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

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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

Measuring and Improving the Quality of Preprocedural Assessments

Preprocedural assessments are used by anesthesia providers to optimize perioperative care for patients undergoing invasive procedures | Anesthesia & Analgesia

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When these assessments are performed in advance by providers who are not caring for the patient during the procedure, there is an additional layer of complexity in ensuring that the workup meets the needs of the primary anesthesia care team. In this study, anesthesia providers were asked to rate the quality of preprocedural assessments prepared by other providers to evaluate anesthesia care team

The overwhelming majority of preprocedural assessments performed at our institution were considered satisfactory or exemplary by day-of-surgery anesthesia providers. This was demonstrated by both the case-by-case ratings and midpoint survey. However, the perceived frequency of “unsatisfactory” evaluations was worse when providers were asked to reflect on the quality of preprocedural evaluations generally versus rate them individually. Analysis of comments left by providers allowed us to identify specific and actionable areas for improvement. This method can be used by other institutions to identify systemic deficiencies in the preprocedural evaluation process.

Full reference: Manji, F. et al. (2017) Measuring and Improving the Quality of Preprocedural Assessments. Anesthesia & Analgesia. 124(6 ) pp. 1846–1854

Frailty Level Accurate Predictor of Post-op Complications

Assessing a patient’s level of frailty before an operation can provide important insight into which individuals might develop postoperative complications.

A study by Dr. Balzer and his colleagues conducted a review of patients 65 years of age or older who were seen in the outpatient anesthesiology department for elective surgery from Jan. 14, 2016 through April 30, 2016. A frailty assessment was administered to 196 patients, consisting of a grip strength measurement, timed up-and-go test, a hemoglobin test, and a body mass index or serum albumin level as a test for malnutrition.

The patients were assigned 1 point for each pathologic test result. Patients scoring 0 to 1 point were designated “non-frail” (reference group; 68%); those with 2 points were “pre-frail” (23%) and those with 3 to 4 points were “frail” (9%). Postoperative complications were analyzed via ICD-10 diagnosis codes, and European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) guidelines were used to estimate operative risk.

Read more at Anesthesiology News

A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients

Hall, M. et al. Anesthesia & Analgesia |Published online: 11 May 2017

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Introduction: Serious complications are common during the intensive care of postoperative cardiac surgery patients. Some of these complications may be influenced by communication during the process of handover of care from the operating room to the intensive care unit (ICU) team. A structured transfer of care process may reduce the rate of communication errors and perioperative complications.

Discussion: The main finding of this investigation is that the introduction of a collaborative, comprehensive transfer of care process from the operating room to the ICU was associated with patients suffering fewer preventable complications.

Read the full abstract here

Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review

Tran, D.T.T. et al. (2017) Anaesthesia 72(6) pp. 765–777

This systematic review was performed to determine whether rocuronium creates intubating conditions comparable to those of succinylcholine during rapid sequence intubation of the trachea.

Overall, succinylcholine was superior to rocuronium for achieving excellent intubating conditions (risk ratio (95%CI) 0.86 (0.81 to 0.92), n = 4151) and clinically acceptable intubation conditions (risk ratio (95%CI) 0.97 (0.95–0.99), n = 3992). A high incidence of detection bias amongst the trials coupled with significant heterogeneity means that the quality of evidence was moderate for these conclusions. Succinylcholine was more likely to produce excellent intubating conditions when using thiopental as the induction agent: risk ratio (95%CI) 0.81 (0.73–0.88), n = 2302) with or without the use of opioids (risk ratio (95%CI) 0.85 (0.78–0.93), n = 2292 or 0.85 (0.76–0.95), n = 1428).

Read the full abstract here

 

Transfusion in critical care – a UK regional audit of current practice

Plumb, J et. al. Transfusion in critical care – a UK regional audit of current practice Anaesthesia. 2017 May; 72(5) :633-640

Introduction blood-2169514_1920

Critical care publications have advised that a restrictive transfusion strategy is non-inferior, and possibly superior, to a liberal strategy for stable, non-bleeding critically ill patients. However, translation into clinical practice has been slow. These authors describe the degree of adherence to UK best practice guidelines in a regional network of nine intensive care units in Wessex.

Methods and results

All transfusions given during a 2-month period were included (n = 444). Those given for active bleeding or within 24 hours of major surgery, trauma or gastrointestinal bleeding were excluded (n = 148). The median (interquartile range [range]) haemoglobin concentration before transfusion was 73 (68–77 [53–106]) g/L, with only 34% of transfusion episodes using a transfusion threshold of <70 g/L. In a subgroup analysis that did not study patients with a history of cardiac disease (n = 42), haemoglobin concentration before transfusion was 72 (68–77 [50–98]) g/L, with only 36% of transfusion episodes using a threshold of < 70 g/L. Most blood transfusions given to critically ill patients who were not bleeding in this audit used a haemoglobin threshold >70 g/L.

 Conclusions

The authors conclude that it is unclear why recommendations on transfusion triggers have not translated into clinical practice. With a clear national drive to decrease usage of blood products and clear evidence that a threshold of 70 g/L is non-inferior, the authors find it surprising that a scarce and potentially dangerous resource is still being overused within critical care. They suggest that simple solutions such as electronic patient records that force pause for thought before blood transfusion, or prescriptions that only allow administration of a single unit in non-emergency circumstances, may help to reduce the incidence of unnecessary blood transfusions.

 

Pain Management Still a Constraint to Outpatient Procedures

Surgery is on the move: With enhanced recovery protocols, procedures that once required several days of in-hospital recovery are shifting to the outpatient setting without compromising patient care. However, there are still major barriers to consider | Anesthesiology News 

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At the Interdisciplinary Conference on Orthopedic Value-Based Care, Tong Joo (T.J.) Gan, MD, FRCA, MHS, assessed the feasibility of outpatient arthroplasty and selected spine procedures. “Carefully selected patients in combination with enhanced recovery principles and pathways enable total knee replacement and spinal surgery to be done on an outpatient basis,” said Dr. Gan, who is professor and chairman of the Department of Anesthesiology, Stony Brook Medicine, in New York, “but pain management, postoperative nausea and vomiting (PONV) and rehabilitation are major constraints.”

In a narrative review by Henrik Kehlet, MD, the so-called “father of enhanced recovery after surgery” (ERAS), several potential barriers to outpatient total knee arthroplasty were delineated, including the patient’s social network and comorbidity profile, but pain was the major limiting factor (Bone Joint J 2015;97-B[10 Suppl A]:40-44). “Severity of pain was shown to be one of the main causes of increased length of stay,” Dr. Gan said. “Approximately 50% of patients reported moderate to major pain following surgery, and 30% had either severe or extreme pain.”

Read the full article here