1. PERIOPERATIVE MYOCARDIAL INJURY AFTER NONCARDIAC SURGERY
Puelacher C, Lurati Buse G, Seeberger D, et al. Perioperative myocardial injury after noncardiac surgery: incidence, mortality, and characterization. Circulation. 2018;137:1221–1232.
In this single-center, prospective, observational study, Puelacher et al measured high-sensitivity cardiac troponin on postoperative days 1 and 2 in 2018 consecutive adult patients >65 years of age (or >45 years of age with a history of coronary or peripheral artery disease or stroke) undergoing 2546 noncardiac surgery with a planned hospital stay of >24 hours. Perioperative myocardial injury (PMI) was prospectively defined as absolute increase in hs-cTn of ≥14 ng/L. Sixteen percent experienced a PMI. In only 6% of these cases, it was associated with typical chest pain, and in 18%, it was associated with any ischemic symptoms; whereas in 71% of cases, there were no additional diagnostic criteria for myocardial infarction. Thirty-day modality was 8.9% in patients with PMI versus 1.5% in those without PMI, and 1-year mortality was 22.5% vs 9.3%. Thirty-day mortality was similar in those with or without at least 1 additional criteria for myocardial infarction (10.4% vs 8.7%). PMI was common and associated with high mortality despite its timely recognition and cardiology evaluation.
2. PERIOPERATIVE ORAL VERSUS INTRAVENOUS ACETAMINOPHEN
Hickman SR, Mathieson KM, Bradford LM, et al. Randomized trial of oral versus intravenous acetaminophen for postoperative pain control. Am J Health Syst Pharm. 2018;75:367–375.
Use of acetaminophen is widely used as a component of multimodal perioperative analgesia, and intraoperative use of intravenous (IV) acetaminophen is advocated. Hickman et al compared the administration of 1000 mg of acetaminophen orally (per os) 80 minutes preoperatively with IV administration just before or ≈20 minutes after start of surgery in a single-center prospective, randomized, placebo-controlled, double-blind study of 486 adults undergoing elective total hip (~30%) or knee (~70%) arthroplasty. Both groups received similar amounts of other analgesics preoperatively. There was no difference in primary outcome (24 hours postoperative morphine milligram equivalent) or in the mean pain scores, time to first pain medication, use of other postoperative analgesic medications, time to ambulate, length of postanesthesia care unit or hospital stay, or postoperative nausea or vomiting. Median pain scores were nonstatistically significantly lower in the first 4 hours postoperatively in the IV group (3.7 vs 4.2; P = .90). These data suggest that in this application, per os acetaminophen is equivalent to IV at considerable cost saving.
3. TAKOTSUBO CARDIOMYOPATHY MAY INDUCE PERSISTENT CARDIAC ABNORMALITIES
Scally C, Rudd A, Mezincescu A, et al. Persistent long-term structural, functional, and metabolic changes after stress-induced (Takotsubo) cardiomyopathy. Circulation. 2018;137:1039–1048.
Takotsubo stress cardiomyopathy (TCM) is increasingly recognized, including in the perioperative period. While it may cause temporary but severe ventricular dysfunction, this is commonly accepted to be transient and self-limiting. The latter concept is challenged by this observational, case-control study by Scally et al, who compared 37 patients (97% women, 64 ± 11 years of age) who were >12 months (mean, 20; range, 13–39) post-TCM with a matched group of patients without a history of TCM. Despite having normal left ventricular ejection fractions and serum markers, post-TCM patients had greater limitation on exercise testing and evidence of impaired cardiac deformation indices and energetic status. These data suggest that TCM has more sustained clinical consequences, which deserve our attention when providing perioperative care of patients with a history of TCM.
4. ASPIRATION PNEUMONIA AFTER EMERGENCY INTUBATION IN EMERGENCY DEPARTMENT
Driver BE, Klein LR, Schick AL, et al. The occurrence of aspiration pneumonia after emergency endotracheal intubation. Am J Emerg Med. 2018;36:193–196.
This single-center, prospective observational study of 879 patients undergoing emergency endotracheal intubation, predominately by senior emergency medicine physicians, observed an 8% incidence of postadmission aspiration pneumonia potentially related to endotracheal intubation. The first attempt used video laryngoscope (C-MAC, Karl Storz Endoscopy America, El Segundo, CA) in 49% of patients, direct laryngoscopy in 45%, and nasal intubation in 4% and was successful in 85%, but associated with hypoxemia (<90%) in 25%. Paralytic agents were used in 87% of patients (73% succinylcholine) and hypnotics in 85% (77% etomidate). No intubation factors were associated with incidence of aspiration pneumonia. Fasting status, duration of the attempted intubation, and use of cricoid pressure were not described.
5. EFFECT OF PERIOPERATIVE ASPIRIN ON OUTCOME OF NONCARDIAC SURGERY IN PATIENTS WITH PRIOR PERCUTANEOUS CORONARY INTERVENTION
Graham MM, Sessler DI, Parlow JL, et al. Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Ann Intern Med. 2018;168:237–244.
Initial analysis of the Perioperative Ischemic Evaluation 2 (POISE-2) trial in 10,010 patients undergoing noncardiac surgery who were at risk of atherosclerotic disease, who had not received a coronary stent within the past 1 year, did not find that aspirin decreased the risk of primary outcome of death or nonfatal myocardial infarction but did observe an increase in the risk of major bleeding. Graham et al present this post hoc analysis of the 470 patients in the POISE-2 study, who had undergone a percutaneous coronary intervention >1 year before (median, 64 months) participating in the POISE-2 trial. About 54% had received bare metal stents, and 25% received drug eluting stents. Unlike the findings in the entire group, when compared with those who did not, patients with percutaneous coronary intervention who received aspirin experienced the primary (adverse) outcome (6.0% vs 11.5%; hazard ratio [HR], 0.50) and nonfatal myocardial infarction (5.1% vs 11.0%; HR, 0.44) less frequently without a statistically significant increase in major or life-threatening bleeding (5.6% vs 4.2%; HR, 1.26). While limited by the post hoc nature of the analysis and the relatively small number of patients, these data suggest continuation or resumption of low-dose aspirin therapy in patients with remote (>1 year) coronary stent placement undergoing noncardiac surgery.
6. FACULTY TRANSITION THROUGH RETIREMENT
Cain JM, Felice ME, Ockene JK, et al. Meeting the late-career needs of faculty transitioning through retirement: one institution’s approach. Acad Med. 2018;93:435–439.
Academic medical faculties are aging, and yet there appears to be a “culture of silence” in addressing retirement. This poses a challenge to the late-career faculty member but an opportunity for institutions to assist their senior faculty and identify ways these retiring faculty can continue to contribute to the multiple tasks of an academic department. In this article, Cain et al describe the development of a multifaceted strategy to address the transition to retirement during its 3 phases (preretirement, retirement, and postretirement) at the University of Massachusetts Medical School. They identify needs and key lessons for retiring faculty members and ways they addressed them. They recommend that “every institution should invest in a comprehensive set of policies, programs, and resources to support faculty during this key career transition” and identify continued roles and support of retired faculty in their institutions.
7. CEREBRAL EMBOLIZATION, INFARCTION, AND NEUROCOGNITIVE DECLINE AFTER THORACIC ENDOVASCULAR AORTIC REPAIR
Perera AH, Rudarakanchana N, Monzon L, et al. Cerebral embolization, silent cerebral infarction and neurocognitive decline after thoracic endovascular aortic repair. Br J Surg. 2018;105:366–378.
Perera et al report findings in a 2-center prospective study of 52 patients (mean age 66 years) undergoing thoracic endovascular aortic repair. Transcranial Doppler imaging in 42 of them revealed multiple high-intensity transient signals, suggesting emboli in all patients. Four (8%) suffered a clinical stroke. Thirty-one underwent cerebral diffusion-weighted magnetic resonance imaging pre- and postprocedure, and 25 (81%) had evidence of brain injury (4 being the stroke patients), but 21 (68%) had evidence of silent infarctions (median of 2 per patient). Neurocognitive testing was performed in 17 patients at a median of 8 days postthoracic endovascular aortic repair. In the 15 patients with silent infarctions, significant decline was found in 6 of the 7 domains, and age was a common predictor. Greater aortic atherosclerotic burden, left subclavian artery bypass, more proximal landing zones, and arch hybrid repairs were associated with increased embolization; however, the amount of embolization was not associated with brain injury.
8. FIVE-YEAR MORTALITY AFTER CORONARY ARTERY BYPASS GRAFTING VERSUS PERCUTANEOUS CORONARY STENTING
Head SJ, Milojevic M, Daemen J, et al. Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data. Lancet. 2018;391:939–948.
Head et al report this systematic review of 11 randomized studies of over 11,000 patients with multivessel or left main coronary disease who did not present with acute myocardial infarction. Among all patients, 5-year all-cause mortality was higher in those undergoing percutaneous coronary interventions with stent than in those undergoing coronary artery bypass grafting (11.2% vs 9.2%; hazard ratio [HR], 1.2). In a subgroup analysis, this was also true in patients with multivessel disease (11.5% vs 8.9%; HR, 1.3) and in those with multivessel disease and diabetes. However, it was not evident in those with left main disease (10.7% vs 10.5%; HR, 1.1) nor in those with multivessel disease and without diabetes (8.7% vs 8.0%; HR, 1.1).
9. RISK AND OUTCOME OF TRANSFUSION-ASSOCIATED CIRCULATORY OVERLOAD
Roubinian NH, Hendrickson JE, Triulzi DJ, et al. Contemporary risk factors and outcomes of transfusion-associated circulatory overload. Crit Care Med. 2018;46:577–585.
As part of the National Heart, Lung, and Blood Institute Recipient Epidemiology and Donor Evaluation Study III, Roubinian et al report this case-control study of transfusion-associated circulatory overload (TACO) between 2015 and 2016 at 4 tertiary care hospitals in the United States among 20,845 patients who received over 125,000 blood components. TACO occurred in 200 patients (0.96%). In the TACO patients, transfusions mainly occurred in the operating room or intensive care unit (≈36% each). About 95% had undergone surgery (35% cardiothoracic; 15% vascular; 12% liver; and 8% each orthopedic, spine, and abdominal). The TACO patients were matched by transfusion intensity 2:1 with 405 patients who did not exhibit TACO. Compared with controls, TACO patients required more mechanical ventilation (71% vs 49%), longer intensive care unit and hospital length of stay, and higher mortality (21% vs 11%), after adjustment for potentially confounding variables. Independent predictors of TACO were acute kidney injury, emergency surgery, pretransfusion diuretic use, and plasma transfusion, especially in females.
10. EPIDURAL ANALGESIA REDUCES MORTALITY OF ACUTE PANCREATITIS
Jabaudon M, Belhadj-Tahar N, Rimmelé T, et al. Thoracic epidural analgesia and mortality in acute pancreatitis: a multicenter propensity analysis. Crit Care Med. 2018;46:e198–e205.
In this European multicenter, retrospective observational study of 1003 intensive care patients with acute pancreatitis, Jabaudon et al assess the association of epidural analgesia (in 4.6% of patients , median duration 8 days) on 30-day mortality. Utilizing 92 propensity score–matched patients for factors associated with mortality, epidural analgesia was associated with a major decrease in mortality (2% vs 17%; odds ratio, 0.12; 95% confidence intervals, 0.07–0.32). Biologic plausibility is suggested by demonstrated improvements in splanchnic perfusion and decreased inflammation associated with epidural analgesia.
11. BEST PRACTICES OF SOCIAL MEDIA USE BY PHYSICIANS
Logghe HJ, Boeck MA, Gusani NJ, et al. Best practices for surgeons’ social media use. J Am Coll Surg. 2018;226:317–327.
Most physicians participate in social media, but this can have an impact on their professional status. While admittedly addressed only at surgeons, as well as lacking high-level evidence and only based on a review of the literature and expert opinion, this special article by Logghe et al is likely relevant to all physicians. They report the conclusions of a task force of the Resident and Associate Society of the American College of Surgeons. They report the disturbing results of an audit of publically available Facebook profiles of residents and faculty, which found potentially unprofessional content (14% and 10%, respectively) or clearly unprofessional content (12% and 5%, respectively). These authors make 10 recommendations for appropriate social media engagements. Notable to this reviewer were the recommendations to periodically self-audit online (by “Googling”) and to establish an online professional profile.
12. OPTIMIZING SLEEP FOR NIGHT SHIFTS
McKenna H, Wilkes M. Optimising sleep for night shifts. BMJ. 2018;360:j5637.
Night-shift work is common in anesthesia and has been shown to have adverse effects on performance in addition to physiological and psychological well-being. Unfortunately, there are limited high-level evidence about ways of minimizing these adverse effects. McKenna and Wilkes distilled the literature to provide a list of 8 interventions that might improve performance. These include minimizing sleep debt and taking preshift naps before nights, taking brief naps and use of caffeine (and possibly armodafinil/modafinil) during the night shift, and optimizing sleep the following day.
OTHER ARTICLES OF POSSIBLE INTEREST
1. Tubal Ectopic Pregnancy
ACOG Practice Bulletin No. 193. Obstet Gynecol. 2018;131:e91–e103.
2. Pregnancy in Women With Congenital Heart Disease
Cauldwell M, Dos Santos F, Steer PJ, et al. BMJ. 2018;360:k478.
3. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect
Mehta LS, Watson KE, Barac A, et al. Circulation. 2018;137:e30–e66.
4. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease
Nishimura RA, Otto CM, Bonow RO, et al. J Am Coll Cardiol. 2017;70:252–289.
5. Flipped Classrooms in Graduate Medical Education
Wittich CM, Agrawal A, Wang AT, et al. Acad Med. 2018;93:471–477.
6. Alzheimer’s Disease in Physicians
Devi G. N Engl J Med. 2018;378:1073–1075.
7. Confronting Unprofessional Behaviour in Medicine
Shapiro J. BMJ. 2018;360:k1025.
8. Persistence of Sexual Harassment and Gender Bias in Medicine Across Generations—Us Too
Shakil S, Lockwood M, Grady D. JAMA Intern Med. 2018;178:324–325.
9. Putting the “She” in Doctor
DeFilippis EM. JAMA Intern Med. 2018;178:323–324.
10. Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock
Pruinelli L, Westra BL, Yadav P, et al. Crit Care Med. 2018;46:500–505.
11. Oxygen Exposure Resulting in Arterial Oxygen Tensions Above the Protocol Goal Was Associated With Worse Clinical Outcomes in Acute Respiratory Distress Syndrome
Aggarwal NR, Brower RG, Hager DN, et al. Crit Care Med. 2018;46:517–524.
Name: Eugene A. Hessel II, MD.
Contribution: This author wrote the manuscript.
This manuscript was handled by: Thomas R. Vetter, MD, MPH.