Guidelines for the safe practice of total intravenous anaesthesia

Joint Guidelines from the Association of Anaesthetists and the Society for Intravenous Anaesthesia | First published  31 October 2018 | Anaesthesia  

This is a consensus document produced by expert members of a Working Party established by the Association of Anaesthetists and the Society for Intravenous Anaesthesia. It has been seen and approved by the Board of Directors of the Association of Anaesthetists and the Society for Intravenous Anaesthesia, and It has been endorsed by the Royal College of Anaesthetists,the College of Anaesthesiologists of Ireland, the Intensive Care Society, the Faculty of Intensive Care Medicine, and the Association of Paediatric Anaesthetists of Great Britain and Ireland.

Summary
Guidelines are presented for safe practice in the use of intravenous drug infusions for general anaesthesia. When maintenance of general anaesthesia is by intravenous infusion, this is referred to as total intravenous anaesthesia. Although total intravenous anaesthesia has advantages for some patients, the commonest technique used for maintenance of anaesthesia in the UK and Ireland remains the administration of an inhaled volatile anaesthetic. However, the use of an inhalational technique is sometimes not possible, and in some situations, inhalational anaesthesia is contraindicated. Therefore, all anaesthetists should be able to deliver total intravenous anaesthesia competently and safely. For the purposes of simplicity, these guidelines will use the term total intravenous anaesthesia but also encompass techniques involving a combination of intravenous infusion and inhalational anaesthesia. This document is intended as a guideline for safe practice when total intravenous anaesthesia is being used, and not as a review of the pros and cons of total intravenous anaesthesia vs. inhalational anaesthesia in situations where both techniques are possible.

Full document at Wiley.com

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Fitter Better Sooner

New patient information toolkit aimed at advising patients on how to prepare for going in to hospital and encouraging them to improve their health before surgery | Royal College of Anaesthetists  

The Fitter Better Sooner toolkit is aimed at patients but delivered by care providers. The toolkit materials can be used in ‘teachable’ moments with patients in order to encourage them to actively participate in their own healthcare choices and enjoy the benefit of a healthy lifestyle after surgery. The toolkit consists of one main leaflet, six specific leaflets on some of the most common surgical procedures and an animation which can be shown in clinics or on portable devices.

Full document: Preparing for surgery: Fitter Better Sooner

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

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