1. Preoperative and intraoperative predictors of cardiac adverse events after general, vascular, and urological surgery. Anesthesiology. 2009 Jan;110(1):58-66. [Article]
Prospective observational study using a single institution database of 7,740 cases, which aims to update the Lee Revised Cardiac Risk Index (LCRI) for non-cardiac surgery. Cardiac event rate was 1.1% & nine independent predictors were identified: age≥68, BMI≥30, emergent surgery, previous coronary intervention/surgery, CCF, CBV disease, hypertension, operative duration>3.8 hrs & blood transfusion. Notably, in contrast to Lee’s index, this study does not confirm DM, renal failure & high risk surgery as predictors. A study limitation was lack of inclusion of surveillance biomarkers and ECG monitoring for cardiac events. Three additional intraoperative risk factors were identified: an episode of MAP<50 mm Hg, 40% decrease in MAP and HR >100 bpm.
Take home message: Both preoperative factors and intraoperative factors may help predict perioperative cardiac risk.
2. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. [Article]
This study shows introduction of a simple (and relatively cheap) surgical checklist (with preop/intraop and postop components) achieves the elusive goal of reduction in surgical mortality (1.5% to 0.8%) and reduction in complications (11% to 7%) in 8 centres worldwide including both developed and developing countries. The most compelling data, in addition to mortality reduction and all complications, was decrease in surgical site infection and unplanned RTOR.
Take Home message: Simple interventions can have a profound impact on perioperative mortality.
3. Why obstetric anesthesiologists get sued. Anesthesiology. 2009 Jan;110(1):8-9 [Article]
Liability associated with obstetric anesthesia: a closed claims analysis. Anesthesiology. 2009 Jan;110(1):131-9. [Article]
A reality-check article. The has been a substantial increase in maternal nerve injury claims including nerve root radiculopathy and paraplegia (haematoma, abscess, cord injection, ASA syndrome). Factors associated with anaesthesia contribution to newborn death/brain damage were anaesthesia delay (including prolonged regional attempts)> poor communication> ‘substandard’ anaesthesia care. Maternal death/brain damage was predominantly associated with high neuraxial block (and inadequate resources/equipment to manage complication), maternal haemorrhage, embolism, difficult intubation and pre-eclampsia.
Take home message: serious morbidity and mortality remain associated with obstetric anaesthesia, some of which is preventable.
4. Paediatric airway management: basic aspects. Acta Anaesthesiol Scand.2009Jan;53(1):1-9. [Article]
A good practical summary of paediatric airway management, aimed at the occasional paediatric anaesthetist (or exam candidate).
Take home message: there are many (avoidable) potential pitfalls associated with management of the paediatric airway.
5. Recommendations for Education and Training in Ultrasound Guided Regional Anesthesia: Why Do We Need These Guidelines? Reg Anesth Pain Med. 2009 Jan-Feb;34(1):8-9. [Article]
Recommendations for Education and Training in Ultrasound-Guided Regional Anesthesia Reg Anesth Pain Med. 2009 Jan-Feb;34(1):40-6. (Online library access required for full article)
Guidelines recommending minimum core competencies and training pathway for USGRA. Accompanying editorial emphasizes that basic ‘sonoatatomy’ is required to safely practice USGRA.
Take home message: a sound knowledge base is a prerequisite when providing USGRA.
6. Ventilatory management during routine general anaesthesia. Eur J Anaesthesiol. 2009 Jan;26(1):1-8.
(Online library access required for full article)A thoughtful approach to something we do everyday, based on basic physiology and available evidence.
Take home message: There may be a better way than VC 500 X10.
7. Laryngoscopy force, visualization, and intubation failure in acute trauma: should we modify the practice of manual in-line stabilization Anesthesiology. 2009 Jan;110(1):6-7 [Article]
Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. [Article]
Small sequential cross-over study (n=9); stopped early after interim analysis) showing MILS associated with a doubling of applied laryngoscope pressure compared with DL and significantly increased intubation difficulty/complications despite experienced anesthesiologists performing intubations. Discusses the existing (weak) evidence that MILS decreases abnormal cervical motion in setting of C-spine pathology.
Take home questions: As accompanying editorial asks, it is time for a reappraisal of MILS?
8. Peri-operative use of paracetamol. Anaesthesia. 2009 Jan;64(1):65-72
(Online library access required for full article)A comprehensive review of perioperative paracetamol use.
Take home message: common (boring) topic, but we need to know it!
9. Trends and outcomes of malignant hyperthermia in the United States, 2000 to 2005. Anesthesiology. 2009 Jan;110(1):89-94.
(Online library access required for full article)Study based on US nationwide database which reports overall MH mortality rate of 11.7% and states that predictors of death include increasing age, female gender, cormorbidity burden, source of admission and geographic region in US.
Take home message: there is evidence to suggest MH rate is increasing in the US, and is still associated with a high mortality.
10. Practice alert for the
perioperative management of patients with coronary artery
stents….. Anesthesiology. 2009
Jan;110(1):22-3
[Article]
Concise (& repetitive) summary of perioperative recommendations for patients with BMS & DES.
Take home message: people who have had recent stents are at a very high risk of serious cardiac events perioperatively, especially if their anti-platelet drugs are ceased.
11. Acute compartment syndrome of the lower limb and the effect of postoperative analgesia on diagnosis. Br J Anaesth. 2009 Jan;102(1):3-11.
This is an interesting read considering how frequently orthopaedic surgeons discourage the use of regional because of the ‘risk of compartment syndrome’. Article states that fractures with highest risk of compartment syndrome are: tibial shaft, diaphyseal fractures of the forearm and distal radial fractures. Article discusses the 8 hour window after which delayed diagnosis results in inevitable morbidity. The available level 3 evidence does not show a convincing association of any particular analgesic modalities to delayed diagnosis of compartment syndrome (including PCA). Classic signs and symptoms were present in many cases reviewed despite effective epidural analgesia/PNB, however, epidurals with a dense motor block have been implicated with delayed diagnosis. Inadequate assessment & monitoring are the most common factors associated with missed diagnosis and so a high index of clinical suspicion is recommended for patients at risk as well as the observation that increasing demands for analgesia should trigger review.
Take home message: it is possible that orthopaedic surgeons may overstate the risk of delayed diagnosis of compartment syndrome in association with peripheral nerve blocks/neuraxial block
.
12. Ultrasound-Guided Regional Anesthesia and Analgesia: A Qualitative Systematic Review. Reg Anesth Pain Med. 2009 Jan-Feb;34(1):47-59.
Balanced review of evidence for ultrasound guided regional. Available evidence suggests reduced time for block performance and less needle passes, but there is insufficient evidence to show improvement in overall success rate. Includes discussion of associated learning curve and future directions.
Take home message: many anaesthetists are still learning USGRA….and associated enthusiasm has not translated to better blocks (yet).
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