204 random observations of handovers between anaesthesia providers (residents and nurse anaesthetists) over a 6-month period in 2016.

INTERVENTION: Two geographically different hospital sites were studied simultaneously (same observations, but no training/checklist at the control site): first a 2-week ‘baseline’ observation period; then handover training and display of checklists in each operating room (at the intervention site only) followed by an ‘immediate’ second and finally a third (3 months later) observation period.

MAIN OUTCOME MEASURES: A 22-item checklist was created by a modified DELPHI method and a checklist score calculated for each handover by adding the individual scores for each item as follows: −1, if error in communicating item; 0, unreported item; 0.5, if partly communicated item; 1, if correctly communicated item.

RESULTS: Before training and display of the checklist, the scores in the interventional and the control groups were similar. There was no improvement in the control group’s scores over the three observation periods. In the interventional group, the mean (95% confidence interval) score increased by 43% [baseline 7.6 (6.7 to 8.4) n = 42; ‘immediate’ 10.9 (9.4 to 12.4) n = 27, P < 0.001]. This improvement persisted at 3 months without an increase in the mean duration of handovers.

CONCLUSION: Intraoperative handover training and display of a checklist in the operating room improved the checklist score for intraoperative transfer of care in anaesthesia.

Full article available at European Journal of Anaesthesiology