Anaesthetic management of patients with myopathies

Schieren, M et al.  Anaesthetic management of patients with myopathies.  European Journal of Anaesthesiology | October 2017 | Volume 34 |Issue 10 | p 641–649

Abstract:

The anaesthetic management of patients with myopathies is challenging. Considering the low incidence and heterogeneity of these disorders, most anaesthetists are unfamiliar with key symptoms, associated co-morbidities and implications for anaesthesia.

The pre-anaesthetic assessment aims at the detection of potentially undiagnosed myopathic patients and, in case of known or suspected muscular disease, on the quantification of disease progression. Ancillary testing (e.g. echocardiography, ECG, lung function testing etc.) is frequently indicated, even at a young patient age.

One must differentiate between myopathies associated with malignant hyperthermia (MH) and those that are not, as this has significant impact on preoperative preparation of the anaesthesia workstation and pharmacologic management. Only few myopathies are clearly associated with MH.

If a regional anaesthetic technique is not possible, total intravenous anaesthesia is considered the safest approach for most patients with myopathies to avoid anaesthesia-associated rhabdomyolysis. However, the use of propofol in patients with mitochondrial myopathies may be problematic, considering the risk for propofol-infusion syndrome. Succinylcholine is contra-indicated in all patients with myopathies.

Following an individual risk/benefit evaluation, the use of volatile anaesthetics in several non-MH-linked myopathies (e.g. myotonic syndromes, mitochondrial myopathies) is considered to be well tolerated. Perioperative monitoring should specifically focus on the cardiopulmonary system, the level of muscular paralysis and core temperature. Given the high risk of respiratory compromise and other postoperative complications, patients need to be closely monitored postoperatively.

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A survey of UK peri-operative medicine: pre-operative care

A.-M. Bougeard et al.  A survey of UK peri-operative medicine: pre-operative care. Anaesthesia.  published online 14th June 2017.

Summary
The majority of UK hospitals now have a Local Lead for Peri-operative Medicine (n = 115).

They were asked to take part in an online survey to identify provision and practice of pre-operative assessment and optimisation in the UK. We received 86 completed questionnaires (response rate 75%).

Our results demonstrate strengths in provision of shared decision-making clinics. Fifty-seven (65%) had clinics for high-risk surgical patients. However, 80 (93%) expressed a desire for support and training in shared decision-making.

We asked about management of pre-operative anaemia, and identified that 69 (80%) had a screening process for anaemia, with 72% and 68% having access to oral and intravenous iron therapy, respectively.

A need for peri-operative support in managing frailty and cognitive impairment was identified, as few (24%) respondents indicated that they had access to specific interventions.

Respondents were asked to rank their ‘top five’ priority topics in Peri-operative Medicine from a list of 22. These were: shared decision-making; peri-operative team development; frailty screening and its management; postoperative morbidity prediction ; and primary care collaboration.

We found variation in practice across the UK, and propose to further explore this variation by examining barriers and facilitators to improvement, and highlighting examples of good practice.

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

Preoperative risk stratification of critically ill patients

Copeland, C.C. et al. (2017) The Journal of Clinical Anesthesia. 39 (June) pp. 122–127

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Highlights:

  • Preoperative assessment of critically ill patients is challenging and understudied.
  • ASA class, RCRI, and SOFA score were studied to predict survival to discharge.
  • One in four ICU patients did not survive to discharge after an intervention.
  • Available scores inadequately discriminated between survivors and non-survivors.
  • SOFA score (AUC = 0.68) outperformed ASA class (AUC = 0.59).

Read the full abstract here

Focused echocardiography: a systematic review of diagnostic and clinical decision-making in anaesthesia and critical care

Heiberg, J. et al. (2016). Anaesthesia. Volume 71(9). pp. 1091–1100

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Image source: Patrick J. Lynch, medical illustrator – Wikipedia // CC BY 2.5

Image shows illustration of transesophageal echocardiography ultrasound diagram

Focused echocardiography is becoming a widely used tool to aid clinical assessment by anaesthetists and critical care physicians. At the present time, most physicians are not yet trained in focused echocardiography or believe that it may result in adverse outcomes by delaying, or otherwise interfering with, time-critical patient management.

We performed a systematic review of electronic databases on the topic of focused echocardiography in anaesthesia and critical care. We found 18 full text articles, which consistently reported that focused echocardiography may be used to identify or exclude previously unrecognised or suspected cardiac abnormalities, resulting in frequent important changes to patient management. However, most of the articles were observational studies with inherent design flaws. Thirteen prospective studies, including two that measured patient outcome, were supportive of focused echocardiography, whereas five retrospective cohort studies, including three outcome studies, did not support focused echocardiography. There is an urgent requirement for randomised controlled trials.

Read the full article here