Health risk factors in the anesthesia population

  • The prevalence of lifestyle risk factors in perioperative patients is high.
  • A total of 30.1% of patients had no lifestyle risk factor.
  • The most prevalent health risk factors were overweight, smoking, and hypertension.
  • Overweight and hypertension are frequently underreported by patients.
  • Patient self-reports require critical appraisal.

Study objective

We investigated the prevalence of lifestyle risk factors in patients admitted to our preoperative assessment outpatient clinic, and compared patient self-reports and anesthetist reports of health risk factors to evaluate the patient self-image of preoperative health status.

Design

Cross-sectional survey.

Setting

The study was performed in an academic teaching hospital in Amsterdam, the Netherlands, during 3 consecutive months at the preoperative screening clinic.

Patients

A total of 1227 adult patients scheduled for surgery were screened, and 1111 were included (patients being excluded where data were incomplete).

Interventions and measurements

Before health risk screening by an anesthetist, patients filled out a lifestyle risk factor questionnaire including overweight, hypertension, diabetes mellitus, smoking, physical activity, and alcohol use. These were compared with risk factors stated in the preoperative assessment report of the anesthetist.

Main results

The study population was aged 51 ± 17 years with a body mass index of 25.6 ± 4.7 kg/m2. The most frequent lifestyle risk factors reported by the anesthetist were overweight and obesity (47.5%), smoking (25.3%), and hypertension (23.7%). The prevalence of no, 1, or 2 lifestyle risk factors in the preoperative assessment outpatient clinic population was, respectively, 30.1%, 35.6%, and 18.5% reported by the anesthetist and 36.4%, 36.7%, and 18.6% reported by the patients. Patients with more lifestyle risk factors were older with a higher body mass index and American Society of Anesthesiologists classification. Differences in reporting of lifestyle risk factors between patients and anesthetist occurred especially with overweight (26.5% vs 47.5%).

Conclusions

The prevalence of lifestyle risk factors in perioperative patients is high, and differences in reporting between patients and anesthetists may suggest that patients are unaware of or ignore their unhealthy state. Further studies are warranted to investigate the association between the lifestyle risk factors and outcome in the anesthesiology setting.

Full reference: Scharwächter, W.H. et al. Health risk factors in the anesthesia population Journal of Clinical Anesthesia. Volume 32, Pages 33–39

Perioperative management of diabetes and the emerging role of anaesthetists as perioperative physicians

Levy, N et al. British Journal of Anaesthesia. (2016) 116 (4):443-447.

Diabetes is the most common metabolic disorder and affects about 6–7% of the population and about 16% of the inpatient population. Diabetes leads to accelerated atherosclerosis and patients are at higher risk of renal impairment, coronary vascular disease, peripheral vascular disease and cerebro-vascular disease. Subsequently, the surgical patient with diabetes is at higher risk of perioperative morbidity and mortality and subsequently longer length of hospital stays. The reasons for this excess morbidity and mortality is multifactorial and includes increased risks of Hypoglycaemia and hyperglycaemia, infective complications (both surgical site infections (SSIs) and systemic infections), medical complications including acute kidney injury (AKI), acute coronary syndromes (ACS) and acute cerebro-vascular events, hospital acquired diabetic ketoacidosis (DKA),use of variable rate i.v. insulin infusion (VRIII), misuse of insulin, complex polypharmacy and multiple co-morbidities including microvascular and macrovascular complications of the diabetes.

On the basis of these concerns, NHS Diabetes commissioned the Joint British Diabetes Societies (JBDS) to produce guidance to optimise the management of the surgical patient with diabetes with the explicit aim of reducing the incidence of hypoglycaemia and hyperglycaemia, the risk of medical and infective complications, the risk of insulin and VRIII related harm and reducing the excess length of stay.

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Disagreement between cardiac output measurement devices: which device is the gold standard?

Y. Le Manach & G. S. Collins. British Journal of Anaesthesia (2016) 116 (4):451-453.

A common research question in perioperative haemodynamics research concerns the assessment of whether a new measurement device can replace an existing device (often referred to as method comparison studies). Typically, a new measurement method is being compared with an established reference method (unfortunately often referred to as the ‘gold standard’).

In a recent issue of the journal, Biais and colleagues reported the comparison of two cardiac output measurement devices, one based on pulse wave transit time (i.e. the new devices) and the other one based on transthoracic echocardiography (i.e. the reference method ‘gold standard’). The study concluded that devices were not interchangeable and that the new device cannot guide haemodynamic interventions in critically ill patients. Their conclusion was based on observing percentage errors exceeding the limits of 30%, suggested by Critchley and Critchley.

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Intubation performance using different laryngoscopes while wearing chemical protective equipment: a manikin study

Schröder, H et al. BMJ Open 2016;6:e010250

Objectives: This study aimed to compare visualisation of the vocal cords and performance of intubation by anaesthetists using four different laryngoscopes while wearing full chemical protective equipment.

Setting: Medical simulation center of a university hospital, department of anaesthesiology.

Participants: 42 anaesthetists (15 females and 27 males) completed the trial. The participants were grouped according to their professional education as anaesthesiology residents with experience of <2 years or <5 years, or as anaesthesiology specialists with experience of >5 years.

Interventions: In a manikin scenario, participants performed endotracheal intubations with four different direct and indirect laryngoscopes (Macintosh (MAC), Airtraq (ATQ), Glidescope (GLS) and AP Advance (APA)), while wearing chemical protective gear, including a body suit, rubber gloves, a fire helmet and breathing apparatus.

Primary and secondary outcome measures: With respect to the manikin, setting time to complete ‘endotracheal intubation’ was defined as primary end point. Glottis visualisation (according to the Cormack-Lehane score (CLS) and impairments caused by the protective equipment, were defined as secondary outcome measures.

Results: The times to tracheal intubation were calculated using the MAC (31.4 s; 95% CI 26.6 to 36.8), ATQ (37.1 s; 95% CI 28.3 to 45.9), GLS (35.4 s; 95% CI 28.7 to 42.1) and APA (23.6 s; 95% CI 19.1 to 28.1), respectively. Intubation with the APA was significantly faster than with all the other devices examined among the total study population (p<0.05). A significant improvement in visualisation of the vocal cords was reported for the APA compared with the GLS.

Conclusions: Despite the restrictions caused by the equipment, the anaesthetists intubated the manikin successfully within adequate time. The APA outperformed the other devices in the time to intubation, and it has been evaluated as an easily manageable device for anaesthetists with varying degrees of experience (low to high), providing good visualisation in scenarios that require the use of chemical protective equipment.

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Anaesthesia for elective open abdominal aortic surgery

Duncan, A & Pichel, A.Anaesthesia & Intensive Care Medicine. Published online: 14 March 2016

Image shows modelling the stresses in an abdominal aortic aneurysm. The areas of greatest stress in this silicon model are highlighted in red. The spots on the image show tiny reflective markers that are part of the measurement techniques.

The prevalence of abdominal aortic aneurysm (AAA) and the number of patients undergoing aneurysm repair is increasing. The UK has worked hard to reduce its operative mortality rates for elective open AAA repair with the introduction of a quality improvement programme and death from ruptured aortic aneurysm through the national screening programme.

Despite the increased prevalence of disease and intervention, the popularity of open repair is diminishing since the advent of endovascular repair (EVAR). The short-term benefits of EVAR when compared to open repair are evident, however, the long-term survival benefits have yet to be proven. The choice of technique for emergency AAA repair is contentious, with the more traditional approach of open repair being rapidly overtaken by endovascular options.

In this article we outline current approaches to risk stratification, describe the key physiological changes that occur during open repair and describe an overview of the approach to perioperative management.

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Ensuring safe anaesthesia for neonates, infants and young children: what really matters

Weiss, M. et al. Archives of Disease in Childhood. Published Online: 2 February 2016

Annually, millions of neonates and young infants worldwide are submitted to surgery and general anaesthesia. The safety of providing anaesthesia for these patients has recently been cast into doubt based on a large number of animal studies demonstrating that anaesthetic exposure during a vulnerable period of brain development (ie, brain growth spurt) causes neurodegeneration (neuroapoptosis) and abnormal synaptic development with functional deficits in learning and behaviour later in life.

Emerging robust human data, however, do not support this laboratory evidence but reveal other factors that more importantly impact long-term neurocognition. The aim of this article is to describe the important perioperative safety issues that matter most to children undergoing surgery and influence outcome in perioperative care.

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Adverse events of postoperative thoracic epidural analgesia, a retrospective analysis of 7273 cases in a tertiary care teaching hospital.

von Hösslin, T et al. European Journal of Anaesthesiology. Published online: March 3, 2016

Background: Thoracic epidural analgesia is a well established technique for postoperative pain relief after major abdominal and thoracic surgery. Safety remains a major concern because of serious adverse events including epidural haematoma, abscess and permanent neurological deficit.

Objective: The aim of this study was to evaluate the incidence and the long-term outcome of serious adverse events associated with thoracic epidural analgesia.

Patients: Data from 7430 patients were prospectively entered into a standardised acute pain service database. A total of 7273 study participants met the inclusion criteria and were included in the final analyses. The inclusion criteria involved surgical patients receiving a postoperative thoracic epidural analgesia catheter treatment for pain control. Exclusion criteria were defined as obstetric, non-surgical, non-epidural analgesia patients and epidural analgesia catheters that had not been placed by an anaesthesiologist.

Main outcome measures: The database was queried for serious adverse events which were defined as spinal or epidural haemorrhage; spinal or epidural abscess; permanent neurological deficits; cardiac arrest; death and incomplete removal of the epidural analgesia catheter. Patients’ charts were comprehensively reviewed in case of a major adverse event. Patients with an unclear outcome received a mailed questionnaire or were contacted by telephone to determine long-term sequelae.

Results: Seven serious adverse events were identified: epidural abscess [n = 1; incidence 1 : 7273 (0.014%, 95% confidence interval, CI, 0 to 0.08%)], persistent neurological damage [n = 1; incidence 1 : 7273 (0.014%, 95% CI, 0 to 0.08%)], cardiac arrest [n = 1; incidence 1 : 7273 (0.014%, 95% CI, 0 to 0.08%)] and catheter breakage leaving a catheter fragment in situ [n = 4; incidence 1 : 1818 (0.055%, 95% CI, 0.01 to 0.14%)]. Apart from the one patient with persistent neurologic deficit, the patients with serious adverse events associated with thoracic epidural analgesia in our cohort suffered no long-term consequences.

Conclusion: In our single-centre study of thoracic epidural analgesia, serious adverse events occurred in 0.1% cases (1 : 1000), whereas long-term outcome was compromised in 0.014% (1.4 : 10 000) which is similar to the serious adverse event rates and outcomes

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