1. PERITONEAL RESUSCITATION OF TRAUMA PATIENTS
Smith JW, Matheson PJ, Franklin GA, et al. Randomized controlled trial evaluating the efficacy of peritoneal resuscitation in the management of trauma patients undergoing damage control surgery. J Am Coll Surg. 2017; 224:396–404.
Normalization of central hemodynamics after hemorrhagic shock may not restore visceral (gastrointestinal and liver) perfusion. Previous animal and retrospective clinical studies suggest benefit from continuous peritoneal dialysis—“peritoneal resuscitation”—via continuous peritoneal lavage. Smith et al report a randomized clinical trial of peritoneal resuscitation in 110 patients after damage control celiotomy for trauma with hemorrhagic shock. Patients receiving peritoneal resuscitation had a lower multiorgan dysfunction syndrome scores after 12 hours, shortened time to definitive abdominal closure (4.1 vs 5.9 days), and shorter intensive care unit stay (8 vs 11 days), but no significant reduction in intraabdominal complications (10% vs 23%), morbidity (48% vs 62%), hospital length of stay (18 vs 22 days), nor mortality (13% vs 27%). The study was likely underpowered for several outcomes, including mortality. Its findings thus need to be reevaluated in larger studies and other groups.
2. SURGICAL SITE INFECTION PREVENTION
Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 update. J Am Coll Surg. 2017;224:59–74.
The American College of Surgeons published this update of their surgical site infection guidelines. Although principally directed at surgeons, they are relevant to anesthesiologists practicing in the perioperative surgical home and to all anesthesiologists providing intraoperative anesthesia. It reviews the incidence and significance of surgical site infection and 22 guidelines summarized in 3 tables. Notably, they emphasize perioperative glucose control in the 110 to 150 mg/dL range, maintaining normothermia with intraoperative monitoring, preoperative warming and intraoperative warming, and administration of 80% oxygen during and in the immediate postoperative period for procedures performed under general anesthesia. The latter has been challenged by the anesthesiology community. These American College of Surgeons guidelines should be compared with other recently published ones1,2 and below.
- Allegranzi B, Bischoff P, De Jonge S, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16:e276–e287.
- Allegranzi B, Zayed B, Bischoff P, et al. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis. 2016;16:e288–e303.
3. SURGICAL SITE INFECTION PREVENTION
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for disease control and prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017 [Epub ahead of print].
The Centers for Disease Control and Prevention published this update of their 1999 guidelines. It includes 17 recommendations, of which only 8 are supported by high- to moderate-quality evidence. They review 25 other issues they consider unresolved by currently available data and thus make no recommendations. The 600-page supplement summarizes relevant evidence. These guidelines also support maintaining normothermia, perioperative glycemic control (but only to <200 mg/dL), and administering increased Fio2 during and after extubation, but acknowledge that trial data are not available to determine the optimal target level, duration, or delivery method of supplemental oxygen. They consider this an unresolved issue and thus make no recommendation. The invited commentary by Lipsett is insightful (JAMA Surg. 3 May 2017 [Epub ahead of print]).
4. EFFECT OF ANESTHESIA ON THE DEVELOPING BRAIN
Walters JL, Paule MG. Review of preclinical studies on pediatric general anesthesia-induced developmental neurotoxicity. Neurotoxicol Teratol. 2017;60:2–23.
The March/April 2017 issue of the journal Neurotoxicology and Teratology is devoted to 15 papers related to “Developmental Neurotoxicology Associated with Pediatric General Anesthesia.” This lead paper by Walters and Paule reviews the history of this concern and more than 70 rodent, nonhuman primates, and other animal studies of the time course and functional outcomes, as well as over 35 preclinical studies of compounds shown to protect against anesthetic-induced neurobehavioral toxicity. These studies in all animal species observed that all tested general anesthetics at clinically relevant doses and exposure duration are associated with neurotoxicity, manifested as subsequent impaired cognitive function. The authors identify the limitations of existing evidence and identify areas that require further investigation, especially the threshold doses/duration and exact period of development during which the brain is sensitive to neurotoxicity.
5. EFFECT OF ANESTHESIA ON THE DEVELOPING BRAIN
Lin EP, Lee JR, Lee CS, et al. Do anesthetics harm the developing human brain? An integrative analysis of animal and human studies. Neurotoxicol Teratol. 2017;60:117–128.
Lin et al reviewed the relevance of over 400 preclinical studies and 32 clinical studies to clinical practice. They indicate that the majority of preclinical studies have found either structural injury and or long-term neurocognitive abnormalities but note that most employed prolonged administration (>6 hours) at an age equivalent to the immature stages of human brain development before birth. However, they note that the animal studies do not clearly identify a minimal exposure that is safe or an age after which anesthetics are not associated with brain abnormalities. They posit that it was highly improbable that humans are uniquely exempt from the adverse biologic effects of anesthetics observed in animals. They conclude that it is premature and potentially deleterious to withhold anesthesia from patients but that we must devise alternative anesthetic techniques and strategies to minimize potential adverse effects.
6. COGNITIVE IMPAIRMENT AFTER SURGERY AND ANESTHESIA
Hughes CG, Patel MB, Jackson JC, et al. Surgery and anesthesia exposure is not a risk factor for cognitive impairment after major noncardiac surgery and critical illness. Ann Surg. 2017;265:1126–1133.
This multicenter prospective observational study of 1040 critically ill adults admitted to intensive care units, compared the incidence of postdischarge cognitive decline assessed at 3 and 12 months, in patients who underwent surgery with general anesthesia (≈40%) versus those who did not (≈60%). Postdischarge cognitive impairment was prevalent and similar in both groups (about 23% performed below typical patients with Alzheimer disease). Multivariable analysis did not demonstrate either surgery with general anesthesia or the degree of this exposure to be independently associated with cognitive dysfunction, but observed that longer in-hospital delirium duration was associated with increased risk of postoperative cognitive impairment, while higher baseline educational level was associated with better outcome.
7. SIGNIFICANCE OF TROPONIN ELEVATION AFTER NONCARDIAC SURGERY
Devereaux PJ, Biccard BM, Sigamani A, et al. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2017;317:1642–1651.
Myocardial injury after noncardiac surgery (MINS) refers to an elevation in troponin levels attributed to myocardial ischemia which may not (or may) meet the universal criteria for myocardial infarction but is strongly prognostically related to 30-day mortality. In this prospective, multicenter observational study of 21,842 patients ≥45 years of age (mean 63), undergoing noncardiac surgery, with general or regional anesthesia and associated with at least a 1 night stay, Devereaux et al sought to determine the association between peak postoperative high-sensitivity troponin T (hsTnT) levels and 30-day mortality and the hsTnT level diagnostic of MINS. The hsTNnT was measured within 12 hours postoperatively and on 3 consecutive days thereafter. A maximum postoperative hsTnT of >20 ng/L, plus an absolute change of >5 ng/L, or a level of >65 ng/L, defined MINS and occurred in 18% of patients. This was associated with an increased 30-day mortality (4.1% vs 0.6%) and other adverse cardiovascular events. Ninety-three percent of these patients did not exhibit ischemia symptoms, and 78% did not exhibit ischemic features, yet had an elevated mortality. Only 22% of MINS cases fulfilled the universal criteria for myocardial infarction, and 68% of these did not experience ischemic symptoms.
8. PRACTICE GUIDELINES FOR OBSTETRIC ANALGESIA AND ANESTHESIA
Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 177: Obstetric analgesia and anesthesia. Obstet Gynecol. 2017;129:e73–e89.
The American College of Obstetricians and Gynecologists have updated their Practice Bulletin on obstetric analgesia and anesthesia. Although addressed to their members, it behooves anesthesiologists to be aware of the content of this detailed and well-referenced document. The preamble states that a material request is a sufficient medical indication for pain relief and that this should not be deprived based on the status of a woman’s health insurance; that anesthesia services should be available to provide labor analgesia and surgical anesthesia in all hospitals that offer maternal care, and that labor nurses should not be restricted from participating in the management of epidural infusions. It then proceeds with a detailed description of available methods of analgesia and anesthesia, including their risks and benefits to mothers and fetuses, and then discusses a number of clinical questions and makes recommendations. The authors' list of “Indications for Anesthesiology Consultation” is particularly pertinent to anesthesiologists.
OTHER ARTICLES OF POSSIBLE INTEREST
1. Outcomes of Coronary Artery Bypass Graft Surgery Versus Drug-Eluting Stents in Older Adults
Chang M, Lee CW, Ahn JM, et al. J Am Geriatr Soc. 2017;65:625–630.
2. Use of Pressure Transducers
Ortega R, Connor C, Kotova F, et al. N Engl J Med. 2017;376:e26.
3. Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients
Reardon MJ, Van Mieghem NM, Popma JJ, et al. N Engl J Med. 2017;376:1321–1331.
4. Letter to a Young Female Physician
Koven S. N Engl J Med. 2017;376:1907–1909.
Name: Eugene A. Hessel II, MD.
Contribution: This author wrote the manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.