The use of anaesthetics in the elderly surgical population

Miller, D. et al. | Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery | Cochrane Database of Systematic Reviews, Issue 8, 2018 

Background
Anaesthesia during surgery in elderly people (more than 60 years of age) is increasing.  Traditionally, general anaesthesia is maintained with an inhaled drug (a vapour which the patient breathes in) which needs to be adjusted to ensure that the patient remains  unconscious during surgery without receiving too much anaesthetic. An alternative method is to use propofol which is injected into a vein throughout the anaesthetic procedure; this is called total intravenous anaesthesia (TIVA).  Elderly people are more likely to experience confusion or problems with thinking following surgery, which can occur up to several days postoperatively. These cognitive problems can last for weeks or months, and can affect the patients’ ability to plan, focus, remember, or undertake activities of daily living.

This review looked at two types of postoperative confusion: delirium (a problem with awareness and attention which is often temporary) and cognitive dysfunction (a persistent problem with brain function).

TIVA with propofol may be a good alternative to inhaled drugs, and it is known that patients who have TIVA experience less nausea and vomiting, and wake up more quickly after anaesthesia. However, it is unknown which is the better anaesthetic technique in terms of postoperative cognitive outcomes.

Review question
To compare maintenance of general anaesthesia for elderly people undergoing non-cardiac surgery using TIVA or inhalational anaesthesia on postoperative cognitive function, number of deaths, risk of low blood pressure during the operation, length of stay in the postanaesthesia care unit (PACU), and hospital stay.

Study characteristics
The evidence is current to November 2017. We included 28 randomized studies with 4507 participants in the review. We are awaiting sufficient information for the classification of four studies.  All studies included elderly people undergoing non-cardiac surgery and compared use of propofol-based TIVA versus inhalationalagents during maintenance of general anaesthesia.

Key results
We found little or no difference in postoperative delirium according to the type of anaesthetic maintenance agents from five studies (321 participants). We found that fewer people experienced postoperative cognitive dysfunction when TIVA with propofol was used in seven studies (869 participants). We excluded one study from analysis of this outcome because study authors had used methods to anaesthetize people which were not standard. We found little or no difference in the number of deaths from three studies (271 participants). We did not combine data for low blood pressure during the operation or length of stay in the PACU because we noted differences in studies, which may be explained by differences in patient management (for low blood pressure), and differences in how length of stay in the PACU is defined in each study . We found little or no difference in length of hospital stay from four studies (175 participants).

Full review available at the Cochrane Library

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Prevention of deep vein thrombosis and pulmonary embolism

Cooray, Ravindra et al.| 2018| Prevention of deep vein thrombosis and pulmonary embolism|Anaesthesia & Intensive Care Medicine |Vol. 0 | 0| Epub ahead of print | DOI: https://doi.org/10.1016/j.mpaic.2018.06.007

The journal Anaesthesia & Intensive Care Medicine has published a new article that considers the  prevention of deep vein thrombosis and pulmonary embolism.

Abstract

Venous thromboembolism is a major cause of perioperative morbidity and mortality. Immobilized medical patients are also at risk. Long-term sequelae represent a significant chronic health burden. Hospitalized patients should be assessed for their risk of thromboembolism and bleeding at regular intervals. Risk stratification using recommended models can be used to guide the choice of thromboprophylaxis. Both mechanical and pharmacological interventions reduce the incidence of venous thromboembolism. Extended prophylaxis is now recommended following high-risk orthopaedic and cancer surgeries and a number of newer oral antithrombotic agents are now available for this. Anaesthesia should be tailored to minimize the risk of venous stasis and maximize early postoperative mobilization.

 

Rotherham NHS staff can request this article here 

Each baby counts: Themed report on anaesthetic care, including lessons identified from Each Baby Counts babies born 2015 to 2017

Royal College of Obstetricians & Gynaecologists| July 2018 | Recommendations made into anaesthetic care to reduce perinatal deaths and brain injuries during childbirth

The Royal College of Obstetricians & Gynaecologists has looked into stillbirths, neonatal deaths and brain injuries that occur during childbirth as part of its quality improvement programme. It has now released a new report into anaesthetic care: Recommendations made into anaesthetic care to reduce perinatal deaths and brain injuries during childbirth

This special report – supported by the Royal College of Anaesthetists and Obstetric Anaesthetists’ Association – will form part of a wider set of findings and recommendations from the Each Baby Counts programme, to be published in autumn 2018.

each baby counts
Image source: rcog.org.uk

 

Key findings of the report include:

  • Many of the lessons on ‘human factors’, identified in the Each Baby Counts 2015 full report, are echoed in this latest report.
  • Although there were no babies for whom anaesthetic problems were thought to be the sole contributor to their outcome, most of the anaesthetic issues noted in these reviews contributed to delays in delivery.
  • There is a clear need to optimise communication about the urgency of delivery to allow for informed choice of method of anaesthesia.
  • Key themes for improvement also included the care of women with partially effective regional anaesthesia and failed intubation.

Recommendations:

  • There is a need for the development of a structured communication tool to include the three-fold elements of the delivery plan: mode of delivery, location of birth and category of urgency. This will form a key Each Baby Counts implementation output from this report, and the RCOG is committed to collaborating with the relevant organisations to produce this at the earliest opportunity.
  • All local reviews conducted into adverse neonatal outcomes should, where relevant, involve an obstetric anaesthetist and should include review of the detailed anaesthetic record.
  • Anaesthetists should always be informed of the degree of urgency of delivery. As an aid to communication, the classification of urgency of caesarean section should be used for all operative deliveries, vaginal as well as abdominal.
  • A decision about the purpose of transfer to theatre and urgency of any delivery should be made, together with the anaesthetist before transfer to theatre. The degree of urgency should be reviewed on entering theatre prior to the WHO check, and the obstetrician should confirm the degrees of urgency directly to the anaesthetist
  • Anaesthetists should use a structured and validated anaesthetic handover tool between shifts and, if possible, participate in the routine labour ward handover/review of the delivery suite board. This will help maintain situational awareness and enable early anticipation of anaesthetic difficulties.
  • All women who receive epidural analgesia should be reviewed to ensure the effectiveness of the epidural and to minimise delays should the need for operative delivery arise. The function of an in-labour epidural should be taken into consideration when deciding on the most appropriate and timely means of anaesthesia.
  • The safety of the mother must be the primary concern at all times. Women should not be put at risk of airway problems through inadequate preparation/positioning due to haste to achieve a rapid delivery. The required equipment for the management of difficult and failed tracheal intubation in obstetrics detailed in the OAA/DAS guidelines should always be available and all anaesthetists should undergo specific difficult airway training.

Source: Royal College of Obstetricians & Gynaecologists

The report Each baby counts can be downloaded here 

Multimodal Pain Management Strategies

Memtsoudis, S. et al. | Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study | Anesthesiology | 2018 Vol. 128, 891-902

Abstract

Background: Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.

Methods: Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into “opioids only” and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.

Results: Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to “opioids only”) experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a –18.5% decrease in opioid prescription (95% CI, –19.7% to –17.2%; 205 vs. 300 overall median oral morphine equivalents), and a –12.1% decrease (95% CI, –12.8% to –11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.

Conclusions: While the optimal multimodal regimen is still not known, the authors’ findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

Full document available here

 

Children exposed to general anaesthestic have poorer development, literacy and numeracy scores

Study finds that children exposed to general anesthesia before 4 years have poorer development at school entry and school performance | Pediatric Anesthesia | via Journal of Anaesthesia Practice

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The new finding is based on a data-linkage study of over 210,000 children in New South Wales, Australia.

211,978 children included in the study were born in New South Wales at 37-plus weeks’ gestation without major congenital anomalies or neurodevelopmental disability. Of these, researchers had data on their school entry developmental assessment in 2009, 2012, or their Grade-3 school test results in 2008-2014.

The researchers compared the development and school results of children exposed to general anaesthesia during hospital procedures (37,880) up to 48 months of age to same-aged children with no exposure to general anaesthesia or hospitalisation (197,301).

Key findings

Compared to children unexposed to general anaesthesia, those exposed to general anaesthesia had a:

  • 17 per cent increased risk of poor child development
  • 34 per cent increased risk of lower numeracy scores on school tests
  • 23 per cent increased risk of lower reading scores on school tests

When the researchers restricted their analyses to children who’d had only one hospitalisation involving a procedure requiring general anaesthesia, they found no increased risk for poor development or reduced reading scores, however the risk of poor numeracy scores remained.

Full story at Journal of Anaesthesia Practice

Journal reference: Francisco J Schneuer, et al. The impact of general anesthesia on child development and school performance: a population-based study |  Pediatric Anesthesia |  2018; DOI: 10.1111/pan.13390

Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children

Abstract

Background

Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017.

Objectives

To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery.

Search methods

We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews.

Selection criteria

We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery.

Data collection and analysis

At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE.

Main results

In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.

Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).

We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution.

Full reference:

Weinstein, E.J. et al.  |Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children |Cochrane Database of Systematic Reviews 2018 |Issue 4 |Art. No.: CD007105. DOI:10.1002/14651858.CD007105.pub3.

The SR is available in full from the Cochrane Library

Perioperative Quality Improvement Programme (PQIP) publishes first annual report

Royal College of Anaesthetists |Perioperative Quality Improvement Programme | April 2018

The Perioperative Quality Improvement Programme (PQIP) has published its first Annual Report.  The study led by the National Institute of Academic Anaesthesia Health Services Research Centre, on behalf of the Royal College of Anaesthetists (RCoA) and a range of stakeholders, with the aim of improving patient outcomes from major surgery.

Since PQIP’s inception in 2017, over 6,500 patients have been recruited from 79 hospitals across England.  The report outlines PQIP’s five national improvement opportunities for 2018-19.  Among them are: a focus on individualised risk assessment, adherence to enhanced recovery principles,  implementation and adherence to enhanced recovery pathways,  and the optimisation of anaemia, diabetes, and postoperative pain.

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Dr Liam Brennan, President of the RCoA, said:  “PQIP demonstrates that while there are pockets of excellence across the NHS, no hospital as yet offers a complete perioperative medicine package for every patient. All hospitals are encouraged to participate in this programme to enhance the delivery of perioperative care across the whole of the NHS .” (Royal College of Anesthetists)

The full press release from the Royal College of Anesthetists can be read here 

More details can be found at PQIP’s website 

The full report can be read here