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

B0008083 Blood clot in a vein

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

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Confronting the Perioperative Pain Paradox

Pain medications, especially opioids, have understandably undergone intense scrutiny due to recent public concern over prescription drug abuse, as well as the known side effects of opioids limiting enhanced recovery programs | Anesthesiology News

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The problem with eliminating opioid use is that major surgery comes with major pain, and opioids are effective at treating major pain. Furthermore, when opioids are finally introduced after attempting to avoid their use, it is usually done “emergently”—only after the patient is in extreme, inconsolable pain that disrupts recovery. This will likely lead to giving patients larger doses and increasing the risk for adverse events that we are all trying to avoid.

Note that severe acute pain is a risk factor for the development of chronic pain, sleep disturbances, changes in mood and behavior (especially in children), poor wound healing and delayed recovery. This avoidance of opioids in the face of intense pain due to their potential short- and long-term negative effects has created, what I call, the “perioperative pain paradox.”

Full reference: Answine, J.F. (2017) Confronting the Perioperative Pain Paradox. Anesthesiology News. Published online: 15 June 2017

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

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

Using Technology to Reduce Childrens’ Anxiety Throughout the Perioperative Period

Goldschmidt, K. & Woolley, A. Journal of Pediatric Nursing | Published online: 27 April 2017

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In the U.S. each year, approximately 5 million children undergo a surgical procedure (Perry, Hooper, & Masiongale, 2012). Surgery is one of the most stressful medical procedures that a child can experience. In fact, approximately 50% of children are reported to experience significant anxiety in the preoperative period (Perry et al., 2012). Pediatric nurses know the importance of incorporating parents into the child’s plan of care and understand that the child is comforted by the presence of someone that they know and love.

Read the abstract here