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.

You may also be interested in the journal watch run by Trainees with an Interest in Perioperative Medicine (TrIPOM), which you can access here: TrIPOM Journal Watch 

Journal Articles

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.

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.