Journal watch

Journal Watch

See which journal articles on perioperative care have caught our attention. 

Below you'll find overviews of some recent articles related to perioperative care, along with links to the open-access articles themselves.

Contributors;

CPOC would like to thank its contributors for their valuable input to Journal Watch. 

Journal Articles

Houghton JSM, Nickinson ATO, Helm JR, Dimitrova J, Dubkova S, Rayt HS, Gray LJ, Haunton VJ, Davies RSM, Sayers RD.  Associations of clinical frailty with severity of limb threat and outcomes in chronic limb-threatening ischaemia. Ann Vasc Surg. 2021; 000:1–11. DOI: https://doi.org/10.1016/j.avsg.2021.04.017

Chronic limb threatening ischaemia (CLTI) represents the advanced stage of peripheral arterial disease and is more commonly observed in older patients and those with multiple co-morbidities and frailty.  Estimating operative risk and planning interventions in this cohort can be challenging and the authors propose that the addition of a frailty assessment may be a useful adjunct to this process.  The authors sought to describe the association between limb threat and frailty and compare their prognostic association with one-year outcomes.

This single-centre retrospective cohort study was undertaken at the Leicester Vascular Limb salvage clinic.  Severity of limb threat was documented using the Wound, Ischaemia, foot Infection (WifI) score and frailty was assessed using the Clinical Frailty Scale (CFS) with a score of 5 or more defining those who were frail. A total of 198 individuals aged 50 and over were included. The primary endpoint was amputation free survival (AFS) at one-year (composite endpoint of major amputation or death). Secondary outcome measures included freedom from major amputation and overall survival at one-year.

190/198 patients had a CFS documented and 98 (52%) were classified as frail.  WIfI scores were available for 192 patients.  Frailty was found to be associated with a greater degree of limb threat, with 68% (30/44) of patients with WIfI stage 4 disease (most severe) classified as frail.  Those who were frail were more likely to be managed non-operatively in the first instance (27% frail vs. 11% non-frail) but the rates of endovascular treatment were similar between the two groups.

The overall AFS rate at one-year was 72% but frail patients had a worse AFS at one year (64%), largely due to a strong association with mortality at one-year rather than major amputation.  WIfI stage 4 disease was the only factor associated with increased risk of major amputation (8.3 fold increased risk).  This suggests the frailest patients with advance-CTLI were more frequently being appropriately managed palliatively/non-operatively.

The authors conclude that frailty is highly prevalent among patients with CLTI and associated with greater severity of limb threat. Frailty assessment may be a useful adjunct to tools such as the Vascular Quality Initiative CLTI Mortality Prediciton Model, in characterising patient risk and informing shared decision making in CLTI management.

Dr Natalie Gaskell, Consultant Geriatrician at the RUH

COVIDSurg Collaborative .Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study. GlobalSurg Collaborative Anaesthesia, 76: 748-758. DOI: https://doi.org/10.1111/anae.15458

There is limited evidence regarding the timing of surgery after SARS-CoV-2 infections. This group performed a prospective international cohort study. In one week in October 2020, they included those patients having surgery. Preoperative SARS-CoV-2 infection and date of diagnosis was recorded. Primary outcome was 30-day postoperative morbidity.

140,231 patients were included from 116 countries. Of those included, 3127 patients had a preoperative SARS-CoV-2 infection diagnosis.  Adjusted 30-day mortality in those without SARS-CoV-2 infection was 1.5%. Adjusted 30-day mortality was increased in those with preoperative SARS-CoV-2 infection. This was 4.1% in those diagnosed with SARS-CoV-2 infection 0-2 weeks prior to surgery. This decreased in every category down to 1.5% in the group diagnosed more than 7 weeks prior to surgery.  The authors suggest delaying surgery for 7 weeks after SARS-CoV-2 infection.

Dr Arun Sahni, ST7 – Barts & The London School of Anaesthesia

Dr Arun Menon, ST4, The Central London School of Anaesthesia

Hogan AM, Luck C, Woods S, Ortu A, Petkov S. The Effect of Orthostatic Hypotension Detected Pre-Operatively on Post-Operative Outcome. J Am Geriatr Soc. 2021 Mar;69(3):767-772. doi: 10.1111/jgs.16966. Epub 2020 Dec 11. PMID: 33314116.

There is an increasingly recognised relationship between orthostatic hypotension (OH) and frailty due to shared underlying co-morbidities. The authors of this paper sought to better understand the relationship between pre-operative OH and post-operative outcome.

They used electronic patient records to retrospectively assess patients who had supine and 1-minute (and 3-minute where available) post-standing blood pressure measurements at a pre-operative assessment clinic – this had been incorporated as a routine assessment alongside electrocardiogram recording in this clinic.

170 patients were identified, with most having abdominal cavity, orthopaedic, or urological/gynaecological/breast surgery. One-quarter of patients demonstrated a significant postural drop, with the drop persisting at 3 minutes in around half of case.

Patients 70 years and older had a higher incidence of OH compared with younger patients (30.9% vs 13.7%, P = .009) however there was no association between age and the severity of the drop.

Patients over 65 with OH had higher frailty scores than those without OH.  Also, patients with OH had longer lengths of stay (2 days, range 0-15 vs 1 day, range 0-12, P= .007) and were more likely to  have symptoms of orthostatic intolerance recorded in their post-operative notes (33.3% vs 7.5%, P < .001)

The authors note a higher incidence of OH in their population compared to community prevalence. They suggest perioperative reasons for this, such as weight change, fasting advice, underlying pathology – including anaemia, immobilisation, upregulated stress hormones and interrupted medication routine may account for this.  

They conclude that larger studies should be conducted to further inform the reasons for and incidence of OH in the perioperative period. In the meantime, they advise that benefit may be derived through greater recognition of this issue and the implementation of pharmacological and non-pharmacological measures. 

Alexandra M. Hogan, PhD FRCA, Claire Luck, BN, Sarah Woods, MSc, Andrea Ortu, EDAIC, and Svet Petkov, FRCA

Ray Yun Gou, MA; Tammy T. Hshieh, MD, MPH; Edward R. Marcantonio, MD, SM; Zara Cooper, MD, MSc; Richard N. Jones, ScD; Thomas G. Travison, PhD; Tamara G. Fong, MD, PhD; Ayesha Abdeen, MD; Jeffrey Lange, MD; Brandon Earp, MD; Eva M. Schmitt, PhD; Douglas L. Leslie, PhD; Sharon K. Inouye, MD, MPH; for the SAGES Study Group

Read the full article here

Delirium after surgery is common and associated with both individual and economic adverse outcomes.

This American prospective cohort study followed 497 patients aged 70 or over who underwent elective major surgery between June 2010 and August 2013. The mean patient-age was 76.8. Patients with prior history of dementia, delirium and severe sensory impairment were amongst those excluded at recruitment.  Eligible surgical procedures with predicted length of stays of 3 days or more were selected from orthopaedic, vascular and GI surgical domains.  Post-operatively patients were evaluated daily for the presence of delirium and graded according to severity using the Confusion Assessment Method.  Inflation-adjusted costs associated with delirium were calculated from clinical data and Medicare reimbursement claims. Regression models were used to determine delirium-associated costs after adjustment for patient demographics and clinical characteristics.

122 (25%) of the 497 patients developed postoperative delirium; at one year follow up, this cohort had additional adjusted mean health care costs of $44 291 (95% CI $34 554 - $ 56 673) per patient per year. The majority of this cost was accrued in the first 3 months through initial hospitalisation, subsequent re-admission and rehabilitation stays. Mean health care cost increased directly with delirium severity; the mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs ascribable to postoperative delirium were estimated at $32.9 billion per year.

This study highlighted the economic impact of delirium on health care in the context of elective surgery. It is hoped this will be a driver to invest in services tailored towards multi-component delirium prevention. Future research is needed to assess the impact of such services on delirium-related health care costs.

 

 

Albini A, Malavasi VL, VItolo M, Imberti JF, Marietta M, Lip GYH, et al. European Journal of Internal Medicine. 2021. doi: https://doi.org/10.1016/j.ejim.2020.12.018. 

In this meta-analysis Albini et al. found that postoperative atrial fibrillation was associated with a more than two-fold risk of stroke (RR 2.51; CI 1.76-3.59).

New-onset postoperative atrial fibrillation is the most common cardiac arrhythmia in patients undergoing noncardiac surgery, with incidence reported up to 15%. Outside the perioperative arena it is accepted that atrial fibrillation is associated with increased stroke risk, with most patients offered prophylactic anticoagulation. However, postoperative atrial fibrillation has traditionally been considered self-limiting, and the long-term implications not fully understood, resulting in considerable heterogeneity in anticoagulant use.

They include fourteen studies, with 3.5 million patients, with follow-up from 1 month to 3.5 years. The overall incidence of new atrial fibrillation was 13.6%.

Postoperative atrial fibrillation was associated with increased incidence of stroke, but interestingly, whilst atrial fibrillation was more common in those undergoing thoracic surgery, stroke was less frequent in this cohort. The authors suggest that this may reflect the mechanism of triggering atrial fibrillation, with thoracic surgeries being the result of direct manipulation of the heart or pulmonary veins, whilst non-thoracic surgical candidates may have a predisposition to atrial fibrillation that was triggered by perioperative stress.

Whilst this study highlights the hazard conferred by postoperative atrial fibrillation on long-term stroke risk, future trials are now needed to assess the safety and efficacy of anticoagulant prophylaxis.

Thillainadesan J, Mudge AM, Aitken SJ, et al. Journal of the American Geriatrics Society 2020. 00:1-8. Doi: 10.1111/jgs.16907. Online ahead of print.

Frail older surgical patients are recognised as having an increased likelihood of postoperative complications and mortality. This Australian prospective observational study sought to examine the association between frailty and lesser investigated hospital-acquired geriatric syndromes delirium and functional decline amongst older vascular surgery inpatients. The prognostic performance of frailty tools Clinical Frailty Scale (CFS) and Frailty Index (FI) in predicting these outcomes was also assessed.

150 patients aged 65 years with a length of stay >2 days from a single centre were included. 117 (78%) underwent operative management. 34 (23%) were deemed frail using the FI (FI>0.25) and 45 (30%) using the CFS (CFS 5). 15 (10%) developed delirium and 28 (19%) functional decline. Frail patients were more likely to develop delirium and functional decline, have hyperpolypharmacy and a high drug burden index (DBI) at discharge compared to non-frail. Frailty adjusted for age, sex, CCI, admission status and surgical management approach was significantly associated with delirium (FI adjusted OR = 5.64, 95% CI 1.47-21.68, CFS adjusted OR = 4.21, 95% CI 1.14-15.5), however not functional decline. The C-statistic for FI and CFS showed acceptable discrimination for delirium at 0.74 and was 0.63-0.64 for functional decline. Both tools had a low positive predictive value of 22-29% and high negative predictive value of 86-96% for delirium and functional decline, suggesting that non-frail patients are unlikely to develop these complications.

These findings support frailty assessment using the CFS or FI to identify older vascular surgical patients at risk of delirium and inform shared decision-making.

Find the journal article here.

 

Susano et al. Anesthesiology 2020; 133:1184-1191 doi: https://doi.org/10.1097/ALN.0000000000003523

Postoperative delirium is a common complication, which affects 20-80% of older surgical patients. This is a single centre prospective cohort study of 229, ≥ 70 year-old patients undergoing elective spinal surgery. Both the five-item FRAIL scale and cognition screening were used preoperatively. The primary outcome was delirium. 25% of the patients developed this. On multivariable analysis, frailty (scores 3-5, OR 6.6; 95% CI, 1.96-21.9; P = 0.002) vs. robust (score 0) on the FRAIL scale, lower animal fluency scores (OR 1.08; 95% CI, 1.01-1.51; P = 0.036), and more invasive surgical procedures (OR 2.69; 95% CI, 1.31-5.50; P = 0.007) vs. less invasive procedures were associated with postoperative delirium. These findings support the guidance from The American College of Surgeons and the American Geriatrics Society, where preoperative frailty screening should form part of a comprehensive preassessment work up in identifying high risk patients.

Read the article here.

Igwe O.E, Nealon J, Mohammed M et al. Journal of Clinical Anaesthesia 2020. 5; 67:110004. doi:10.1016/j.jclinane.2020.110004

Read the full article here

Post-operative delirium (POD) is a frequent complication in older people and is associated with poor perioperative outcomes. This systematic review examined both pharmacological and non-pharmacological interventions used to reduce POD in older adults (> 65yrs) undergoing elective and emergency surgery.

Twenty-five quasi-experimental studies and randomised control were included (16 pharmacological vs 9 non-pharmacological interventions). Pharmacological interventions included haloperidol, other antipsychotics, dexmedetomidine, melatonin, benzodiazepines, anticholinesterase inhibitors, sevoflurane and propofol based anaesthetic agents. Non-pharmacological studies consisted of multi-component programmes focussing on multidisciplinary education, pain management and geriatric medicine approaches to care.

A meta-analysis of the four studies that evaluated the use of haloperidol observed no reduction in the incidence of POD. A narrative synthesis of the remaining studies showed inconclusive evidence for other pharmacological interventions. In comparison, multicomponent interventions consistently demonstrated a significant reduction in the incidence of POD.

Significant heterogeneity of the study designs, populations and interventions limits conclusive results being drawn. Nevertheless, the findings of this review are congruent with NICE recommendations for use of tailored multicomponent interventions packages for addressing delirium in hospital and institutionalised patients. This highlights the need for multidisciplinary collaboration to develop effective intervention protocols in clinical practice and to drive future high-quality research in this area.

Castillo-Angeles M et al JAMA Surg. Published online November 25, 2020. doi:10.1001/jamasurg.2020.5397

Read the full article here

The effect of frailty on morbidity and mortality after elective surgery has been extensively studied, however its contribution after emergency general surgery (EGS) is less well established. This is a cross-sectional study analysing 882 929 Medicare inpatient profiles between Jan 2007-Dec 2015. The primary outcome measured was overall 30-day mortality after discharge. EGS were stratified as low and high-risk dependent on surgical magnitude. Frailty was assessed using a model similar to the Rockwood Frailty Index. Frailty was significantly associated with mortality (OR, 1.64; 95%CI, 1.60-1.68). After stratification, this remained significant for high-risk (OR, 1.53; 95%CI, 1.49-1.58) and low-risk (OR, 2.05; 95%CI, 1.94-2.17) procedures. Frailty was associated with EGS related mortality, with greater risk in low-risk procedures.

Togioka, B M. et al. British Journal of Anaesthesia, Volume 124, Issue 5, 553 – 561. DOI:https://doi.org/10.1016/j.bja.2020.01.016

Residual neuromuscular blockade has been associated with post-operative pulmonary complications. 200, >70 year-old patients were enrolled in an open-label, assessor blinded RCT; patients either received 2mg/kg sugammadex or 0.07mg/kg neostigmine. There were no significant differences in the primary end-point of post-operative pulmonary complications (33% vs 40%; OR, 0.74; 95%CI, 0.40-1.37; P=0.30). Sugammadex decreased residual neuromuscular block (10% vs 49%; OR, 0.11, 95%CI, [0.04-0.25]; P<0.001). Phase 1 recovery time was comparable between sugammadex and neostigmine, difference –12.7 min (95% CI, –29.2-3.9], P=0.13). In an exploratory analysis, there were fewer 30-day hospital readmissions in the sugammadex group compared with the neostigmine group (5% vs 15%; OR, 0.30, 95%CI, 0.08-0.91]; P=0.03).

McIsaac DI,Taljard M, Bryson GL et al, BJA 2020, 125 (5):704-711                 

DOI: https://doi.org/10.1016/j.bja.2020.07.003

This Canadian study is one of the first to look at postoperative trajectories in the context of frailty, and followed up 687 patients aged >65 years for the first year following major elective noncardiac surgery.

Patients’ frailty was assessed using the Fried Phenotype (FP) and the Clinical Frailty Scale (CFS). The primary outcome was patient reported disability score (using the WHO Disability Assessment) at baseline, 30, 90 and 365 days after surgery.

 Frail patients experienced a decrease in disability score at 365 days while those without frailty had no significant change in their disability score from baseline. (P<0.0001) However, patients with frailty were more likely to experience an initial postoperative worsening in disability and the authors conclude that frail patients may stand to benefit from their procedures to a greater extent, provided the initial postoperative course can be weathered.

Dr Charlotte Crossland, ST4 Anaesthetics, KSS School of Anaesthesia 

Dushianthan A, Knight M, Russell P et al,  Perioper Med 2020, 9, 30 

DOI: https://doi.org/10.1186/s13741-020-00161-5

This systematic review looked at the specific effect of GDHT on postoperative pulmonary complications (PPCs).  66 RCTs and 9548 patients were included. PPCs were defined as pneumonia, atelectasis, acute lung injury, aspiration pneumonitis, pulmonary embolism, and pulmonary oedema.

The use of GDHT reduced overall pulmonary complications significantly (OR 0.74, 95% CI 0.59 to 0.92). The incidence of pulmonary infections was lower with GDHT use (OR 0.72, CI 0.60 to 0.86) as was pulmonary oedema (OR 0.47, CI 0.30 to 0.73). There were no differences in rates of pulmonary embolism or acute respiratory distress syndrome.

Sub-group analyses demonstrated the benefit was seen in general and cardiothoracic surgery and when the GDHT protocol used fluids and inotropes/vasopressors in combination, rather than fluid alone.

Dr Charlotte Crossland, ST4 Anaesthetics, KSS School of Anaesthesia 

Buse G., Puelacher C., Gualandro D. et al. British Journal of Anaesthesia 2020 bja.2020.08.041

Link to article

A third of all surgical interventions, worldwide per year, are performed on patients with high cardiovascular risk, therefore accurate risk stratification is important to inform shared decision making, and to identify which patients should be seen in a pre-operative clinic for optimisation. Functional capacity has been identified as being a useful predictor of peri-operative risk and is measured in a manner of different ways: using cardiopulmonary exercise testing, the validated Duke Activity status index (often lengthy, patients may not be able to answer all questions) or using semi quantitative self reported functional activity with cut off reference activities. Authors hypothesised that self-reported functional capacity, estimated by the ability of climbing less than two flights of stairs (4 metabolic equivalents), was independently associated with adverse cardiac events, and the addition of functional capacity to existing risk scores improved risk classification.

They performed a preplanned secondary analysis from a prospective diagnostic cohort study on patients identified as having a high risk of perioperative cardiovascular complications undergoing noncardiac surgery. In pre-op clinic patients were asked about their ability to walk up two flights of stairs and this was recorded. 4560 patents met inclusion criteria and follow up was completed in 99.3%. After statistical analysis authors found self-reported functional capacity of less than two flights of stairs was associated with cardiac death and cardiac events at 30 days, and all-cause mortality at 30 days and 1 year. They also found that the addition of self-reported functional capacity to surgical and clinical risk (revised cardiac risk index) stratification tools resulted in significant reclassification improvement (risk of major adverse cardiac events). This will guide shared decision making and optimisation.

COVIDSurg Collaborative.(2020), Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet Published online May 29 2020

Link to open access article.

This is the first paper published by COVIDSurg – an international, observational cohort study assessing the outcomes of surgical patients with COVID-19 infection.

1128 patients with perioperative SARS-CoV-2 infection between January and March 2020 were included. 235 hospitals in 24 countries contributed data.

Perioperative infection: SARS-CoV-2 infection diagnosed within 7 days before or 30 days after surgery.

Surgery: any indication and with any type of anaesthesia.

Diagnosis of SARS-CoV-2 infection: RT-PCR testing (86% of patients), clinical or radiological findings.

The majority (74%) of patients were undergoing emergency surgery. A minority (26%) had the infection confirmed preoperatively, with the rest postoperatively.

Very high rates of mortality and postoperative pulmonary complications were found.

30-day mortality was 24% - a higher mortality than the highest risk groups in the 2019 NELA report.

Mortality was higher in males, those over 70, ASA3-5 and those undergoing emergency surgery, major surgery or surgery for malignancy. The greatest increased risk was for age >70 (OR 2.3) and ASA 3-5 compared with ASA1-2 (OR 2.35)

Postoperative pulmonary complications occurred in half (51%) of patients with perioperative COVID-19 and 30-day mortality in these patients was 38%.

There are clear drawbacks to a retrospective study without a control arm – it may be that SARS-CoV-2 infected patients who did well postoperatively were less likely to be tested or diagnosed, making the complication and death rate in the positive group appear falsely higher. However, the mortality rates found are exceptionally high and plausible, given the combination of the inflammatory and prothrombotic state that results from COVID-19 and that that results from surgery.

The difficult next step is how health care systems and individual doctors use this information to inform the risk/benefit conversation around restarting elective surgery both on a population and on an individual level. The authors of the paper suggest that thresholds for surgery should be higher than normal, particularly in the higher risk groups, and non-operative treatment should be considered where possible.

The future CovidSurg-Cancer study will be looking at the safety of surgery for cancers during the pandemic and the impact the pandemic has had on cancer treatment pathways and will hopefully add to the information we need for this discussion. 

Published comment from Paul Myles and Salome Maswime can be read here.

Boyd‐Carson, H., Shah, A., Sugavanam, A., Reid, J., Stanworth, S.J. and Oliver, C.M. (2020), The association of pre‐operative anaemia with morbidity and mortality after emergency laparotomy. Anaesthesia 75: 904-912. doi:10.1111/anae.15021

Link to open access article.

This study adds to the growing body of evidence that pre-operative anaemia is associated with poorer outcomes, with previous studies mostly concentrating on elective surgery. It remains unclear whether this relationship is causal although current thinking is that it should be investigated and treated prior to elective surgery.

The NELA group looked at outcomes for patients undergoing laparotomy (excluding laparotomy for haemorrhage) between December 2013 - November 2017.

52% of patients were anaemic (WHO definitions). All levels of anaemia were associated with increased 30 and 90-day mortality and prolonged hospital stay. Moderate and severe anaemia were also associated with an increased risk of return to theatre.

It remains unclear how this information should be used. The timescale available in emergency surgery to address anaemia is small and red cell transfusions are known to be associated with harm. It is not known whether targeted treatment with v iron, B12 or folic acid would improve outcomes in this group.

Odor P M, Bampoe S, Gilhooly D, Creagh-Brown B, Moonesinghe S R (2020), Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis BMJ 2020;368:m540

Postoperative pulmonary complications (PPCs) are a common cause of perioperative morbidity and mortality and are particularly topical with recent data indicating a very high rate among patients infected with SARS-CoV2.  Diverse, pre-, intra- and post-operative interventions have been considered to try and reduce PPCs.

This group looked at RCTs of protocolised interventions aimed at reducing PPCs in non-cardiac surgery.

95 trials were studied but no high-quality evidence was found for any intervention.

Moderate quality evidence supported a reduction in PPCs with lung protective intraoperative ventilation and goal directed haemodynamic therapy.  Further (trial sequential) analysis showed evidence of benefit for goal directed haemodynamic therapy, enhanced recovery pathways, prophylactic respiratory physiotherapy and epidural analgesia.

Moderate quality evidence showed no benefit for incentive spirometry.

PPCs are a diverse group of complications, their measurement can be subjective and blinding to (often visible, physical) interventions can be problematic making studies in this area difficult. Hopefully future trials will provide greater clarity.

Campbell AM, Axon DR, Martin JR, Slack MK, Mollon L, Lee JK. Melatonin for the prevention of postoperative delirium in older adults: a systematic review and meta-analysis. BMC Geriatr. 2019;19(1):272. Published 2019 Oct 16. doi:10.1186/s12877-019-1297-6

Link to open access article

Postoperative delirium is a common complication of surgery, particularly in the elderly, and is associated with poor outcomes such as prolonged reduction in cognition, institutionalisation and mortality. Many non-pharmacological strategies are already recommended for reducing delirium but pharmacological interventions are limited.

Six studies were considered (4 using melatonin, 2 using ramelteon – a melatonin receptor agonist).

Patients taking melatonin had 37% lower odds of experiencing delirium.

There were only a small number of studies that met inclusion criteria, dosing was heterogenous and delirium assessment and diagnosis was variable. However, melatonin is a relatively low-cost drug with few side effects and this paper highlights a promising line of future research into the prevention of delirium - a complication we have, thus far, had limited success in reducing.

McIlveen, E.C., Wright, E., Shaw, Edwards, J., Vella, M., Quasim, T. and Moug, S.J. (2020), A prospective cohort study characterising patients declined emergency laparotomy: survival in the ‘NoLap’ population. Anaesthesia, 75: 54-62. doi:10.1111/anae.14

Link to open access article.

This single centre UK-based study considered the often-overlooked group where laparotomy is indicated but not performed (the ‘NoLap group’). Of 314 patients 68.2% had surgery, 31.8% did not (cf Australian audit – 94% had surgery)1 The main reason for lack of surgery was futility (80%).

NoLap group patients unsurprisingly had higher predicted mortality (P-POSSUM and a general survival model), worse renal function, higher lactate, a higher ASA and were older, more dependant and co-morbid and more likely to have bowel ischaemia.

Two variables were associated with survival (after multivariate analysis) – background mortality and acute pre-op lactate.

Post op mortality rates over the follow up period (median 1.3 years) in those undergoing surgery were similar to those predicted (24%). A third of the NoLap patients survived to 30 days and mortality rates were higher than would have been predicted had they had surgery, indicating that surgery might prolong in some of these patients. However, there may be unmeasured confounding factors in the discrepancy between expected and observed mortality rates in this group and an increase in survival duration may not be in accordance with the patient’s wishes or best interests -the decision not to operate is complex and must be individualised.

  1. Broughton KJ, Aldridge O, Pradhan S, JR A, The Perth Emergency Laparotomy Audit. Australia and New Zealand Journal of Surgery 2017;87.

The HIP ATTACK investigators. Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial. Lancet Published Online Feb 9, 2020 

Link to open access article. 

This international RCT looked at patients >45 yrs requiring hip fracture surgery. 770 fulfilled eligibility criteria, 2970 were enrolled - lack of operating space being the main limiting factor.

Patients were allocated to a goal of surgery <6hrs from diagnosis or to standard care (median time to surgery from diagnosis 24 hours). Accelerated surgery was only performed during normal working hours.

No significant different difference was found between the groups in 90-day mortality or a composite of major complications. Accelerated surgery was associated with a lower risk of delirium and infection, faster mobilisation, fewer strokes, moderate to severe pain and a shorter length of stay. No harm was seen from the accelerated pathway.

Post-hoc analysis demonstrated a mortality benefit from earlier surgery in those with pre-operative elevated troponins.

Sessler, D , Pei L, Huang Y, Fleischmann E, Marhofer P, Kurz A et al  Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial. Lancet 2019 394(10211); 1807-1815 doi: 10.1016/S0140-6736(19)32313-X.

 

The ongoing concern that use of volatile anaesthetics and opiates worsen breast cancer recurrence rates was examined in this international RCT. Women undergoing surgery for breast cancer were randomised to anaesthesia with paravertebral blocks and propofol or sevoflurane (volatile) and opiates. Effects on incisional pain was also considered.

Over 2000 women were included and followed up for a median of 36 months. Despite a putative mechanism in favour of regional anaesthesia reducing recurrence rates (reduction in the immune suppressive stress response to surgery) and evidence from animal models, no effect was found overall nor in the subpopulations considered (age, oestrogen receptor status, tumour stage). There was also no impact on persistent incisional pain levels.

 

Webb, A.R., Coward, L., Soh, L., Waugh, L., Parsons, L., Lynch, M., Stokan, L.‐A. and Borland, R. (2020), Smoking cessation in elective surgical patients offered free nicotine patches at listing: a pilot study. Anaesthesia, 75: 171-178. doi:10.1111/anae.14863

Link to open access article. 

The risks of smoking in general as well as perioperatively are well known, as are the benefits of quitting. Surgery is being increasingly seen as a ’teachable moment’ – an opportunity to help people make lifestyle changes to benefit their health both for surgery and thereafter.

This group randomly assigned 600 smokers awaiting non-urgent surgery to a written offer of 5 weeks’ worth of free nicotine patches or usual care (which included written information about stopping smoking). 39% of those offered the patches accepted them and 12.5% used them for >3 weeks. Of those offered patches, 9% quit smoking for >4 weeks before surgery compared with 6% of controls (non-significant difference). Significantly more of those offered nicotine replacement had i) attempted quitting during the study period, ii) reduced their smoking by the time of surgery. Of those who had given up smoking on the day of surgery, 59% had relapsed at 6 months.

The study suggests a high number needed to treat (31) but at low cost. The authors comment that adding fast-acting oral nicotine to patches increases cessation rates and might increase the effectiveness of the intervention.

Richards T, Baikady R R, Clevenger B, Butcher A et al. Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial. The Lancet (2020) 

Link to open article.

This free to access trial has produced results that were unexpected by most and caused some debate as to what to do next. 


30-60% of patients undergoing elective surgery are anaemic, the commonest cause being iron deficiency. This is associated with an increased risk of blood transfusion, complications and delayed discharge. Inflammation (as often seen due to the disease process in surgical patients) limits oral absorption of iron and hence intravenous (IV) iron has been recommended in recent years in the UK (NICE, NHSE)


A double-blind RCT was conducted to look at whether IV iron given to anaemic patients before major open elective abdominal surgery would correct anaemia, reduce the need for blood transfusion and improve patent outcomes. Anaemia was defined as <130g/L for men and <120 g/L for women. 487 participants were allocated to IV iron (1000mg ferric carboxymaltose) or placebo 10-42 days before surgery between 2014 and 2018. There was no significant difference in transfusion rates or death. There were no differences in safety endpoints measured.


The IV iron group had significantly higher Hb concentrations at 8 weeks but levels were similar between the two groups in the immediate postoperative period. Postoperative complications were similar in the two groups and there was no difference in hospital length of stay. Readmissions following discharge were significantly lower in the IV iron group in the first 8 weeks following surgery with the most common reason for readmission being a post-operative complication or wound infection. 


There was no comment on any adverse outcomes resulting from IV iron. 


Further considerations – anaemia is associated with poorer outcomes but this may due to it being a marker of underlying disease rather than it being the direct cause. The effect on Hb came later than the surgical event and may be related to the reduction in readmission rates.

Aucoin SD, Hao M, Sohi R, Shaw J, et al . Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery: A Systematic Review and Meta-analysis. Anesthesiology. 2020;133(1):78-95. doi:10.1097/ALN.0000000000003257

Link to open access article.

Preoperative assessment of frailty is strongly recommended but implementation is not routine – a barrier may be confusion around which of the many tools to use. This free to access work considered which frailty score is the best predictor of adverse perioperative outcomes. 


A systematic review and meta-analysis of 45 studies looking at 35 frailty assessment tools found that different tools were better predictors for different outcomes: 
•    The Clinical Frailty Scale (CFS) was found to be most strongly associated with mortality and discharge not to home. 
•    The Edmonton Frail Scare (EFS) was a better predictor of complications. 
•    The Frailty (Fried) Phenotype was most strongly associated with postoperative delirium. 


Looking at overall feasibility (ease of use, logistical and environmental barriers and time to administrate) and accuracy, the authors concluded that the evidence best supported the use of the CFS for preoperative use. The Fried Phenotype was also felt to be accurate but took considerably longer to complete than the CFS.


Further considerations may be how reliable frailty assessment is when done by non-geriatricians and whether the type of surgery has an effect on the outcome as predicted by frailty scores. 

Aitken R M, Partridge J S L, Oliver C M, Murray D, et al. Older patients undergoing emergency laparotomy: observations from the National Emergency Laparotomy Audit (NELA) years 1–4, Age and Ageing 2020; 49 (4) July 2020, P 656–663

Link to open article.

This free to access study looks at patients 65 years included in the National Emergency Laparotomy Audit (NELA). This group is the largest in the NELA population (57%). Perhaps unsurprisingly the authors found that patients 65 years had higher mortality rates, longer LOS and were more likely to be discharged to a care-home than younger patients. However, mortality rates did reduce over time (2013-2017) and this reduction was greater in the older population than the reduction seen in younger patients. The proportion of older NELA patients seen post-operatively by a geriatrician increased over time (although only 16.5% are seen). Preoperative geriatrician review was associated with higher mortality. These patients also had a longer median time to theatres, were more likely to be ASA 4, have a predicted mortality 5% and have been admitted from care homes, indicating that the sickest patients were referred. The patients referred post operatively to geriatricians had similar profiles (were also the sickest) but mortality reduced significantly in those reviewed by geriatricians (P<0.001). 


The authors point out that NELA does not record those who do not go onto have emergency laparotomies and that this may account for some of the decline in mortality rates in older patients as higher-risk patients may have been excluded from surgery. Additionally, patient reported outcomes are still not measured. Barriers to increasing geriatrician input into this high-risk group of patients include funding, workforce and interspeciality collaboration. 
 

Deiner S, Baxter M G, Mincer J S, Sano M, et al. Human Plasma biomarker responses to inhalational general anaesthesia without surgery. Brit J Anaes 2020; 125(3) p282-290

Link to article. 

There is increasing interest in postoperative cognitive dysfunction and this study aimed to separate out the effects of a general anaesthetic (GA) from those of surgery. Previous studies have demonstrated an increase in cytokines and other biomarkers in patients undergoing surgery under GA and there are theories that the anaesthesia causes a form of neurotoxicity in vulnerable patients. The biomarkers included (IL-6), TNF, CRP and markers of neural injury such as tau, glial fibrillary acidic protein (GFAP) and neurofilament light (NF-L). Healthy volunteers aged 40-80 years underwent a 2 hour GA without surgery and biomarker levels were recorded. 5 hours after induction of anaesthesia (sevoflurane) IL-6 was increased by a biologically insignificant degree, TNF and CRP were unchanged and the neural injury markers were significantly decreased. The authors conclude that GA with sevoflurane did not provoke an inflammatory state or neuronal injury in the hours after induction, perhaps indicating that the inflammation is provoked by the surgery itself. 


Further considerations may be in the measurement of NF-L and GFAP which were found to increase with age in this study, and might offer a mechanism for risk stratification, changes in biomarkers at later time points and in the effects of non-inhalational anaesthesia. 

Recent Guidelines

Woodcock, T., Barker, P., Daniel, S., Fletcher, S., Wass, J.A.H., Tomlinson, J.W., Misra, U., Dattani, M., Arlt, W. and Vercueil, A. (2020),

Guidelines for the management of glucocorticoids during the peri‐operative period for patients with adrenal insufficiency. Anaesthesia. doi:10.1111/anae.14963

Access the guidelines. 

Review

Santhirapala, R., Partridge, J. and MacEwen, C.J. (2020),

The older surgical patient – to operate or not? A state of the art review. Anaesthesia, 75: e46-e53. doi:10.1111/anae.14910

Link to open access article. 

A free to access review article looking at the need to, difficulties in and benefits of integrating shared decision making and personalised care into our perioperative care pathways. It considers the increased post-operative burden of medical complications suffered by older patients and the need for patient reported outcome measures in this group. The outcome benefits of a comprehensive geriatric assessment in surgical patients as well as preoperative investigations to guide risk assessment and therefore shared decision making are looked at. The need for appropriately trained health care professionals to have these discussions is highlighted. The benefits and unanswered questions around physiological prehab in the elderly population are considered as well as the emerging evidence for psychological preparation, including the use of surgical schools. The overriding need for excellent leadership and true teamworking between specialities is stressed.