1. ASSESSING THE COMPETENCY OF THE AGING PHYSICIAN
Dellinger EP, Pellegrini CA, Gallagher TH. The aging physician and the medical profession: a review. JAMA Surg. 2017. doi: 10.1001/jamasurg.2017.2342. Epub ahead of print.
Nearly a quarter of physicians are ≥65 years of age. Studies have documented adverse effects of aging on physicians’ physical and cognitive performance. Other safety-conscious industries have placed age restrictions on their personnel. Dellinger et al focus on recent reports from the American Medical Association Council on Medical Education and the American College of Surgeons, which have called for voluntary monitoring of the competency of aging physicians. Dellinger et al describe the implementation of such policies at 3 prominent medical institutions in the United States and in the province of Ontario, Canada. The authors recommend that all institutions implement mandatory wellness testing and peer evaluation at a certain age, and identify the role of individual physicians and health care organizations in this effort. They posit that the public expects, and medical professionalism requires, that we assure safe practice by all physicians.
2. ANESTHETIC MANAGEMENT OF PATIENTS WITH SPINAL CORD STIMULATORS
Harned ME, Gish B, Zuelzer A, Grider JS. Anesthetic considerations and perioperative management of spinal cord stimulators: literature review and initial recommendations. Pain Physician. 2017;20:319–329.
Spinal cord stimulators are more frequently used in managing chronic pain, and thus, it is likely that anesthesiologists will encounter these patients in the course of their perioperative practice. Harned et al undertook a systematic review of the literature and manufacturer labeling to develop initial recommendations for the management of these patients. After a brief description of spinal cord stimulators, the authors address the impact of the operating room environment, including electrocautery, interaction with cardiovascular implanted electronic devices, relation to neuraxial blockade especially in obstetric anesthesia, and interaction with magnetic resonance imaging.
3. DEMENTIA AFTER CARDIAC SURGERY
Lingehall HC, Smulter NS, Lindahl E, et al. Preoperative cognitive performance and postoperative delirium are independently associated with future dementia in older people who have undergone cardiac surgery: a longitudinal cohort study. Crit Care Med. 2017;45:1295–1303.
These authors report a rigorous study of 114 patients ≥75 years of age, without evidence of dementia preoperatively, who underwent cardiac surgery with cardiopulmonary bypass and were evaluated preoperatively, 1 and 4 days postextubation, and 1, 3, and 5 years postoperatively. Fifty-six percent experienced postoperative delirium, and 26% developed dementia during the next 5 years. A lower preoperative Mini-Mental State Examination score and the occurrence of postoperative delirium were associated with developing dementia. The authors suggest that cognitive function should be screened preoperatively in older cardiac surgery patients, and those who experience postoperative delirium should be followed for early detection of dementia.
4. BENEFITS AND RISKS OF GABAPENTINOIDS IN CHRONIC PAIN
Shanthanna H, Gilron I, Rajarathinam M, et al. Benefits and safety of gabapentinoids in chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. PLoS Med. 2017;14:e1002369.
Gabapentinoids are approved by the Food and Drug Administration only for limited specific pain syndromes, but they are increasingly being prescribed for other chronic pain conditions, partly in response to the current mandate to limit opioid use. Goodman and Bretta have expressed concern about this trend. Shanthanna et al conducted a systematic review of the 8 randomized controlled trials assessing the benefit and risks with use of gabapentinoids for chronic low back pain. Most trials had a considerable risk of bias. Minimal to no improvement in pain was noted versus a significant increase in dizziness, fatigue, and difficulties with mentation. These findings do not support the use of gabapentinoids for chronic low back pain, and there is a need for high-quality trials to determine their role.
aGoodman CW, Brett AS. Gabapentinoids and pregabalin for pain—is increased prescribing a cause for concern? NEJM. 2017;377:411–413.
5. IMPACT OF SURGICAL SAFETY CHECKLISTS
Zingiryan A, Paruch JL, Osler TM, Hyman NH. Implementation of the surgical safety checklist at a tertiary academic center: impact on safety culture and patient outcomes. Am J Surg. 2017;214:193–197.
The use of surgical safety checklists has been widely advocated and adopted. Zingiryan et al evaluated the perceptions of team members (nurses, surgeons, and anesthesiologists) and the impact on perioperative morbidity and mortality with initiation of “sign in,” “time out,” and “sign out” surgical safety checklists at the University of Vermont Medical Center. Most responders in all groups felt their use improved patient safety and communication and helped prevent errors. However, the rates of 9 complications were not altered.
6. ANGIOTENSIN II FOR VASODILATORY SHOCK
Khanna A, English SW, Wang XS, et al. Angiotensin II for the treatment of vasodilatory shock. N Engl J Med. 2017;377:419–430.
Khanna et al reported on an international, multicenter, phase 3 randomized control trial of use of a modified bovine angiotensin II for vasodilatory shock not responding to high-dose norepinephrine in 321 patients. Use of angiotensin II versus placebo was associated with greater achievement of the primary hemodynamic goal (70% vs 23%) and greater improvement in the cardiovascular Sequential Organ Assessment score at 48 hours, but no significant difference in 28-day mortality (46% vs 54%) or serious adverse events. If confirmed in other studies, this may introduce a new class of drugs to treat vasodilatory shock. (See also article of possible interest by Busse et al below.)
7. PREOPERATIVE C-REACTIVE PROTEIN PREDICTS POSTOPERATIVE DELIRIUM
Vasunilashorn SM, Dillon ST, Inouye SK, et al. High C-reactive protein predicts delirium incidence, duration, and feature severity after major noncardiac surgery. J Am Geriatr Soc. 2017;65:e109–e116.
This prospective observational study assessed the association between preoperative and postoperative day 2 C-reactive protein (CRP) levels and postoperative delirium (POD) in 560 patients ≥70 years of age (mean 76.7 years) undergoing major noncardiac surgery. POD occurred in 24% of patients. A preoperative CRP of ≥3 mg/L was associated with a 1.5 times increased risk of POD, more severe delirium, and more prolonged delirium. Similar associations were found with postoperative CRP in the highest quartile (≥235.7 mg/L). If confirmed by future studies, CRP may be a useful predictor of POD, supporting the role of inflammation in POD.
8. OBESITY AND PULMONARY COMPLICATIONS AFTER OUTPATIENT SURGERY
De Oliveira GS Jr, McCarthy RJ, Davignon K, et al. Predictors of 30-day pulmonary complications after outpatient surgery: relative importance of body mass index weight classifications in risk assessment. J Am Coll Surg. 2017;225:312–323.
Using data from the American College of Surgeons National Surgical Quality Improvement Program database for 2012 and 2013, De Oliveira et al evaluated the relationship between increased body mass index (BMI) and incidence of a pulmonary complication after outpatient surgery. The odds ratio for a pulmonary complication was 1.4, with a BMI of 35 to <40, and 1.7 for a BMI of 40 to <50. However, this elevated risk was lower than or equal to other risk factors, including current smoking, and the effect was limited to patients <50 years of age and otherwise healthy patients. Pulmonary embolism was observed to be of greater risk with obesity.
OTHER ARTICLES OF POSSIBLE INTEREST
1. Clinical Experience With IV Angiotensin II Administration: A Systematic Review of Safety
Busse LW, Wang XS, Chalikonda DM, et al. Crit Care Med. 2017;45:1285–1294.
2. Can Patients Make Recordings of Medical Encounters? What Does the Law Say?
Elwyn G, Barr PJ, Castaldo M. JAMA. 2017;318:513–514.
3. Acute Respiratory Distress Syndrome
Thompson BT, Chambers RC, Liu KD. N Engl J Med. 2017;377:562–572.
4. Continuing Professional Development for Faculty: An Elephant in the House of Academic Medicine or the Key to Future Success?
Davis DA, Rayburn WF, Smith GA. Acad Med. 2017;92:1078–1081.
5. Saying Goodbye to Lectures in Medical School–Paradigm Shift or Passing Fad?
Schwartzstein RM, Roberts DH. N Engl J Med. 2017;377:605–607.
6. Just Because I am Teaching Doesn’t Mean They Are Learning: Improving our Teaching for a New Generation of Learners
Sklar DP. Acad Med. 2017;92:1061–1063.
7. Perioperative Beta Blockers and Statins for Noncardiac Surgery Patients With Coronary Stents
Richman JS, Graham LA, DeRussy A, et al. Am J Surg. 2017;214:180–185.
8. Coronary Balloon Angioplasty, Stents, and Scaffolds
Byrne R, Stone G, Ormiston J, Kastrati A. Lancet. 2017;390:781–792.
9. Association Between Persistent Pain and Memory Decline and Dementia in a Longitudinal Cohort of Elders
Whitlock EL, Diaz-Ramirez LG, Glymour MM, et al. JAMA Intern Med. 2017;177:1146–1153.
10. Effect of Cerebral Embolic Protection Devices on CNS Infarction in Surgical Aortic Valve Replacement: A Randomized Clinical Trial
Mack MJ, Acker MA, Gelijns AC, et al. JAMA. 2017;318:536–547.
11. Should All Massively Transfused Patients be Treated Equally? An Analysis of Massive Transfusion Ratios in the Nontrauma Setting
Etchill EW, Myers SP, McDaniel LM, et al. Crit Care Med. 2017;45:1311–1316.
12. Use of the Dual-Antiplatelet Therapy Score to Guide Treatment Duration After Percutaneous Coronary Intervention
Piccolo R, Gargiulo G, Franzone A, et al. Ann Intern Med. 2017;167:17–25.
Name: Eugene A. Hessel II, MD.
Contribution: This author wrote the manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.