Must Read Articles

Special issue: Patient optimisation before surgery

Reference: Anaesthesia 2019; 74 (Suppl.1).
Take home message: In this special issue of Anaesthesia, a series of articles comprehensively reviewed the multi-faceted goal of patient optimisation before surgery. Numerous important take home messages were presented, which included (not limited to):

• Risk Prediction: most of the commonly used risk prediction models either lack context in time (from survival in the present), or space (from survival outside hospital). A risk prediction model encompassing comparisons with outcomes outside hospital will help both patients and clinicians to understand further the value of our health care provisions.
• Share decision making (SDM): SDM is the central component of the international priority of delivering patient‐centred healthcare. The SHARE approach provides a useful framework to SDM, and is consisted of ’Seeking’ your patient’s participation, ‘Helping’ your patient to understand management options, ‘Assessing’ your patient’s values, ‘Reaching’ a decision with your patient, and ‘Evaluating’ your patient’s decision.
• Multi-modal prehabilitation: the importance of prehabilitation is increasingly recognised. There is a need to not only focus on exercise prehabilitation, but to also optimise nutrition and psychological wellbeing, to improve both the adherence and the response to the physical training stimulus. There is also an urgent need for high-quality prospective trials to evaluate the benefit of psychological intervention as part of multimodal prehabilitation. The Wessex fit for cancer surgery trial is an example of such a trial, which attempts to assess the benefit of psychological prehabilitation.

Reference: Perioperative Quality Initiative-3 workgroup. BJA 2019; 122(5): 542-86
Take home message: This series of 4 articles by the Perioperative Quality Initiative group featured an in-depth discussion of the physiology and review of perioperative management of blood pressure (BP) against patient outcomes. Important take home messages included (not limited to):

• Ambulatory BP measurement is the optimal method to establish baseline BP
• There is insufficient evidence to support cancellation of elective surgery based solely upon a preoperative BP value
• There is increasing evidence that even brief durations of SBP <100 mm Hg and MAP <60–70 mm Hg are harmful during non-cardiac surgery
• There is insufficient evidence to recommend a general upper limit of BP at which therapy should be initiated, although SBP >160 mm Hg have been associated with myocardial injury and infarction during non-cardiac surgery

Reference: OBTAIN Investigators of European Society of Anaesthesiology. BJA 2019; 122(2): 120–79
Take home message: This international multicentre study of 847 patients who have undergone previous PCI, showed the unadjusted risk ratio for major adverse cardiac events (MACE) in patients receiving dual anti-platelets therapy (DAPT) compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In propensity matched analysis, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32 and the risk ratio of bleeding in the DAPT group was 4.00 (1.15–13.93), P=0.031. This study is limited by its observational nature, the small sample size, and the lack of long-term monitoring of MACE.