1. OVERLAPPING SURGERY (AND ANESTHESIA)?
Kent M, Whyte R, Fleishman A, et al. Public perceptions of overlapping surgery. J Am Coll Surg. 2017;224:771–778.
Overlapping surgery (the practice of 2 operations being performed in separate operating rooms under the supervision of 1 attending surgeon) is common in academic centers. Kent et al conducted a public survey of 1454 persons. Only ≈4% of respondents were aware of this practice, and only 31% supported this practice. Ninety-five percent of respondents believed the surgeon should inform them of this practice, and 92% of respondents believed that if done, the surgeon should define the critical components for which he or she would be present. Although briefly touched on in this study, it raises a question of how attending anesthesiologists should inform their patients about “overlapping anesthesia.”
2. INTRAOPERATIVE DEXMEDETOMIDINE DOES NOT REDUCE INCIDENCE OF POSTOPERATIVE DELIRIUM AND COGNITIVE DYSFUNCTION
Deiner S, Luo X, Lin HM, et al. Intraoperative infusion of dexmedetomidine for prevention of postoperative delirium and cognitive dysfunction in elderly patients undergoing major elective noncardiac surgery: a randomized clinical trial. JAMA Surg. 2017[Epub ahead of print].
Evidence suggests that dexmedetomidine sedation in intensive care units reduces the incidence of delirium. In this multicenter, randomized double-blind placebo controlled trial, Deiner et al examined the effect of infusion of dexmedetomidine (0.5 µg/kg/h) versus saline during surgery and for 2 hours postoperatively in 390 older patients (median age 74 years) undergoing major, elective, noncardiac surgery under general anesthesia. They excluded American Society of Anesthesiologists status IV or V patients and those with planned intensive care unit admission. They observed no difference in incidence of postoperative delirium (12.2% vs 11.4%) or postoperative cognitive performance at 3 and 6 months postoperatively in those receiving intraoperative dexmedetomidine versus saline. The study was stopped for futility in accordance with a planned annual interim Data Safety Monitoring Board analysis.
3. EARLY ADMINISTRATION OF TRANEXAMIC ACID REDUCES DEATH DUE TO BLEEDING IN WOMEN WITH POSTPARTUM HEMORRHAGE
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with postpartumhaemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;389:2105–2116.
This multicenter international study of 20,060 women with postpartum hemorrhage assessed the effect of administration of tranexamic acid (TXA) (1 g intravenously over 10 minutes) versus placebo. TXA administration was associated with an ≈20% decrease in death due to bleeding (1.5% vs 1.9%). This effect was greater (≈30%) if TXA was administered within 3 hours of giving birth, but not apparent if given later. Adverse events including thromboembolic complications did not differ between the 2 groups. TXA administration did not decrease the risk of hysterectomy nor death from all causes.
4. EARLY ADMINISTRATION OF TRANEXAMIC ACID ASSOCIATED WITH LOWER MORTALITY IN PATIENTS WITH SEVERE TRAUMA
Shiraishi A, Kushimoto S, Otomo Y, et al. Effectiveness of early administration of tranexamic acid in patients with severe trauma. Br J Surg. 2017;104:710–717.
The Japanese Association for the Surgery of Trauma attempted to resolve reported concerns regarding the Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) study in a propensity score–matched analysis of a multicenter observational study. Shiraishi et al compared the outcome of 250 severely injured patients (injury severity score ≥16) who received tranexamic acid (TXA) within 3 hours (1 g over 10 minutes followed by 1 g over 8 hours) with a matched group who did not. The 28-day mortality was lower in those who received TXA (10.0% vs 18.4%; odds ratio [OR], 0.49) and a lower mortality from primary brain injury (6.0% vs 13.2%; OR, 0.42). The authors hypothesized that TXA may have improved hemostasis in intracranial bleeding. Interestingly, mortality from hemorrhage was not statistically significantly lower (2.8% vs 4.0%), and there no reduction in transfusion of blood products. Thromboembolic complications were not different.
5. SMOKING ON DAY OF SURGERY ASSOCIATED WITH INCREASED RISK OF SURGICAL SITE INFECTION
Nolan MB, Martin DP, Thompson R, et al. Association between smoking status, preoperative exhaled carbon monoxide levels, and postoperative surgical site infection in patients undergoing elective surgery. JAMA Surg. 2017;152:476–483.
This observational, nested, matched case–control study confirmed previous observations that current smoking was associated with an increased risk of surgical site infection (odds ratio, 1.51, 95% confidence interval, 1.2–1.9). Unique was their finding that among current smokers, abstaining from smoking on the day of surgery, before surgery, was associated with a lower risk of surgical site infection. Using multivariable analysis adjustment, the odds ratio for surgical site infection was 1.75 (95% confidence interval, 1.1–2.8) in those who smoked on the day of surgery versus those who did not. While causal effect was not established, these data suggest that current smokers should abstain from smoking on the morning of surgery even if they are unwilling to undertake more prolonged preoperative abstinence.
6. DEXAMETHASONE DECREASES POSTOPERATIVE NAUSEA AND VOMITING AFTER GASTROINTESTINAL SURGERY
DREAMS Trial Collaborators and West Midlands Research Collaborative. Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial). BMJ. 2017;357:j1455.
This multicenter, randomized, observer-blinded, pragmatic (no placebo) trial of 1350 nondiabetic patients evaluated the effect of a single intravenous dose of dexamethasone (8 mg) at induction on incidence of postoperative nausea and vomiting after elective open or laparoscopic bowel surgery. As the local standard of care, ≈96% of both groups received an additional intraoperative antiemetic, which in ≈87% included ondansetron. Patients receiving dexamethasone had a lower incidence of vomiting within 24 hours (25.5% vs 33.0%; relative risk, 0.77; number needed to treat, 13), as well as reduced administration of another antiemetic (39.3% vs 51.9%; relative risk, 0.76; number needed to treat, 8) and a sooner return to a regular diet (62% vs 53%) in the first 24 hours postoperatively. No increase in complications was detected.
7. PERIOPERATIVE PHARMACOLOGICAL THROMBOPROPHYLAXIS IN PATIENTS WITH CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS
Guo Q, Huang B, Zhao J, et al. Perioperative pharmacological thromboprophylaxis in patients with cancer: a systematic review and meta-analysis. Ann Surg. 2017;265:1087–1093.
Both malignancy and surgery are associated with greater risk of venous thromboembolism, and the American Society of Clinical Oncology recommends perioperative prophylaxis in patients undergoing major cancer surgery. Guo et al sought to assess this recommendation through a systematic review of the literature. They found that pharmacological thromboprophylaxis reduced the incidence of deep venous thrombosis (DVT) (0.5% vs 1.2 %) but was associated with an increased incidence of bleeding events (relative risk, 2.5) and reoperation for bleeding (relative risk, 2.9). The reduction of DVT was only observed in patients undergoing abdominopelvic surgery. The reported incidence of pulmonary embolism (PE) was 0.3%, and not lower in those receiving pharmacologic thromboprophylaxis. Fatal outcomes related to venous thromboembolism were rare (0.05%), and not different in those receiving pharmacologic thromboprophylaxis. Compared with unfractionated heparin, low molecular weight heparin reduced the rate of DVT but not PE or bleeding complications. Standard extended thromboprophylaxis was associated with a lower incidence of DVT but not of PE. The authors recommend: (1) careful assessment of need for pharmacologic thromboprophylaxis in cancer patients undergoing surgery; and (2) mechanical prophylaxis may be sufficient in cancer patients undergoing nonabdominopelvic surgery.
8. ACUTE KIDNEY INJURY AFTER NONCARDIAC SURGERY
O’Connor ME, Hewson RW, Kirwan CJ, et al. Acute kidney injury and mortality 1 year after major noncardiacsurgery. Br J Surg. 2017;104:868–876.
In this single-center, retrospective cohort study, O’Connor et al analyzed the association of postoperative acute kidney injury (AKI) with hospital and 1-year mortality in 1869 patients undergoing elective major inpatient noncardiac surgery. AKI occurred in 6.8%, which was predominantly (≈79%) only Kidney Disease: Improving Global Outcome (KDIGO) stage 1. Black ethnicity, urologic surgery, baseline serum albumin, and preoperative estimated glomerular filtration rate were risk factors for postoperative AKI. Hospital mortality (13.3% vs 0.9%) and 1-year mortality (26.6% vs 6.1%) were much higher in those with versus those without AKI. There was no statistical association between unadjusted 1-year mortality and stage of AKI. The adjusted hazard ratio for death between 8 and 365 days after surgery was 2.96 in patients with postoperative AKI. The apparent adverse effects of even mild postoperative AKI underscore the need for prevention and early diagnosis, as reviewed in the article by Vanmassenhove et al listed below.
OTHER ARTICLES OF POSSIBLE INTEREST
1. Acute Myocardial Infarction
Anderson JL, Morrow DA. N Engl J Med. 2017;376:2053–2064.
2. Management of Chronic Pain in the Aftermath of the Opioid Backlash
Kroenke K, Cheville A. JAMA. 2017;317:2365–2366.
3. Incidence of Severe Critical Events in Paediatric Anaesthesia (APRICOT): A Prospective Multicentre Observational Study in 261 Hospitals in Europe
Habre W, Disma N, Virag K, et al. Lancet Respir Med. 2017;5:412–425.
4. Committee Opinion No. 696: Nonobstetric Surgery During Pregnancy
Committee on Obstetric Practice and the American Society of Anesthesiologists. Obstet Gynecol. 2017;129:777–778.
5. Management of Patients at Risk of Acute Kidney Injury
Vanmassenhove J, Kielstein J, Jörres A, Biesen WV. Lancet. 2017;389:2139–2151.
Name: Eugene A. Hessel II, MD.
Contribution: This author wrote the manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.