Perioperative Precision Medicine: Promise, Progress, and Pitfalls

Wanderer, J& Nathan, N. (2017) Anesthesia & Analgesia. 124(4) pp. 1028

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Image source: Anesthesia & Analgesia

The promise of perioperative precision medicine is the ability to make drug and dosage choices that are informed by each patient’s genomic data. While substantial progress towards understanding drug-genome interactions has been made, large gaps exist between current state and fulfillment of precision medicine’s potential. In this infographic, we describe the relevant perioperative genomic interactions, and demonstrate some of the current limitations for this approach.

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Time to take action on doctor fatigue

March 17th is World Sleep Day and the Royal College of Anaesthetists and  the Association of Anaesthetists of Great Britain and Ireland are calling for action on the issue of safe working hours for doctors.

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On World Sleep Day, which highlights the importance of getting adequate sleep, the Association of Anaesthetists of Great Britain and Ireland (AAGBI) sets out its three-point plan to address the culture surrounding doctor fatigue in hospitals and tackle the problem of excessive fatigue. Such fatigue is known to impair decision making, with consequences for both doctors and their patients. Fatigue at the end of night shifts is of particular concern, with the tragic reports of doctors who have died in car accidents, having fallen asleep at the wheel on their drive home following a night shift.

A survey by the Royal College of Anaesthetists (RCoA) also shows that 85% of junior anaesthetists are at high risk of burnout; fatigue is known to be a risk factor for this.

Through a fatigue task group with partners including the RCoA, the AAGBI has devised the following 3-point plan:

  1. Support publication of a national survey about junior doctor fatigue, covering accessibility of hospital rest facilities, commuting after working night shifts and the impact of fatigue on physical and psychological health.
  2. Roll out of a fatigue education programme informing doctors and their managers about fatigue and how they can reduce its risks.
  3. Defining the standards for adequate rest facilities and cultural attitudes towards rest in hospitals.

 

Quality of clinical practice guidelines in delirium

Bush, S.H. et al. (2017) BMJ Open. 7:e013809

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Objective: To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality.

 

Conclusions: Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.

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Airway management for Cesarean delivery performed under general anesthesia

Rajagopalan S, et al. (2017) International Journal of Obstetric Anesthesia. 29(3) pp. 64-9

Introduction: With the increasing popularity of neuraxial anaesthesia, there has been a decline in the use of general anaesthesia for Caesarean delivery. These authors sought to examine the incidence, outcome and characteristics associated with a failed airway in patients undergoing Caesarean delivery under general anaesthesia.

Conclusions: The authors conclude that advances in adjunct airway equipment, availability of an experienced anaesthetist and simulation-based teaching of failed airway management in obstetrics may have contributed to their improved maternal outcomes in patients undergoing Caesarean delivery under general anaesthesia.

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Impact of spinal anaesthesia vs. general anaesthesia on peri-operative outcome in lumbar spine surgery

Meng, T. et al. (2017) Anaesthesia. 72(3) pp. 391-401

Introduction: The authors systematically reviewed the comparative evidence for the use of spinal anaesthesia versus general anaesthesia for lumbar spinal surgery.

Results: Eight studies with a total of 625 patients were included. These were considered to be at high risk of bias. Compared with general anaesthesia, the risk ratio (95% confidence interval [CI]) with spinal anaesthesia for intraoperative hypertension was 0.31 (0.15 to 0.64), I2 = 0% (p=0.002); for intraoperative tachycardia 0.51 (0.30 to 0.84), I2 = 0% (p=0.009); for analgesic requirement in the post-anaesthesia care unit 0.32 (0.24 to 0.43), I2 = 0% (p<0.0001); and for nausea/vomiting within 24 hours postoperatively 0.29 (0.18 to 0.46), I2 = 12% (p<0.00001). The standardised mean difference (95% CI) for hospital stay was -1.15 (–1.98 to –0.31), I2 = 89% (p=0.007). There was no evidence of a difference in intraoperative hypotension and bradycardia, blood loss, surgical time and analgesic requirement within 24 hours postoperatively or nausea/vomiting in the post-anaesthesia care unit.

Conclusions: The authors conclude that spinal anaesthesia appears to offer advantages over general anaesthesia for lumbar spine surgery.

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Low Back Pain in Children and Adolescents

Moreno, M. (2017) JAMA Pediatrics. 171(3):312

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Image source: H – – J – Flickr // CC BY-NC-ND 2.0

Low back pain is often thought of as an adult condition. However, it is relatively common as children grow older.

At 7 years of age, about 1% of children will have experienced low back pain; at 10 years of age, about 6% of children will have experienced low back pain; and at 14 to 16 years of age, about 18% of adolescents will have experienced low back pain.

Unfortunately, having low back pain as a child or adolescent is a significant risk factor for having low back pain as an adult.

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Alternative techniques for tracheal intubation

McCluskey, K. & Stephens, M.  Anaesthesia and intensive care medicine | Published online: 4 March 2017

Conventional direct laryngoscopy with the curved Macintosh blade is a fundamental skill for all anaesthetists and has been the cornerstone of airway management for many years. This technique relies on the operator aligning the oro-pharyngo-laryngeal structures and inserting an endotracheal tube into the trachea under direct vision. There is a recognized failure rate with this technique and thus alternative techniques for tracheal intubation should be available for use in difficult situations.

Awake fibreoptic intubation (AFOI) remains the ‘gold standard’ method for securing the airway in an anticipated difficult intubation. Advances in optical technology over recent years have lead to the development of several rigid indirect devices, which improve glottic visualization by enabling the operator to ‘see around the corner’. With improved views at laryngoscopy these videolaryngoscopes are emerging as important tools in airway management and useful teaching and training aids.

Read the abstract here