Must read articles

The challenge of perioperative advance care planning

Reference: Ramachenderan J et al. J Pain Symptom Manage 2019; 58(3): 538-542
Case summary: Hector, an elderly World War 2 veteran, lived in an Australian rural town and was married to Vera for 75 years. Together, they had five children, 15 grand-children, and 10 great-grandchildren. Despite kidney disease, ischemic cardiomyopathy, and symptomatic heart failure, when Vera developed progressive dementia, Hector became her fulltime caregiver. At 93 years old, Hector was admitted to hospital with dyspnoea, chest tightness, and abdominal pain. He had a myocardial infarction, new atrial fibrillation, acute kidney injury, and subacute bowel obstruction. After three days of conservative management, Hector’s symptoms unfortunately worsened and it was clear that he was developing mesenteric ischemia. Hector has previously completed an Advance Health Directive (AHD), which stated how he does not wish to receive artificial ventilation or cardiopulmonary resuscitation ‘if facing a life-threatening condition.’ Despite this AHD, the treating teams were unable to negotiate a clear treatment pathway between conservative management or emergency laparotomy. Hector’s family’s views diverged, with his daughter and son-in law ‘wanting everything to be done’ but two other children requesting for ‘dad to be comfortable’…

‘What should you do for Hector?’

Take home message: As our population becomes older, health concerns related to aging and frailty are increasingly encountered. As was seen in this case, clinicians providing perioperative care are often presented with the challenging question of ‘What should I do?’. This case highlights the importance of three particular issues that are pertinent to older, frail patients facing emergency surgery: the value of advance care planning in preparing patients and families for in-the-moment decision making, not-for-resuscitation orders and their implications in the perioperative period, and the establishment of clear goals of care to help direct patients away from futile and inappropriate measures.

Advance care planning and end-of-life discussions in the perioperative period: a review of healthcare professionals' knowledge, attitudes, and training

Reference: Blackwood D et al. Br J Anaesth 2018; 121(5): 1138-1147
Take home message: Advance care planning (ACP) has an important role in shared decision-making for patients who have significant, life-limiting illnesses. However, this review showed there is a paucity of evidence to guide ACP in the perioperative setting. Where evidence exists, healthcare professionals mostly have a positive view toward ACP and end of life discussion in the perioperative period. However, there is little training or educational content available and there was no evidence of ACP becoming a routine part of practice in the care of patients planned for high-risk surgery.

Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study

Reference: The NeuroVISION Investigators. Lancet 2019 Aug 14 [Epub ahead of print]
Take home message: Perioperative covert stroke (= an acute brain infarct detected on MRI after non-cardiac surgery, with no clinical stroke symptoms) was found in this international, multi-centre study to have an incidence of 7%, in patients aged 65 years and older. Perioperative covert stroke is associated with increased risks of cognitive decline (adjusted odds ratio 1.98, 95% CI 1.22–3.20, absolute risk increase 13%; p=0.0055), perioperative delirium (hazard ratio [HR] 2.24, 95% CI 1.06–4.73, absolute risk increase 6%; p=0.030), and overt stroke or transient ischaemic attack (HR 4.13, 1.14–14.99, absolute risk increase 3%; p=0.019) at 1 year follow-up after non-cardiac surgery.

Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant

Reference: Douketis J et al. JAMA Intern Med 2019 Aug 5 [Epub ahead of print]
Take home message: In this study, patients with AF who had direct oral anticoagulant (DOAC) therapy interruption for elective surgery or procedure, a simple standardised perioperative management strategy without heparin bridging or measurement of coagulation function was associated with low rates of 30-day postoperative major bleeding (<2%) and arterial thromboembolism (<1%). These complication rates were similar to previous comparable studies such as the BRIDGE trial (heparin bridging vs. no bridging, in patients with AF who had perioperative warfarin treatment interruption), in which patients who were not bridged had a 30-day postoperative rates of major bleeding of 1.3% and arterial thromboembolism of 0.4%.