Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis

BACKGROUND:Death and anoxic brain injury from unrecognized postoperative respiratory depression (PORD) is a serious concern for patient safety. The American Patient Safety Foundation has called for continuous electronic monitoring for all patients receiving opioids in the postoperative period. These recommendations are based largely on consensus opinion with currently limited evidence. The objective of this study is to review the current state of knowledge on the effectiveness of continuous pulse oximetry (CPOX) versus routine nursing care and the effectiveness of continuous capnography monitoring with or without pulse oximetry for detecting PORD and preventing postoperative adverse events in the surgical ward. METHODS:We performed a systematic search of the literature databases published between 1946 and May 2017. We selected the studies that included the following: (1) adult surgical patients (>18 years old); (2) prescribed opioids during the postoperative period; (3) monitored with CPOX and/or capnography; (4) primary outcome measures were oxygen desaturation, bradypnea, hypercarbia, rescue team activation, intensive care unit (ICU) admission, or mortality; and (5) studies published in the English language. Meta-analysis was performed using Cochrane Review Manager 5.3. RESULTS:In total, 9 studies (4 examining CPOX and 5 examining continuous capnography) were included in this systematic review. In the literature on CPOX, 1 randomized controlled trial showed no difference in ICU transfers (6.7% vs 8.5%; P = .33) or mortality (2.3% vs 2.2%). A prospective historical controlled trial demonstrated a significant reduction in ICU transfers (5.6–1.2 per 1000 patient days; P = .01) and rescue team activation (3.4–1.2 per 1000 patient days; P = .02) when CPOX was used. Overall, comparing the CPOX group versus the standard monitoring group, there was 34% risk reduction in ICU transfer (P = .06) and odds of recognizing desaturation (oxygen saturation [SpO2] 1 hour) was 15 times higher (P

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Perioperative Patient Blood Management to Improve Outcomes

Anemia is common in elective surgery and is an independent risk factor for morbidity and mortality. Historical management of anemia has focused on the use of allogeneic blood transfusion but this in itself is not without risk. It too has been independently associated with morbidity and mortality, let alone the costs and relative shortage of this resource. In recognition of this, patient blood management (PBM) shifts the focus from the product to the patient and views the patient's own blood as a resource that should be conserved and managed appropriately as a standard of care. It consists of 3 pillars: the optimization of red blood cell mass; reduction of blood loss and bleeding; and optimization of the patient's physiological tolerance toward anemia. Integration of these 3 pillars in the form of multimodal care bundles and strategies into perioperative pathways should improve care processes and patient outcome. Preoperative anemia is most commonly caused by functional iron deficiency and should be treated with oral iron, intravenous iron, and/or recombinant erythropoietin. An individualized assessment of the thrombotic risk of discontinuing anticoagulant and antiplatelet medication should be balanced against the risk of perioperative bleeding. Neuraxial anesthetic techniques should be considered and minimally invasive surgery undertaken where appropriate. Cell salvage should be used if significant blood loss is anticipated and pharmacological treatments such as tranexamic acid and fibrin sealants have been shown to reduce blood loss. Point of care tests can guide the perioperative management of dynamic coagulopathy. Blood testing sampling should be performed only when indicated and when taken, sample volume and waste should be minimized. Restrictive blood transfusion thresholds and reassessment after single unit transfusion should be incorporated into clinical practice where appropriate. For PBM to become standard practice in routine surgical care, national health care quality change initiatives must set the agenda for change but the patient-centered approach to PBM should be delivered in a way that is also hospital centered. Characterization of the current practice of PBM at each hospital is crucial to facilitate the benchmarking of performance. Barriers to effective implementation such as lack of knowledge should be identified and acted on. Continuous audit of practice with a focus on transfusion rates and patient outcomes can identify areas in need of improvement and provide iterative feedback to motivate and inspire the main stakeholders. Accepted for publication September 8, 2017. The authors declare no conflicts of interest. Funding: None. Reprints will not be available from the authors. Address correspondence to Neel Desai, FRCA, Department of Anaesthetics, Royal Free Hospital, Pond St, London, NW3 2QG, London, United Kingdom. Address e-mail to neel_d83@hotmail.com. © 2017 International Anesthesia Research Society

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Incidence of Anaphylaxis Associated With Sugammadex

We retrospectively investigated the incidence of potential sugammadex-induced anaphylaxis at a single center in Japan over a period of 3 years. The overall incidence of intraoperative hypersensitivity reaction was 0.22% (95% confidence interval [CI], 0.17%–0.29%), and the incidence of anaphylaxis was 0.059% (95% CI, 0.032%–0.10%). The total number of patients who received sugammadex during the study period was 15,479, and the incidence of anaphylaxis associated with sugammadex was 0.039% (n = 6; 95% CI, 0.014%–0.084%). This result implies that the incidence of sugammadex-associated anaphylaxis could be as high as that for succinylcholine or rocuronium. A prospective study, including testing for identification of cause, is necessary to confirm the exact incidence of sugammadex-induced anaphylaxis; however, the present finding calls attention to this potential. Accepted for publication September 12, 2017. Funding: This work was funded by the Department of Anesthesiology, Jikei University School of Medicine. The authors declare no conflicts of interest. The findings of this study were presented in part at the Annual Meeting of the Japanese Society of Anesthesiologists in Fukuoka, Japan, May 27, 2016, and the Annual Meeting of the American Society of Anesthesiologists in Chicago, IL, October 22, 2016. Reprints will not be available from the authors. Address correspondence to Hiroshi Sunaga, MD, Department of Anesthesiology, Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minatoku, Tokyo 105-8461, Japan. Address e-mail to hs-031@jikei.ac.jp. © 2017 International Anesthesia Research Society

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Evidence Basis for Regional Anesthesia in Ambulatory Arthroscopic Knee Surgery and Anterior Cruciate Ligament Reconstruction: Part II Adductor Canal Nerve Block—A Systematic Review and Meta-analysis

BACKGROUND:Adductor canal block (ACB) has emerged as an effective analgesic regional technique for major knee surgeries in the last decade. Its motor-sparing properties make it particularly attractive for ambulatory knee surgery, but evidence supporting its use in ambulatory arthroscopic knee surgery is conflicting. This systematic review and meta-analysis evaluates the analgesic effects of ACB for ambulatory arthroscopic knee surgeries. METHODS:We conducted a comprehensive search of electronic databases for randomized controlled trials examining the analgesic effects of ACB compared to control or any other analgesic modality. Both minor arthroscopic and anterior cruciate ligament reconstruction (ACLR) surgeries were considered. Rest and dynamic pain scores, opioid consumption, opioid-related adverse effects, time to first analgesic request, patient satisfaction, quadriceps strength, and block-related complications were evaluated. Data were pooled using random-effects modeling. RESULTS:Our search yielded 10 randomized controlled trials comparing ACB with placebo or femoral nerve block (FNB); these were subgrouped according to the type of knee surgery. For minor knee arthroscopic surgery, ACB provided reduced postoperative resting pain scores by a mean difference (95% confidence interval) of −1.46 cm (−2.03 to −0.90) (P

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No Significant Association Between the Transfusion of Small Volumes of Leukocyte-Depleted Red Blood Cells and Mortality Over 7 Years of Follow-up in Patients Undergoing Cardiac Surgery: A Propensity Score Matched Analysis

BACKGROUND:The impact of red blood cell (RBC) transfusion on long-term clinical outcome is controversial. METHODS:We prospectively recorded follow-up data of 6124 cardiac surgical patients who received no transfusion (RBC− group) or 1–2 units of leukocyte-depleted RBC (RBC+ group) at our institution. The primary end point was overall mortality up to 7 years after cardiac surgery; secondary end point was coronary artery revascularization during follow-up. To correct for nonrandomized group assignment, propensity score (PS) matching was performed. A subgroup analysis was also performed in patients with preoperative anemia. RESULTS:PS matching was possible in 4118 patients. During a mean follow-up of 4.05 years (range, 0.0–7.3 years), 140 patients (14.6%) died in the RBC− group and 173 (17.2%) died in the RBC+ group. The hazard ratio for the RBC+ group versus the RBC− group was 1.00 (95% confidence interval, 0.79–1.25; P = .969). The number of revascularizations was 96 (9.9%) and 125 (10.6%), respectively, with a hazard ratio of 1.21 (95% confidence interval, 0.92–1.58; P = .166) for the RBC+ group. Preoperative anemia was not a risk factor for postoperative mortality, even when patients were transfused. CONCLUSIONS:This PS-matched analysis does not provide evidence for an association of the transfusion of small volumes of leukocyte-depleted RBCs with an increased postoperative mortality in cardiac surgical patients. Moreover, preoperative anemia could not be identified as a risk factor for increased postoperative mortality. Accepted for publication September 6, 2017. Funding: This work was supported by the Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Ruhr-University of Bochum, Germany. The authors declare no conflicts of interest. The first two authors contributed equally to this study. Reprints will not be available from the authors. Address correspondence to Armin Zittermann, PhD, Clinic for Thoracic and Cardiovascular Surgery, Herz- und Diabeteszentrum NRW, Ruhr-University of Bochum, Georgstr 11, D-32545 Bad Oeynhausen, Germany. Address e-mail to azittermann@hdz-nrw.de. © 2017 International Anesthesia Research Society

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Patients’ Perspectives on the Impact of Genital Psoriasis: A Qualitative Study

Abstract

Introduction

Plaque psoriasis is a chronic skin disease where genital involvement is relatively common. Yet health care providers do not routinely evaluate psoriasis patients for genital involvement and patients do not readily initiate discussion of it.

Methods

A qualitative study of 20 US patients with dermatologist-confirmed genital psoriasis (GenPs) and self-reported moderate-to-severe GenPs at screening was conducted to identify key GenPs symptoms and their impacts on health-related quality of life (HRQoL).

Results

Patients had a mean age of 45 years, 55% were female, and patients had high rates of current/recent moderate-to-severe overall (65%) and genital (70%) psoriasis. Patients reported the following GenPs symptoms: genital itch (100%), discomfort (100%), redness (95%), stinging/burning (95%), pain (85%), and scaling (75%). Genital itching (40%) and stinging/burning (40%) were the most bothersome symptoms. Impacts on sexual health included impaired sexual experience during sexual activity (80%), worsening of symptoms after sexual activity (80%), decreased frequency of sexual activity (80%), avoidance of sexual relationships (75%), and reduced sexual desire (55%). Negative effects on sexual experience encompassed physical effects such as mechanical friction, cracking, and pain as well as psychosocial effects such as embarrassment and feeling stigmatized. Males reported a higher burden of symptoms and sexual impacts. Other HRQoL impacts were on mood/emotion (95%), physical activities (70%), daily activities (60%), and relationships with friends and family (45%). These impacts significantly affected daily activities. Physical activities were affected by symptoms and flares, and increased sweat and friction worsened symptoms. Patients reported daily practices to control outcomes.

Conclusion

The high level of reported symptoms and sexual and nonsexual impacts reflects the potential burden of moderate-to-severe GenPs. GenPs can impact many facets of HRQoL and providers should evaluate their patients for the presence of genital psoriasis and its impact on their quality of life.

Funding

Eli Lilly and Company.

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Clinical Thyroidology for the Public – Highlighted Article

From Clinical Thyroidology for the Public: There has been a steady rise of thyroid cancers over the past several decades. Some of this is likely due to the increased use of imaging such as CT scans. However, it is likely that other factors play a role as well, including chemicals in our environment. Read More….

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