Must read articles
Anaesthetic depth and complications after major surgery
Reference: Short T et al. Lancet 2019; 394(10212): 1907-14
Take home message: this multi-centre, international RCT aimed to address the question of whether light anaesthesia (BIS 50) compared with deep anaesthesia (BIS 35) improves survival at 1-year. The study found that among patients (n=6644) at increased risk of complications after major surgery, there was no difference in mortality or serious complication between light and deep anaesthesia. A broad range of anaesthetic depth can be delivered safely using volatile anaesthetic agents titrated against processed electroencephalographic monitoring. Across this range of anaesthetic depth (BIS 35-50), the incidence of awareness remained very rare (approximately 3 in 10,000).
Special issue: Advances in perioperative care
Reference: Anaesthesia 2020; 75 (Suppl.1)
Take home message: In this special issue of Anaesthesia, broad aspects of perioperative care, ranging from generic to specific topics were discussed. Numerous important take home messages were presented, which included (not limited to):
- ‘Enhanced postoperative recovery: good from afar, but far from good?’: ERAS pathways have revolutionised surgical care at a global scale, however many challenges lie ahead still, which included both challenges in its implementation and conceptual improvement. Based on our improved understanding and control of perioperative pathophysiology and organ dysfunction, factors to consider in future ERAS programmes were summarised (fig. 1).
Figure 1. Pathophysiological factors to consider for future improvement of ERAS programmes. (image courtesy of Kehlet H, Anaesthesia 2020)
- ‘The older surgical patient – to operate or not? A state of the art review’: in our ageing population, the challenge to answer the question of whether to operate or not is increasingly recognised and a number of different perspectives need to be considered. Centring it all is the view of the patient, which reiterates the necessity of shared decision making, based on collaborations between multidisciplinary health professionals and the patient, to achieve personalised and evidence-based care. To manage this issue requires innovative models of perioperative care. Despite the challenges inherent in this process, getting it right should help to establish sustainable and improved, clinician-reported, patient-reported and process outcomes following surgery.
Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial
Reference: The HIP ATTACK Investigators. Lancet 2020 Feb [Epub ahead of print]
Take home message: this RCT assessed whether accelerated surgery compared with standard care, could reduce mortality and major complications in patients undergoing hip fracture repair. The median time from hip fracture diagnosis to surgery in the accelerated group was 6 hours (IQR 4-9), and in the standard-care group was 24 hours (IQR 10-42). Among the 2970 patients in the study, accelerated surgery did not reduce the risk of 90-day mortality (HR 0.91, 95% CI 0.72-1.14) or major complications (HR 0.97, 95% CI 0.83-1.13). Accelerated surgery was associated with lower risk of delirium (OR 0.72, 95% CI 0.58-0.92), faster mobilisation (absolute median difference 21 hours, 95% CI 20-22), and a shorter time from randomisation to hospital discharge (absolute mean difference 1 day, 95% CI 1-2).
Integration of the Duke Activity Status Index into preoperative risk evaluation: a multicentre prospective cohort study
Reference: Wijeysundera D et al. Br J Anaesth. 2019 Dec [Epub ahead of print]
Take home message: the Duke Activity Status Index (DASI) questionnaire is a measure of functional capacity which was shown in the Measurement of Exercise Tolerance before Surgery (METS) study to be associated with predicting death or myocardial infarction after surgery. However, the thresholds in DASI scores to prognosticate perioperative risk remain unclear. This study analysed data from the large METS study sample (n=1546) to define the association of preoperative DASI scores with postoperative cardiac and moderate-to-severe complications. A DASI score of 34 or less was identified as a threshold for predicting postoperative 30-day death or myocardial infarction (odds ratio: 1.05 per 1 point decrease below 34; 95% CI: 1.00-1.09), and moderate-to-severe complications (odds ratio: 1.03 per 1 point decrease below 34; 95% CI: 1.01-1.05). Incorporation of DASI scores into preoperative evaluation will help to identify patients at an elevated risk of post-operative adverse events.
Special Issue: Perioperative Care in the Elderly
Reference: Loh M, Fernando J. Annals, Academy of Medicine, Singapore 2019; 48(11)
In this special issue, topical subjects of geriatric perioperative care were discussed, which included: ERAS, sarcopenia, emergency laparotomy and prehabilitation. Elderly surgical patients often present with unique challenges that go beyond the boundary of the surgeon’s expertise and the concept of a transdisciplinary based, perioperative care is perhaps most applicable in these patients.