Must Read Articles

Kicking on while it’s still kicking off – getting surgery and anaesthesia restarted after COVID-19

Reference: Cook T, Harrop-Griffiths W. Anaesthesia 2020 May 19 [online ahead of print]
Take home message: In some parts of the world, including the UK, Australia and New Zealand, political and social minds are turning to loosening lockdown and moving into the new ‘post-pandemic normality’. In the health sector during the COVID-19 pandemic, cancelling all non-emergency surgery and redeploying theatre personnel, equipment and space, to focus on a single disease, have inevitably led to a backlog of non-COVID-19 affected patients awaiting treatment. This editorial provides an insightful discussion on the challenges associated with restarting ‘planned surgery’ after COVID-19, with considerations for the needs of protecting perioperative patients and staff, proportionating PPE, bringing back repurposed staff and resources, and the ethical challenges in prioritisation of surgery. Now, more than ever, ‘anaesthetists, perioperative physicians, surgeons and all other team members will need to use all of their vision, skills, experience and compassion if we are going to kick on while it’s still kicking off.’

Featured Articles: Perioperative care of the frail patient

Reference: Anesth Analg 2020; 130(6)
Take home message: In this June issue of Anesthesia & Analgesia featuring perioperative care of the frail patient, numerous important issues were presented, which included (not limited to): 

• Preoperative evaluation of the frail patient: a number of instruments for assessment of frailty exist and most are able to predict postoperative adverse outcomes. Among these, the Clinical Frailty Scale (CFS) which involves evaluation of patient’s comorbidity and function, typically takes <5 minutes to complete and appears to be feasible for use in the perioperative setting. 
• Prehabilitation for the frail syndrome: frailty is often associated with a range of geriatric syndromes such as cognitive impairment, functional dependency and malnutrition. Although robust trials are still required to guide definite perioperative care of frail patients, identification of frailty may allow for optimisation via multimodal prehabilitation programmes, encompassing exercise, nutritional and psychosocial interventions. 
• American Society for Enhanced Recovery and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Postoperative Delirium Prevention: postoperative delirium occurs in up to 50% of patients after major surgery and is associated with long term functional decline and cognitive impairments. The sixth POQI consensus conference provide evidence-based consensus statements regarding prevention of this common and consequential complication. Strong recommendation was made (grade B evidence) for use of multicomponent nonpharmacologic interventions for the prevention of postoperative delirium in older high-risk patients. Although the components of these bundles are often varied and institution-specific, successful programmes often contain items summarised in figure 1 below: 

Randomized clinical trial of intraoperative dexmedetomidine to prevent delirium in the elderly undergoing major non-cardiac surgery

Reference: Li C et al. Br J Surg 2020; 107(2): e123-e132
Take home message: this double-blind RCT compared the incidence of delirium between 620 elderly patients undergoing major surgery, who were randomised to receive either intraoperative dexmedetomidine or placebo. Compared to the control group, the incidence of delirium during the 5 days after surgery was lower with intraoperative dexmedetomidine treatment (5.5% vs 10.3%, RR 0.53, 95% CI 0.30-0.94; P=0.026). The rates of acute agitation, tachycardia and early postoperative nausea and vomiting were significantly lower with dexmedetomidine treatment. However, the rate of bradycardia requiring treatment was significantly higher in the dexmedetomidine group (11.0% vs 5.5%, RR 2.01, 95% CI 1.15-3.51; P=0.013). Other safety outcomes (hypotension, hypertension, delayed extubation, oversedation, desaturation) did not differ between groups. 
 

Early elevation in plasma high-sensitivity troponin T and morbidity after elective noncardiac surgery: prospective multicentre observational cohort study

Reference: Ackland G et al. Br J Anaesth 2020; 124(5): 535-543
Take home message: Asymptomatic myocardial injury, defined by troponin elevation, occurs commonly after noncardiac surgery and is associated with higher mortality. In this prospective observational study, clinically asymptomatic increases in troponin within 24 h of elective major noncardiac surgery were common (25%), and associated with higher risk of subsequent development of postoperative complications. Clavien-Dindo ≥grade 3 occurred in 16.8% of patients with myocardial injury, compared with 9.5% of patients without troponin elevation (OR 1.78, 95% CI 1.48-2.14). Detecting elevated troponin early after noncardiac surgery may help stratify the levels of postoperative care.