Anaesthesia Latest Evidence Newsletter February 2016

Outreach Your Outreach Librarian can help facilitate evidence-based practise for all Anaesthesia staff, as well as assisting with academic study and research. We can help with literature searching, obtaining journal articles and books, and setting up individual evidence alerts.

Literature Searching We provide a literature searching service for any library member. For those embarking on their own research it is advisable to book some time with one of the librarians for a 1 to 1 session where we can guide you through the process of creating a well-focused literature research and introduce you to the health databases access via NHS Evidence.

Critical Appraisal Training We also offer one-to-one or small group training in literature searching, accessing electronic journals, and critical appraisal/Statistics. These are essential courses that teach how to interpret clinical papers.

For more information, email: [email protected]

Books Books can be searched for using SWIMS our online catalogue at www.swims.nhs.uk. Books and journals that are not available on site or electronically may be requested from other locations. Please email requests to: [email protected]

Contents

1: Latest database articles

2: Tables of Contents from February’s Anaesthesia journals

3: New activity in UpToDate

4: Latest relevant Systematic Reviews from the Cochrane Library

5: Quick exercise

Latest Database Articles

If you require full articles please email: [email protected]

Title: Hypotensive Anesthesia Is Associated With Shortened Length of Hospital Stay Following Orthognathic Surgery.

Citation: Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, Jan 2016, vol. 74, no. 1, p. 130-138 (January 2016)

Author(s): Ettinger, Kyle S, Yildirim, Yavuz, Weingarten, Toby N, Van Ess, James M, Viozzi, Christopher F, Arce, Kevin

Abstract: To evaluate the impact of induced hypotensive anesthesia on length of hospital stay (LOS) for patients undergoing maxillary Le Fort I osteotomy in isolation or in combination with mandibular orthognathic surgery. A retrospective cohort study design was implemented and patients undergoing a Le Fort I osteotomy as a component of orthognathic surgery at the Mayo Clinic from 2010 through 2014 were identified. The primary predictor variable was the presence of induced hypotensive anesthesia during orthognathic surgery. Hypotensive anesthesia was defined as at least 10 consecutive minutes of a mean arterial pressure no higher than 60 mmHg documented within the anesthetic record. The primary outcome variable was LOS in hours after completion of orthognathic surgery. The secondary outcome variable was the duration of surgery in hours. Multiple covariates also abstracted included patient age, patient gender, American Society of Anesthesiologists score, complexity of surgical procedure, and volume of intraoperative fluids administered during surgery. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables. A total of 117 patients were identified undergoing Le Fort I orthognathic surgery in isolation or in combination with mandibular surgery. Induced hypotensive anesthesia was significantly associated with shortened LOS (odds ratio [OR] = 0.33; 95% confidence interval [CI], 0.12-0.88; P = .026) relative to patients with normotensive regimens. This association between hypotensive anesthesia and LOS remained statistically significant in a subgroup analysis of 47 patients in whom isolated Le Fort I surgery was performed (OR = 0.13; 95% CI, 0.03-0.62; P = .010). Induced hypotensive anesthesia was not statistically associated with shorter duration of surgery. Induced hypotensive anesthesia represents a potential factor that minimizes postoperative LOS for patients undergoing routine maxillary orthognathic surgery alone or in combination with mandibular procedures. Hypotensive anesthesia does not appear to be effective in minimizing the duration of surgery within this same patient population. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Title: What lessons for clinical practice can be learned from systematic reviews of animal studies? The case of anesthetic neurotoxicity.

Citation: Paediatric anaesthesia, Jan 2016, vol. 26, no. 1, p. 4-5 (January 2016)

Author(s): Loepke, Andreas W, Vutskits, Laszlo

Title: Comparative Effectiveness of Two Ultrasound-Guided Regional Block Techniques for Surgical Anesthesia in Open Unilateral Inguinal Hernia Repair.

Citation: Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine, Jan 2016, vol. 35, no. 1, p. 177-182 (January 2016)

Author(s): Steffel, Lauren, Kim, T Edward, Howard, Steven K, Ly, Daphne P, Kou, Alex, King, Robert, Mariano, Edward R

Abstract: Transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (II/IH) nerve blocks have been described as analgesic adjuncts for inguinal hernia repair, but the efficacy of these techniques in providing intraoperative anesthesia, either individually or together, is not known. We designed this retrospective cohort study to test the hypothesis that combining TAP and II/IH nerve blocks ("double TAP" technique) results in greater accordance between the preoperative anesthetic plan and actual anesthetic technique provided when compared to TAP alone. Based on this study, double TAP may be preferred for patients undergoing open inguinal hernia repair who wish to avoid general anesthesia.

Title: Intrathecal Sufentanil Does Not Reduce Shivering During Neuraxial Anesthesia: A Meta- Analysis.

Citation: Medical science monitor : international medical journal of experimental and clinical research, Jan 2016, vol. 22, p. 258-266 (2016)

Author(s): Feng, Lin Shao, Hong, Gao, Yan, Zhao, Qiu, Liu Yan, Liang, Li An

Abstract: BACKGROUND We performed this meta-analysis to evaluate the efficacy of intrathecal sufentanil in preventing shivering during neuraxial anesthesia. MATERIAL AND METHODS We searched the Cochrane Library, PubMed, and Embase for all randomized controlled trials (RCT) on use of intrathecal sufentanil for preventing shivering during neuraxial anesthesia. References of retrieved articles were also screened. The quality of the studies was evaluated by the method recommended by the Cochrane Collaboration. Meta-analysis was conducted using the Cochrane Collaboration's RevMan 5.3 software. The primary outcome was incidence and severity of shivering, and the secondary outcomes were drug-related complications of pruritus, nausea, vomiting, hypotension, and bradycardia. RESULTS Eight original RCTs investigating a total of 1032 patients, of whom 599 received sufentanil and 473 received placebo, met the inclusion criteria. Compared to the placebo group, sufentanil did not reduce incidence of shivering (OR, 0.60; 95% CI, 0.35 to 1.01; P=0.06), but it increased the incidence of pruritus (OR, 12.52; 95% CI, 5.07 to 30.91; P<0.00001). Compared to the placebo group, sufentanil did not increase the incidence of nausea (OR, 0.69; 95% CI, 0.41 to 1.16; P=0.16), hypotension (OR, 0.93; 95% CI, 0.62 to 1.41; P=0.74), or bradycardia (OR, 0.86; 95% CI, 0.41 to 1.82; P=0.70). In addition, sufentanil reduced the incidence of vomiting during neuraxial anesthesia (OR, 0.45; 95% CI, 0.22 to 0.92; P=0.03). CONCLUSIONS Neither epidural nor subarachnoid intrathecal sufentanil reduced shivering during neuraxial anesthesia, but it did increase the incidence of pruritus.

Title: Comparison of Anaesthetic Efficacy of 4% Articaine Primary Buccal Infiltration Versus 2% Lidocaine Inferior Alveolar Nerve Block in Symptomatic Mandibular First Molar Teeth.

Citation: Journal of the College of Physicians and Surgeons--Pakistan : JCPSP, Jan 2016, vol. 26, no. 1, p. 4-8 (January 2016)

Author(s): Zain, Muhammad, Rehman Khattak, Shakeel Ur, Sikandar, Huma, Shah, Shafqat Ali, Fayyaz

Abstract: To evaluate success of pulpal anaesthesia of mandibular 1st molar by using 4% articaine in buccal infiltration versus 2% lidocaine in inferior alveolar nerve block. Randomized control trial. Department of Operative Dentistry, Sardar Begum Dental College, Gandhara University, Peshawar, from March to August 2014. One hundred and fifty-six emergency patients, who had 1st molar diagnosed with irreversible pulpitis, participated in the study. Subjects were divided into two groups by random allocation. One group received 4% articaine buccal infiltration and the other group received inferior alveolar nerve block of 2% lidocaine. Subjects’self-reported pain response was recorded on Heft Parker Visual Analogue Scale after local anaesthetic administration during access cavity preparation and pulp extirpation. Mean age of subjects was 31.46 ±10.994 years. The success rate of 4% buccal infiltration was 76.9%; whereas the success rate of 2% lidocaine inferior alveolar nerve block was 62.8%. There was no statistically significant difference between the two groups. 4% articaine buccal infiltration can be considered a viable alternative to 2% lidocaine inferior alveolar nerve block in securing successful pulpal anaesthesia for endodontic therapy.

Title: A systematic review of methodology applied during preclinical anesthetic neurotoxicity studies: important issues and lessons relevant to the design of future clinical research.

Citation: Paediatric anaesthesia, Jan 2016, vol. 26, no. 1, p. 6-36 (January 2016)

Author(s): Disma, Nicola, Mondardini, Maria C, Terrando, Niccolò, Absalom, Anthony R, Bilotta, Federico

Abstract: Preclinical evidence suggests that anesthetic agents harm the developing brain thereby causing long-term neurocognitive impairments. It is not clear if these findings apply to humans, and retrospective epidemiological studies thus far have failed to show definitive evidence that anesthetic agents are harmful to the developing human brain. The aim of this systematic review was to summarize the preclinical studies published over the past decade, with a focus on methodological issues, to facilitate the comparison between different preclinical studies and inform better design of future trials. The literature search identified 941 articles related to the topic of neurotoxicity. As the primary aim of this systematic review was to compare methodologies applied in animal studies to inform future trials, we excluded a priori all articles focused on putative mechanism of neurotoxicity and the neuroprotective agents. Forty-seven preclinical studies were finally included in this review. Methods used in these studies were highly heterogeneous-animals were exposed to anesthetic agents at different developmental stages, in various doses and in various combinations with other drugs, and overall showed diverse toxicity profiles. Physiological monitoring and maintenance of physiological homeostasis was variable and the use of cognitive tests was generally limited to assessment of specific brain areas, with restricted translational relevance to humans. Comparison between studies is thus complicated by this heterogeneous methodology and the relevance of the combined body of literature to humans remains uncertain. Future preclinical studies should use better standardized methodologies to facilitate transferability of findings from preclinical into clinical science. © 2015 John Wiley & Sons Ltd.

Title: A Bayesian framework systematic review and meta-analysis of anesthetic agents effectiveness/tolerability profile in electroconvulsive therapy for major depression.

Citation: Scientific reports, Jan 2016, vol. 6, p. 19847. (2016)

Author(s): Fond, Guillaume, Bennabi, Djamila, Haffen, Emmanuel, Brunel, Lore, Micoulaud-Franchi, Jean-Arthur, Loundou, Anderson, Lançon, Christophe, Llorca, Pierre-Michel, Auquier, Pascal, Boyer, Laurent

Abstract: The aim of this study was to assess the efficacy and tolerability/acceptability of 6 anesthetic agents in ECT for depressive disorders. We systematically reviewed 14 double-blind randomized controlled trials (610 participants). Efficacy was measured by the mean scores on validated depression scales at 6 ECT (or the nearest score if not available), number of responders at the end of treatment and seizure duration. The acceptability was measured by the proportion of patients who dropped out of the allocated treatment, and the tolerability by the number of serious adverse events and post-treatment cognition assessment. After excluding the trials responsible for heterogeneity, depression scores of patients who were administered methohexital were found to be significantly more improved than those who received propofol (p = 0.001). On the contrary, those who were administered propofol had lower depression scores than those with thiopental at the end of treatment (p = 0.002). Compared to propofol, methohexital was found to be significantly associated with higher seizure duration (p = 0.018). No difference was found for the acceptability profile (all p > 0.05). In summary, ketamine and methohexital may be preferred to propofol or thiopental in regard of effectiveness in depression scores and increased seizure duration. Further studies are warranted to compare ketamine and methohexital.

Title: Risk of Hemorrhage during Needle-Based Ophthalmic Regional Anesthesia in Patients Taking Antithrombotics: A Systematic Review.

Citation: PloS one, Jan 2016, vol. 11, no. 1, p. e0147227. (2016)

Author(s): Takaschima, Augusto, Marchioro, Patricia, Sakae, Thiago M, Porporatti, André L, Mezzomo, Luis André, De Luca Canto, Graziela

Abstract: Patients undergoing ophthalmic surgery are usually elderly and, due to systemic disease, may be on long-term therapy, such as antithrombotic agents. Rates of hemorrhagic complications associated with invasive procedures may be increased by the use of anticoagulants and antiplatelet agents. To compare the incidence of hemorrhagic complications in patients undergoing needle- based ophthalmic regional anesthesia between patients on antithrombotic therapy and those not on such therapy. A systematic review was conducted by two independent reviewers based on searches of Cochrane, LILACS, PubMed, Scopus, Web of Science, and the "gray" literature (Google Scholar). The end search date was May 8, 2015, across all databases. Five studies met the eligibility criteria. In three studies, individual risk of bias was low, and in two of them, moderate. In all studies, no differences regarding mild to moderate incidence of hemorrhagic complications were found between patients using antithrombotics (aspirin, clopidogrel, and warfarin) and those not using them. Rates of severe hemorrhagic complication were very low (0.04%) in both groups, supporting the safety of needle blocks, even in patients using antithrombotics. High heterogeneity across studies prevented meta-analysis. Limitations to these results include low statistical power in three experimental studies and a large 95% confidence interval in the two retrospective cohorts. In this review, none of the selected studies showed significant bleeding related to needle-based ophthalmic regional anesthesia in association with the use of aspirin, clopidogrel, or vitamin K inhibitors. Since the available data is not powerful enough to provide a reliable evaluation of the true effect of antithrombotics in this setting, new studies to address these limitations are necessary.

Full Text: Available from ProQuest in PLoS One

Title: Time to talk about work-hour impact on anesthesiologists: The effects of sleep deprivation on Profile of Mood States and cognitive tasks.

Citation: Paediatric anaesthesia, Jan 2016, vol. 26, no. 1, p. 66-71 (January 2016)

Author(s): Saadat, Haleh, Bissonnette, Bruno, Tumin, Dmitry, Thung, Arlyne, Rice, Julie, Barry, N'Diris, Tobias, Joseph

Abstract: A physician's fatigue raises significant concerns regarding personal and patient safety. Effects of sleep deprivation on clinical performance and the quality of patient care are major considerations of today's health care environment. To evaluate the impact of partial sleep deprivation after a 17-h overnight call (3 pm-7 am) on the mood status and cognitive skills of anesthesiologists in an academic clinical hospital setting, as compared to these parameters during regular working hours. Taking circadian rhythm into account, the following measures were assessed in 21 pediatric anesthesiologists at two time points over the course of the study; (i) between 7 and 8 am on a regular non call day, and (ii) between 7 and 8 am after a 17-h in-house call (3 pm-7 am). Six mood states were assessed using the Profile of Mood States. A Total Mood Disturbance (TMD) score was obtained as the sum of all mood scores minus vigor. The total score provides a global estimate of affective state. Simple cognitive tests were similarly administered to assess cognitive skills. A two- tailed paired t-test was used to compare data between regular and post call days. A P < 0.05 was used. The study cohort included 21 pediatric anesthesiologists at a tertiary care children's hospital. Tension, anger, fatigue, confusion, TMD, irritability, feeling jittery, and sleepiness were significantly affected (P < 0.05). A decrease in vigor, energy, and confidence was observed after a night call shift (P < 0.05). There was also a decrease in being "talkative" after the call shift (P < 0.05). Partial sleep deprivation affects the total mood status of anesthesiologists and impacts their cognitive skills. These findings are particularly relevant in a context of increased work expectation, particularly on clinical performance in our modern medical system. Such observations suggest that there may be changes that impact the safety of our patients and the quality of health care that is provided. © 2015 John Wiley & Sons Ltd.

Title: The effects of Anesthesia and opioids on the upper airway: A systematic review.

Citation: The Laryngoscope, Jan 2016, vol. 126, no. 1, p. 270-284 (January 2016)

Author(s): Ehsan, Zarmina, Mahmoud, Mohamed, Shott, Sally R, Amin, Raouf S, Ishman, Stacey L

Abstract: Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are poorly understood. Our aim was to systematically review existing literature on the effects of anesthetic agents on the upper airway. PubMed, CINAHL, EBM reviews and Scopus (all indexed years). Inclusion criteria included English language articles containing original human data. Two investigators independently reviewed all articles for outcomes related to upper airway morphology, dynamics, neuromuscular response, and respiratory control. The initial search yielded 180 abstracts; 56 articles were ultimately included (total population = 8,540). The anesthetic agents studied were: topical lidocaine, propofol, dexmedetomidine, midazolam, pentobarbital, sevoflurane, desflurane, ketamine, and opioids. Outcome measures were diverse and included imaging studies, genioglossus electromyography, endoscopic airway assessment, polysomnography, upper airway closing pressure, and clinical evidence of obstruction. All agents caused some degrees of airway collapse. Dexmedetomidine did not have dose-dependent effects when evaluated using cine magnetic resonance imaging, unlike sevoflurane, isoflurane, and propofol, and caused less dynamic collapse than propofol. Studies assessing the effect of anesthesia on the upper airway in patients with and without OSA are limited, and few compare effects between agents. Medications with minimal effect on respiratory control (e.g., dexmedetomidine) may work best for DISE. Laryngoscope, 126:270-284, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Title: A retrospective analysis of episodes of single tooth extraction under general anaesthesia for adults.

Citation: British dental journal, Jan 2016, vol. 220, no. 1, p. 21-24 (January 15, 2016)

Author(s): Hong, B, Birnie, A

Abstract: Objectives To investigate the provision of adult dental extraction under general anaesthesia (DGA) at the Royal Cornwall Hospitals NHS Trust (RCHT) - specifically adult single tooth DGA episodes in regards to numbers, demographics, justifications, and appropriateness regarding the use of resources.Method Data were collected retrospectively from the patient case notes and electronic records for the complete study cohort. This study included all episodes of adult single tooth DGA in all RCHT sites during 2014, except for mandibular third molar and impacted teeth. Each case was tested against the DGA case selection criteria empirically devised for this study.Results In 2014, 106 episodes of adult single tooth DGA were carried out in RCHT that met the inclusion criteria. Younger females from more socio-economically deprived areas of Cornwall were increasingly likely to have this procedure. Mental disorders were the most prevalent co-morbidity (21.7%) in this cohort. The vast majority of patients (93.4%) had previously tolerated dental treatment without the need for general anaesthesia (GA). Many referrals (46.2%) and listings (30.2%) specifically stated patient demand-driven reasons. None of the cohort had DGA due to failure of sedation. There were potentially 11 episodes that met the DGA case selection criteria. Patients waited for 126 days (median) from the referral date for an operation which took seven minutes (median) to complete. The majority (83%) of the cases were simple exodontia. Twenty patients (18.9%) had previous DGA.Conclusion Potentially a considerable proportion of GA prescription appeared to be driven by patient demand rather than clinical need. This study poses a fundamental question - what drives the demand for DGA? National data collection and specific DGA case selection criteria are recommended.

Title: Hypotensive Anesthesia Is Associated With Shortened Length of Hospital Stay Following Orthognathic Surgery.

Citation: Journal of Oral & Maxillofacial Surgery (02782391), 2016, vol./is. 74/1(130-138), 02782391

Abstract: Purpose: To evaluate the impact of induced hypotensive anesthesia on length of hospital stay (LOS) for patients undergoing maxillary Le Fort I osteotomy in isolation or in combination with mandibular orthognathic surgery.Materials and Methods: A retrospective cohort study design was implemented and patients undergoing a Le Fort I osteotomy as a component of orthognathic surgery at the Mayo Clinic from 2010 through 2014 were identified. The primary predictor variable was the presence of induced hypotensive anesthesia during orthognathic surgery. Hypotensive anesthesia was defined as at least 10 consecutive minutes of a mean arterial pressure no higher than 60 mmHg documented within the anesthetic record. The primary outcome variable was LOS in hours after completion of orthognathic surgery. The secondary outcome variable was the duration of surgery in hours. Multiple covariates also abstracted included patient age, patient gender, American Society of Anesthesiologists score, complexity of surgical procedure, and volume of intraoperative fluids administered during surgery. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables.Results: A total of 117 patients were identified undergoing Le Fort I orthognathic surgery in isolation or in combination with mandibular surgery. Induced hypotensive anesthesia was significantly associated with shortened LOS (odds ratio [OR] = 0.33; 95% confidence interval [CI], 0.12-0.88; P = .026) relative to patients with normotensive regimens. This association between hypotensive anesthesia and LOS remained statistically significant in a subgroup analysis of 47 patients in whom isolated Le Fort I surgery was performed (OR = 0.13; 95% CI, 0.03-0.62; P = .010). Induced hypotensive anesthesia was not statistically associated with shorter duration of surgery.Conclusion: Induced hypotensive anesthesia represents a potential factor that minimizes postoperative LOS for patients undergoing routine maxillary orthognathic surgery alone or in combination with mandibular procedures. Hypotensive anesthesia does not appear to be effective in minimizing the duration of surgery within this same patient population.

Title: Early Anesthesia Exposure and the Effect on Visual Acuity, Refractive Error, and Retinal Nerve Fiber Layer Thickness of Young Adults.

Citation: Journal of Pediatrics, 2016, vol./is. 169/(256-256), 00223476

Abstract: Objective: To investigate whether being anesthesia administered at least once in early life influenced 3 main proxies of visual function: visual acuity, refractive error, and optic nerve health in young adulthood.Study Design: At age 20 years, participants of the Western Australian Pregnancy Cohort Study had comprehensive ocular examinations including visual acuity, postcycloplegic refraction, and multiple scans of the optic disc. We identified individuals who had at least 1 procedure requiring anesthesia during the first 3 years of life (between 1990 and 1994) and compared their visual outcomes with nonexposed individuals. We excluded 40 participants with strabismus or other ophthalmic disease or surgery and 136 with non-European background.Results: Of 834 participants, 15.2% (n = 127) were exposed to anesthesia at least once before age 3 years. In both exposed and nonexposed groups, median visual acuity (measured using the logarithm of the minimum angle of resolution [LogMAR] chart) was -0.06 LogMAR in the right eye and -0.08 LogMAR in the left eye (P > .05). Median spherical equivalent refractive error was +0.44 diopters (IQR -0.25, +0.63) and +0.31 diopters (IQR -0.38, +0.63) in the exposed and nonexposed group, respectively (P = .126). No difference was detected in mean global retinal nerve fiber layer thickness of the 2 groups (100.7 vs 100.1 μm, P = .830).Conclusions: We were unable to demonstrate an association of exposure to anesthesia as a child with reduced visual acuity or increased myopia or thinning of retinal nerve fiber layer. These findings support the view that anesthesia is unlikely to impair visual development, but further work is needed to establish whether more subtle defects are present and repeated exposures have any effects.

Title: Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial.

Citation: Lancet, 2016, vol./is. 387/10015(239-250), 00995355

Title: Tachyphylaxis to local anaesthetics. What is the clinical evidence? A systematic review.

Citation: Acta anaesthesiologica Scandinavica, Jan 2016, vol. 60, no. 1, p. 6-14 (January 2016)

Author(s): Kongsgaard, U E, Werner, M U

Abstract: Tachyphylaxis or acute tolerance to local anaesthetics has been reported, but the prevalence in clinical analgesia is obscure, and the mechanisms behind this phenomenon remain unclear. We sought to examine the clinical significance of tachyphylaxis from the available literature. We performed a systematic review of the literature utilising the databases PubMed and Embase employing the search terms [Tachyphylaxis AND Local Anaesthetics AND Human] AND [Tolerance AND Local Anaesthetics AND Human]. A total of 66 records were identified. Thirty-four articles were assessed in full text for eligibility. Twenty studies were considered relevant for qualitative analyses, but only six studies were randomised controlled trials. Because of the heterogeneity of the randomised controlled trials, it was not possible to conduct a meta-analysis. Studies documenting tachyphylaxis with clinical use of local anaesthetics are surprisingly scarce, and the mechanisms behind it remain unclear. © 2015 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.

Title: Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring for surgical hip repair in two patients with severe aortic stenosis.

Citation: Brazilian journal of anesthesiology (Elsevier), Jan 2016, vol. 66, no. 1, p. 82-85 (2016 Jan- Feb)

Author(s): López, María Mercedes, Guasch, Emilia, Schiraldi, Renato, Maggi, Genaro, Alonso, Eduardo, Gilsanz, Fernando

Abstract: Aortic stenosis increases perioperative morbidity and mortality, perioperative invasive monitoring is advised for patients with an aortic valve area <1.0cm(2) or a mean aortic valve gradient >30mmHg and it is important to avoid hypotension and arrhythmias. We report the anaesthetic management with continuous spinal anaesthesia and minimally invasive haemodynamic monitoring of two patients with severe aortic stenosis undergoing surgical hip repair. Two women with severe aortic stenosis were scheduled for hip fracture repair. Continuous spinal anaesthesia with minimally invasive haemodynamic monitoring was used for anaesthetic management of both. Surgery was performed successfully after two consecutive doses of 2mg of isobaric bupivacaine 0.5% in one of them and four consecutive doses in the other. Haemodynamic conditions remained stable throughout the intervention. Vital signs and haemodynamic parameters remained stable throughout the two interventions. Our report illustrates the use of continuous spinal anaesthesia with minimally invasive haemodynamic monitoring as a valid alternative to general or epidural anaesthesia in two patients with severe aortic stenosis who are undergoing lower limb surgery. However, controlled clinical trials would be required to establish that this technique is safe and effective in these type or patients. Copyright © 2013 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Title: Effectiveness of dexmedetomidine use in general anesthesia to prevent postoperative shivering: a systematic review.

Citation: JBI database of systematic reviews and implementation reports, Jan 2016, vol. 13, no. 12, p. 287-313 (2016)

Author(s): Hoffman, Jeffrey, Hamner, Casi

Abstract: Postanesthetic shivering remains a significant source of distress following general anesthesia. Despite numerous studies investigating pharmacologic prophylaxis for postanesthetic shivering, no gold standard medication has been identified. Prophylactic dexmedetomidine administration has been examined as a possible preventative treatment modality for postanesthetic shivering; however its effectiveness has not been established. The objective of this review was to evaluate the effectiveness of intravenous prophylactic dexmedetomidine for reduction of postanesthetic shivering during the first two hours after general anesthesia. The participants included in this study were adults between 18 and 68 years of age receiving general anesthesia for any surgical procedure. Only participants with American Society of Anesthesiologist physical status I or II were included. Types of intervention(s): This review evaluated the effectiveness of intravenous dexmedetomidine in preventing postanesthetic shivering. Studies that compared preoperative or intraoperative administration of dexmedetomidine to placebo were included. Types of studies: The studies included in this review were all randomized controlled trials. Types of outcomes: This review assessed all studies that included the following outcome measure: presence of postanesthetic shivering observed in the post-anesthesia care unit during the first two hours after the completion of surgery. A three-step search strategy was utilized in this review to find published and unpublished studies. Only studies published in English between 1999 and 2015 were included in this review. Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. Data was extracted from papers included in the review using the standardized data extraction tool from Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Quantitative data was pooled in statistical meta-analysis using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. All results were subject to double data entry. Effect sizes were expressed as odds ratio and the 95% confidence intervals were calculated for analysis. Heterogeneity was assessed statistically using the standard Chi-square test. This review included eight randomized controlled trials with 625 participants. The results of the meta-analysis revealed a statistically significant decrease in postanesthetic shivering for the dexmedetomidine group. The Mantel-Haenszel overall relative risk ratio was 0.27 in favor of the dexmedetomidine group [relative risk 0.27, at 95% confidence interval 0.19, 0.36, P < 0.0001]. A relative risk reduction value was calculated as 0.73. The prophylactic administration of intravenous dexmedetomidine reduces the incidence of postanesthetic shivering in patients undergoing general anesthesia. The Joanna Briggs Institute.

Title: Comparison of tramadol and lornoxicam in intravenous regional anesthesia: a randomized controlled trial.

Citation: Brazilian journal of anesthesiology (Elsevier), Jan 2016, vol. 66, no. 1, p. 44-49 (2016 Jan- Feb)

Author(s): Çelik, Hande, Abdullayev, Ruslan, Akçaboy, Erkan Y, Baydar, Mustafa, Göğüş, Nermin

Abstract: Tourniquet pain is one of the major obstacles for intravenous regional anesthesia. We aimed to compare tramadol and lornoxicam used in intravenous regional anesthesia as regards their effects on the quality of anesthesia, tourniquet pain and postoperative pain as well. After the ethics committee approval 51 patients of ASA physical status I-II aged 18-65 years were enrolled. The patients were divided into three groups. Group P (n=17) received 3mg/kg 0.5% prilocaine; group PT (n=17) 3mg/kg 0.5% prilocaine+2mL (100mg) tramadol and group PL (n=17) 3mg/kg 0.5% prilocaine+2mL (8mg) lornoxicam for intravenous regional anesthesia. Sensory and motor block onset and recovery times were noted, as well as tourniquet pains and postoperative analgesic consumptions. Sensory block onset times in the groups PT and PL were shorter, whereas the corresponding recovery times were longer than those in the group P. Motor block onset times in the groups PT and PL were shorter than that in the group P, whereas recovery time in the group PL was longer than those in the groups P and PT. Tourniquet pain onset time was shortest in the group P and longest in the group PL. There was no difference regarding tourniquet pain among the groups. Group PL displayed the lowest analgesic consumption postoperatively. Adding tramadol and lornoxicam to prilocaine for intravenous regional anesthesia produces favorable effects on sensory and motor blockade. Postoperative analgesic consumption can be decreased by adding tramadol and lornoxicam to prilocaine in intravenous regional anesthesia. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

Title: A Multicenter Evaluation of a Closed-Loop Anesthesia Delivery System: A Randomized Controlled Trial.

Citation: Anesthesia and analgesia, Jan 2016, vol. 122, no. 1, p. 106-114 (January 2016)

Author(s): Puri, Goverdhan D, Mathew, Preethy J, Biswas, Indranil, Dutta, Amitabh, Sood, Jayashree, Gombar, Satinder, Palta, Sanjeev, Tsering, Morup, Gautam, P L, Jayant, Aveek, Arora, Inderjeet, Bajaj, Vishal, Punia, T S, Singh, Gurjit

Abstract: Closed-loop systems for anesthesia delivery have been shown to outperform traditional manual control in different clinical settings. The present trial was aimed at evaluating the feasibility and efficacy of Bispectral Index (BIS)-guided closed-loop anesthesia delivery system (CLADS) in comparison with manual control across multiple centers in India. Adult patients scheduled for major surgical procedures of an expected duration of 1 to 3 hours were randomized across 6 sites into 2 groups: a CLADS group and a manual group. In the manual control group, propofol infusion was titrated manually by the attending anesthesiologist to a BIS of 50 during induction and maintenance. Analgesia was maintained with fentanyl infusion and nitrous oxide in both groups. In the CLADS group, both induction and maintenance of anesthesia were performed automatically using CLADS. The primary outcome measure was the performance of the system as assessed by the percentage of total anesthesia time BIS remained ±10 of target BIS. The secondary outcome measures were a percentage of anesthesia-time heart rate and mean arterial pressure within 25% of the baseline, median absolute performance error, wobble, and global score. Wobble indicates intraindividual variability in the control of BIS, and global score reflects the overall performance; lower values indicate superior performance for both parameters. The performance parameters of the system also were compared among the participating sites. Two hundred forty-two patients were randomized. BIS was maintained within ±10 of target for significantly longer time in the CLADS group (81.4% ± 8.9 % of anesthesia duration) than in the manual group (55.34% ± 25%, P < 0.0001). The indices that assess performance were significantly better in the CLADS group than the manual group as follows: median absolute performance error was 10 (10, 12) (median [interquartile range]) in the CLADS group versus 18 (14, 24) in the manual group, P < 0.0001; wobble was 9 (8, 10) in CLADS group versus 10 (8, 14) in the manual group, P = 0.0009; and Global score, which reflects overall performance, was 24 (19, 30) in the CLADS group versus 51 (31, 99) in the manual group, P < 0.0001. The percentage of time heart rate was within 25% of the baseline was significantly greater in the CLADS group (heart rate of 95 [87, 99], median [interquartile range], in the CLADS group versus 90 [75, 98] in the manual group P = 0.0031). On comparison of data between the centers, the performance parameters did not differ significantly among the centers in the CLADS group (P = 0.94), but the parameters differed significantly among the centers in the manual group (P < 0.001). Our study in a multicenter setting proves the consistently better performance of automated anesthesia drug delivery compared with conventional manual control. This highlights an important advantage of an automated system for delivering standardized anesthesia, thereby overcoming differences in practices among anesthesiologists.

Full Text: Available from Ovid in Anesthesia and Analgesia

Title: Rigorous anaesthesia management protocol for patients with intracranial arterial stenosis: a prospective controlled-cohort study.

Citation: BMJ open, Jan 2016, vol. 6, no. 1, p. e009727. (2016)

Author(s): Laiwalla, Azim N, Ooi, Yinn Cher, Van De Wiele, Barbara, Ziv, Keren, Brown, Adam, Liou, Raymond, Saver, Jeffrey L, Gonzalez, Nestor R

Abstract: Reducing variability is integral in quality management. As part of the ongoing Encephaloduroarteriosynangiosis Revascularisation for Symptomatic Intracranial Arterial Stenosis (ERSIAS) trial, we developed a strict anaesthesia protocol to minimise fluctuations in patient parameters affecting cerebral perfusion. We hypothesise that this protocol reduces the intraoperative variability of targeted monitored parameters compared to standard management. Prospective cohort study of patients undergoing encephaloduroarteriosynangiosis surgery versus standard neurovascular interventions. Patients with ERSIAS had strict perioperative management that included normocapnia and intentional hypertension. Control patients received regular anaesthetic standard of care. Minute-by-minute intraoperative vitals were electronically collected. Heterogeneity of variance tests were used to compare variance across groups. Mixed-model regression analysis was performed to establish the effects of treatment group on the monitored parameters. Tertiary care centre. 24 participants: 12 cases (53.8 years±16.7 years; 10 females) and 12 controls (51.3 years±15.2 years; 10 females). Adults aged 30-80 years, with transient ischaemic attack or non-disabling stroke (modified Rankin Scale <3) attributed to 70-99% intracranial stenosis of the carotid or middle cerebral artery, were considered for enrolment. Controls were matched according to age, gender and history of neurovascular intervention. Variability of heart rate, mean arterial blood pressure (MAP), systolic blood pressure and end tidal CO2 (ETCO2) throughout surgical duration. There were significant reductions in the intraoperative MAP SD (4.26 vs 10.23 mm Hg; p=0.007) and ETCO2 SD (0.94 vs 1.26 mm Hg; p=0.05) between the ERSIAS and control groups. Median MAP and ETCO2 in the ERSIAS group were higher (98 mm Hg, IQR 23 vs 75 mm Hg, IQR 15; p<0.001, and 38 mm Hg, IQR 4 vs 32 mm Hg, IQR 3; p<0.001, respectively). The ERSIAS anaesthesia protocol successfully reduced intraoperative fluctuations of MAP and ETCO2. The protocol also achieved normocarbia and the intended hypertension. NCT01819597; Pre-results. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Full Text: Available from Highwire Press in BMJ Open

Tables of Contents from February’s Anaesthesia journals

If you require full articles please email: [email protected]

Anesthesia February 2016, Volume 71, Issue 2

Anesthesia & Analgesia February 2016, Volume 122, Issue 2

Anesthesiology February 2016, Volume 124, Issue 2

British Journal of Anaesthesia February 2016, Volume 116, Issue 2

Current Opinion in Anaesthesiology February 2016, Volume 29, Issue 1

Pediatric Anesthesia March 2016, Volume 26, Issue 3

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Morphine interference with antiplatelet effect of P2Y12 receptor blockers in patients with acute MI (January 2016)

In patients with acute myocardial infarction (MI), several small studies have suggested that morphine may worsen outcomes. In the IMPRESSION trial, 70 acute MI patients treated with ticagrelor were randomly assigned to receive intravenous morphine (5 mg) or placebo [1]. Morphine lowered ticagrelor plasma concentration and impaired its antiplatelet effect. A decreased or delayed antiplatelet effect of other P2Y12 receptor blockers (ie, clopidogrel and prasugrel) has also been observed in acute MI patients receiving morphine relative to those not receiving it [2,3]. We reserve morphine for use in patients who have an unacceptable level of chest pain. (See "Overview of the acute management of ST elevation myocardial infarction", section on 'Morphine'.)

FDA approval of sugammadex for reversal of neuromuscular blockade (January 2016)

Neuromuscular blockade due to rocuronium (or vecuronium) can be rapidly reversed with sugammadex, a novel chelating agent. Several trials have demonstrated that, compared with neostigmine, administration of sugammadex at the end of surgery results in faster complete reversal of neuromuscular blockade due to rocuronium or vecuronium, with shorter time to discharge from the operating room. Use of rocuronium with sugammadex reversal may be especially useful for potentially difficult or rapid sequence intubations, since sugammadex also results in a faster recovery of neuromuscular function compared with spontaneous recovery after succinylcholine administration. Sugammadex has been available in many countries for several years and was approved by the US Food and Drug Administration (FDA) in December 2015 [12]. (See "Induction of general anesthesia", section on 'Sugammadex' and "Management of the difficult airway for general anesthesia" and "Overview of complications occurring in the post-anesthesia care unit" and "Neuromuscular blocking agents (NMBA) for rapid sequence intubation in adults".)

Latest relevant Systematic Reviews from the Cochrane Library

Intranasal or transdermal nicotine for the treatment of postoperative pain

Perioperative angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults

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