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American Society of Anesthesiologists (ASA): Annual Meeting
Platelet inhibition test helps predict surgical bleeding
SAN FRANCISCO – Preoperative light transmission aggregometry assessments of platelet aggregation may help identify which patients on dual antiplatelet therapy are at greater risk of sustained bleeding from noncardiac surgery, a prospective study of 147 consecutive patients suggests.
The light transmission aggregometry (LTA) assessments of blood drawn immediately before noncardiac surgery were significantly lower in the 32% of patients with sustained bleeding than in the other patients.
All patients were on dual antiplatelet therapy, 95% of them on maintenance therapy with aspirin plus clopidogrel. Timing of the surgery was at the discretion of the surgeons. Treating physicians were blinded to LTA results. The mean preoperative washout period for dual antiplatelet therapy was 1.5 days. Patients had vascular (76%), orthopedic (10%), abdominal (7%), or other (7%) surgery.
The ongoing study might help define a "bleeding cutoff" measure by LTA to better individualize the timing of surgery, Dr. Wolfgang Toller and his colleagues said in a poster session at the annual meeting of the American Society of Anesthesiologists.
In general, approximately 5% of patients in their first year of dual antiplatelet therapy undergo noncardiac surgery, which creates a conundrum for management. Discontinuing dual antiplatelet therapy before noncardiac surgery has been associated with a 20% risk of major adverse cardiac events, but there’s a 20%-40% risk of moderate to severe bleeding if dual antiplatelet therapy is continued during noncardiac surgery, said Dr. Toller of the Medical University of Graz, Austria.
The 147 patients in the study underwent vascular surgery (76%), orthopedic surgery (10%), abdominal surgery (7%), or other surgical procedures (7%). All had been on P2Y12 receptor inhibitors within 7 days before surgery.
Investigators used the Chronolog 700 Lumi-Aggregometer to assess platelet aggregation in preoperative blood, using 5 mcm of adenosine diphosphate as the specific inductor for platelet aggregation.
Overall, they found an average 40% maximum change in light transmission from baseline after adding the adenosine diphosphate to blood samples. In patients with increased bleeding, however, the mean maximum change in light transmission was approximately 30% (suggesting less platelet aggregation), compared with a more than 40% change in patients who bled less from the surgery.
Dr. Toller reported having no financial disclosures.
Surgery adds risk of perioperative bleeding
Dr. Lary Robinson, FCCP, comments: The vast majority of patients on dual platelet therapy (aspirin plus another agent such as clopidogrel) have had implantation of a drug-eluting coronary stent, who need to remain on this regimen for 1 year, after which it may be safely reduced to aspirin alone in most cases. In this first year, urgent surgery, such as that needed for cancer, as well as vascular surgery for ischemia or trauma, comes with the added risk of significant perioperative bleeding.
Anesthesiologists Wolfgang Toller and associates describe using the in vitro platelet function test, called light transmission aggregometry, in 147 patients. When used just prior to surgery, the test was somewhat predictive of which patients were at elevated bleeding risk. They propose that this test may better define and individualize the timing of surgery. However, the differences in test results are small and recommendations are not yet definite. Nevertheless, refinements in testing may lead to more specific recommendations about which patients should have surgery postponed due to a much greater bleeding risk.
Dr. Lary Robinson, FCCP, comments: The vast majority of patients on dual platelet therapy (aspirin plus another agent such as clopidogrel) have had implantation of a drug-eluting coronary stent, who need to remain on this regimen for 1 year, after which it may be safely reduced to aspirin alone in most cases. In this first year, urgent surgery, such as that needed for cancer, as well as vascular surgery for ischemia or trauma, comes with the added risk of significant perioperative bleeding.
Anesthesiologists Wolfgang Toller and associates describe using the in vitro platelet function test, called light transmission aggregometry, in 147 patients. When used just prior to surgery, the test was somewhat predictive of which patients were at elevated bleeding risk. They propose that this test may better define and individualize the timing of surgery. However, the differences in test results are small and recommendations are not yet definite. Nevertheless, refinements in testing may lead to more specific recommendations about which patients should have surgery postponed due to a much greater bleeding risk.
Dr. Lary Robinson, FCCP, comments: The vast majority of patients on dual platelet therapy (aspirin plus another agent such as clopidogrel) have had implantation of a drug-eluting coronary stent, who need to remain on this regimen for 1 year, after which it may be safely reduced to aspirin alone in most cases. In this first year, urgent surgery, such as that needed for cancer, as well as vascular surgery for ischemia or trauma, comes with the added risk of significant perioperative bleeding.
Anesthesiologists Wolfgang Toller and associates describe using the in vitro platelet function test, called light transmission aggregometry, in 147 patients. When used just prior to surgery, the test was somewhat predictive of which patients were at elevated bleeding risk. They propose that this test may better define and individualize the timing of surgery. However, the differences in test results are small and recommendations are not yet definite. Nevertheless, refinements in testing may lead to more specific recommendations about which patients should have surgery postponed due to a much greater bleeding risk.
Dr. Lary Robinson, FCCP, comments: The vast majority of patients on dual platelet therapy (aspirin plus another agent such as clopidogrel) have had implantation of a drug-eluting coronary stent, who need to remain on this regimen for 1 year, after which it may be safely reduced to aspirin alone in most cases. In this first year, urgent surgery, such as that needed for cancer, as well as vascular surgery for ischemia or trauma, comes with the added risk of significant perioperative bleeding.
Anesthesiologists Wolfgang Toller and associates describe using the in vitro platelet function test, called light transmission aggregometry, in 147 patients. When used just prior to surgery, the test was somewhat predictive of which patients were at elevated bleeding risk. They propose that this test may better define and individualize the timing of surgery. However, the differences in test results are small and recommendations are not yet definite. Nevertheless, refinements in testing may lead to more specific recommendations about which patients should have surgery postponed due to a much greater bleeding risk.
SAN FRANCISCO – Preoperative light transmission aggregometry assessments of platelet aggregation may help identify which patients on dual antiplatelet therapy are at greater risk of sustained bleeding from noncardiac surgery, a prospective study of 147 consecutive patients suggests.
The light transmission aggregometry (LTA) assessments of blood drawn immediately before noncardiac surgery were significantly lower in the 32% of patients with sustained bleeding than in the other patients.
All patients were on dual antiplatelet therapy, 95% of them on maintenance therapy with aspirin plus clopidogrel. Timing of the surgery was at the discretion of the surgeons. Treating physicians were blinded to LTA results. The mean preoperative washout period for dual antiplatelet therapy was 1.5 days. Patients had vascular (76%), orthopedic (10%), abdominal (7%), or other (7%) surgery.
The ongoing study might help define a "bleeding cutoff" measure by LTA to better individualize the timing of surgery, Dr. Wolfgang Toller and his colleagues said in a poster session at the annual meeting of the American Society of Anesthesiologists.
In general, approximately 5% of patients in their first year of dual antiplatelet therapy undergo noncardiac surgery, which creates a conundrum for management. Discontinuing dual antiplatelet therapy before noncardiac surgery has been associated with a 20% risk of major adverse cardiac events, but there’s a 20%-40% risk of moderate to severe bleeding if dual antiplatelet therapy is continued during noncardiac surgery, said Dr. Toller of the Medical University of Graz, Austria.
The 147 patients in the study underwent vascular surgery (76%), orthopedic surgery (10%), abdominal surgery (7%), or other surgical procedures (7%). All had been on P2Y12 receptor inhibitors within 7 days before surgery.
Investigators used the Chronolog 700 Lumi-Aggregometer to assess platelet aggregation in preoperative blood, using 5 mcm of adenosine diphosphate as the specific inductor for platelet aggregation.
Overall, they found an average 40% maximum change in light transmission from baseline after adding the adenosine diphosphate to blood samples. In patients with increased bleeding, however, the mean maximum change in light transmission was approximately 30% (suggesting less platelet aggregation), compared with a more than 40% change in patients who bled less from the surgery.
Dr. Toller reported having no financial disclosures.
Surgery adds risk of perioperative bleeding
Dr. Lary Robinson, FCCP, comments: The vast majority of patients on dual platelet therapy (aspirin plus another agent such as clopidogrel) have had implantation of a drug-eluting coronary stent, who need to remain on this regimen for 1 year, after which it may be safely reduced to aspirin alone in most cases. In this first year, urgent surgery, such as that needed for cancer, as well as vascular surgery for ischemia or trauma, comes with the added risk of significant perioperative bleeding.
Anesthesiologists Wolfgang Toller and associates describe using the in vitro platelet function test, called light transmission aggregometry, in 147 patients. When used just prior to surgery, the test was somewhat predictive of which patients were at elevated bleeding risk. They propose that this test may better define and individualize the timing of surgery. However, the differences in test results are small and recommendations are not yet definite. Nevertheless, refinements in testing may lead to more specific recommendations about which patients should have surgery postponed due to a much greater bleeding risk.
SAN FRANCISCO – Preoperative light transmission aggregometry assessments of platelet aggregation may help identify which patients on dual antiplatelet therapy are at greater risk of sustained bleeding from noncardiac surgery, a prospective study of 147 consecutive patients suggests.
The light transmission aggregometry (LTA) assessments of blood drawn immediately before noncardiac surgery were significantly lower in the 32% of patients with sustained bleeding than in the other patients.
All patients were on dual antiplatelet therapy, 95% of them on maintenance therapy with aspirin plus clopidogrel. Timing of the surgery was at the discretion of the surgeons. Treating physicians were blinded to LTA results. The mean preoperative washout period for dual antiplatelet therapy was 1.5 days. Patients had vascular (76%), orthopedic (10%), abdominal (7%), or other (7%) surgery.
The ongoing study might help define a "bleeding cutoff" measure by LTA to better individualize the timing of surgery, Dr. Wolfgang Toller and his colleagues said in a poster session at the annual meeting of the American Society of Anesthesiologists.
In general, approximately 5% of patients in their first year of dual antiplatelet therapy undergo noncardiac surgery, which creates a conundrum for management. Discontinuing dual antiplatelet therapy before noncardiac surgery has been associated with a 20% risk of major adverse cardiac events, but there’s a 20%-40% risk of moderate to severe bleeding if dual antiplatelet therapy is continued during noncardiac surgery, said Dr. Toller of the Medical University of Graz, Austria.
The 147 patients in the study underwent vascular surgery (76%), orthopedic surgery (10%), abdominal surgery (7%), or other surgical procedures (7%). All had been on P2Y12 receptor inhibitors within 7 days before surgery.
Investigators used the Chronolog 700 Lumi-Aggregometer to assess platelet aggregation in preoperative blood, using 5 mcm of adenosine diphosphate as the specific inductor for platelet aggregation.
Overall, they found an average 40% maximum change in light transmission from baseline after adding the adenosine diphosphate to blood samples. In patients with increased bleeding, however, the mean maximum change in light transmission was approximately 30% (suggesting less platelet aggregation), compared with a more than 40% change in patients who bled less from the surgery.
Dr. Toller reported having no financial disclosures.
Surgery adds risk of perioperative bleeding
Dr. Lary Robinson, FCCP, comments: The vast majority of patients on dual platelet therapy (aspirin plus another agent such as clopidogrel) have had implantation of a drug-eluting coronary stent, who need to remain on this regimen for 1 year, after which it may be safely reduced to aspirin alone in most cases. In this first year, urgent surgery, such as that needed for cancer, as well as vascular surgery for ischemia or trauma, comes with the added risk of significant perioperative bleeding.
Anesthesiologists Wolfgang Toller and associates describe using the in vitro platelet function test, called light transmission aggregometry, in 147 patients. When used just prior to surgery, the test was somewhat predictive of which patients were at elevated bleeding risk. They propose that this test may better define and individualize the timing of surgery. However, the differences in test results are small and recommendations are not yet definite. Nevertheless, refinements in testing may lead to more specific recommendations about which patients should have surgery postponed due to a much greater bleeding risk.
Major finding: The mean maximum change in light transmission on LTA assessment of preoperative blood was approximately 30% in patients with increased bleeding from surgery, significantly lower than the more than 40% change in those who bled less.
Data source: Prospective study of 147 patients on dual antiplatelet therapy who underwent noncardiac surgery at one institution.
Disclosures: Dr. Toller reported having no financial disclosures.
Fistula risk quadrupled with hyperthermia during pancreaticoduodenectomy
SAN FRANCISCO – A patient body temperature higher than 99.5° F (37.5° C) at the end of elective pancreaticoduodenectomy predicted a fourfold increased risk of postoperative pancreatic fistula in a retrospective study of 123 patients.
Two factors independently predicted a significantly increased risk for postoperative pancreatic fistula in a multivariate logistic regression analysis – body temperature at the end of surgery and a soft pancreatic texture (which conferred a 34-fold increase in risk), Dr. Tadashi Tanioku and his associates.
It wasn’t clear whether pancreatic fistula caused the intraoperative elevated body temperature or the hyperthermia contributed to postoperative development of fistula, but the findings suggest that body temperature at the conclusion of surgery may provide a clue to a patient’s risk of postoperative pancreatic fistula, said Dr. Tanioku of Wakayama (Japan) Medical University.
The study included all patients who underwent pancreaticoduodenectomy for benign or malignant diseases in the pancreatic head and the periampullary region during a 2-year period at his hospital. Thirty-six percent developed postoperative pancreatic fistulas, the investigators reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In a univariate logistic regression analysis, significant predictors for postoperative pancreatic fistula included a body temperature higher than 99.5 degrees Fahrenheit in 45% of patients, soft pancreatic texture in 52%, and a pancreatic duct diameter less than 3 mm in 43% of patients. Having a body mass index greater than 25 kg/m2 (in 17% of patients) was not a significant predictor).
Previous studies have reported an association between hyperthermia on postoperative day 3 after pancreaticoduodenectomy and the development of postoperative pancreatic fistula. Other data have shown an association between intraoperative hyperthermia during colorectal surgery and increased risk of postoperative anastomotic leakage.
In general, operative mortality after pancreaticoduodenectomy had declined to less than 5% but postoperative morality rates are still 40%-50%, mainly from postoperative pancreatic fistula, Dr. Tanioku said.
Patients who developed pancreatic fistula were significantly younger than those who didn’t (a mean of 68 vs. 72 years, respectively) and were significantly more likely to have a main pancreatic duct diameter less than 3 mm (59% vs. 30%, respectively). Fifty-nine percent of patients who developed postoperative fistulas and 37% of those who didn’t had a body temperature higher than 99.5° F at the end of surgery. Eighty-six percent of patients who went on to develop fistulas and 29% of those who didn’t had a soft pancreatic texture.
Dr. Tanioku reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – A patient body temperature higher than 99.5° F (37.5° C) at the end of elective pancreaticoduodenectomy predicted a fourfold increased risk of postoperative pancreatic fistula in a retrospective study of 123 patients.
Two factors independently predicted a significantly increased risk for postoperative pancreatic fistula in a multivariate logistic regression analysis – body temperature at the end of surgery and a soft pancreatic texture (which conferred a 34-fold increase in risk), Dr. Tadashi Tanioku and his associates.
It wasn’t clear whether pancreatic fistula caused the intraoperative elevated body temperature or the hyperthermia contributed to postoperative development of fistula, but the findings suggest that body temperature at the conclusion of surgery may provide a clue to a patient’s risk of postoperative pancreatic fistula, said Dr. Tanioku of Wakayama (Japan) Medical University.
The study included all patients who underwent pancreaticoduodenectomy for benign or malignant diseases in the pancreatic head and the periampullary region during a 2-year period at his hospital. Thirty-six percent developed postoperative pancreatic fistulas, the investigators reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In a univariate logistic regression analysis, significant predictors for postoperative pancreatic fistula included a body temperature higher than 99.5 degrees Fahrenheit in 45% of patients, soft pancreatic texture in 52%, and a pancreatic duct diameter less than 3 mm in 43% of patients. Having a body mass index greater than 25 kg/m2 (in 17% of patients) was not a significant predictor).
Previous studies have reported an association between hyperthermia on postoperative day 3 after pancreaticoduodenectomy and the development of postoperative pancreatic fistula. Other data have shown an association between intraoperative hyperthermia during colorectal surgery and increased risk of postoperative anastomotic leakage.
In general, operative mortality after pancreaticoduodenectomy had declined to less than 5% but postoperative morality rates are still 40%-50%, mainly from postoperative pancreatic fistula, Dr. Tanioku said.
Patients who developed pancreatic fistula were significantly younger than those who didn’t (a mean of 68 vs. 72 years, respectively) and were significantly more likely to have a main pancreatic duct diameter less than 3 mm (59% vs. 30%, respectively). Fifty-nine percent of patients who developed postoperative fistulas and 37% of those who didn’t had a body temperature higher than 99.5° F at the end of surgery. Eighty-six percent of patients who went on to develop fistulas and 29% of those who didn’t had a soft pancreatic texture.
Dr. Tanioku reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – A patient body temperature higher than 99.5° F (37.5° C) at the end of elective pancreaticoduodenectomy predicted a fourfold increased risk of postoperative pancreatic fistula in a retrospective study of 123 patients.
Two factors independently predicted a significantly increased risk for postoperative pancreatic fistula in a multivariate logistic regression analysis – body temperature at the end of surgery and a soft pancreatic texture (which conferred a 34-fold increase in risk), Dr. Tadashi Tanioku and his associates.
It wasn’t clear whether pancreatic fistula caused the intraoperative elevated body temperature or the hyperthermia contributed to postoperative development of fistula, but the findings suggest that body temperature at the conclusion of surgery may provide a clue to a patient’s risk of postoperative pancreatic fistula, said Dr. Tanioku of Wakayama (Japan) Medical University.
The study included all patients who underwent pancreaticoduodenectomy for benign or malignant diseases in the pancreatic head and the periampullary region during a 2-year period at his hospital. Thirty-six percent developed postoperative pancreatic fistulas, the investigators reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In a univariate logistic regression analysis, significant predictors for postoperative pancreatic fistula included a body temperature higher than 99.5 degrees Fahrenheit in 45% of patients, soft pancreatic texture in 52%, and a pancreatic duct diameter less than 3 mm in 43% of patients. Having a body mass index greater than 25 kg/m2 (in 17% of patients) was not a significant predictor).
Previous studies have reported an association between hyperthermia on postoperative day 3 after pancreaticoduodenectomy and the development of postoperative pancreatic fistula. Other data have shown an association between intraoperative hyperthermia during colorectal surgery and increased risk of postoperative anastomotic leakage.
In general, operative mortality after pancreaticoduodenectomy had declined to less than 5% but postoperative morality rates are still 40%-50%, mainly from postoperative pancreatic fistula, Dr. Tanioku said.
Patients who developed pancreatic fistula were significantly younger than those who didn’t (a mean of 68 vs. 72 years, respectively) and were significantly more likely to have a main pancreatic duct diameter less than 3 mm (59% vs. 30%, respectively). Fifty-nine percent of patients who developed postoperative fistulas and 37% of those who didn’t had a body temperature higher than 99.5° F at the end of surgery. Eighty-six percent of patients who went on to develop fistulas and 29% of those who didn’t had a soft pancreatic texture.
Dr. Tanioku reported having no financial disclosures.
On Twitter @sherryboschert
AT THE ASA ANNUAL MEETING
Major finding: The likelihood of postoperative pancreatic fistula quadrupled in patients with a body temperature higher than 99.5 degrees F at the end of pancreaticoduodenectomy.
Data source: Retrospective study of 123 patients undergoing elective pancreaticoduodenectomy at one hospital.
Disclosures: Dr. Tanioku reported having no financial disclosures.
Simulations may improve intraoperative handoffs
SAN FRANCISCO – A 1-day course with simulated intraoperative handoffs improved the rate of failed communications from 30% before the course to 17% immediately after the course, with a further improvement 1 year later to a 13% failure rate in a study of 10 anesthesiology residents.
The course combined simulation-based education, which has been used previously to train residents on postoperative handoffs, and deliberate practice, an educational strategy that has been used previously to teach technical skills to residents. Each resident in the study performed a simulated intraoperative handoff, followed by a debriefing with the whole group and individual feedback on the handoff performance. Participants together discussed barriers to effective communication and created an intraoperative handoff checklist. Each resident then repeated a simulated handoff to practice with the checklist.
One year later, 7 of the 10 residents did another simulated intraoperative handoff that was recorded on video and scored by trained raters using a handoff assessment tool to characterize the type and frequency of communication failures.
Before the course, none of the 10 residents knew the Joint Commission definition of a handoff, and none knew that patient handoff communication was a patient safety goal of the Joint Commission. A year later, all seven residents could accurately define the Joint Commission goal, Dr. Erin W. Pukenas reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
At the beginning of the course, residents had set individual communication goals for handoffs. Forty-six percent said they wanted to develop a more systematic approach to their handoffs, and 31% wanted to be more thorough in their handoffs. A year later, all residents said they had met or exceeded their goals, reported Dr. Pukenas of Rowan University, Camden, N.J.
The study was the first to assess retention of knowledge and skills 1 year after the course was added to the curriculum, she said.
Investigators may next study the effects of simulation-based handoff education and deliberate practice on handoff communications in clinical settings, she said.
The Accreditation Council for Graduate Medical Education requires handoff training for all medical residents.
Dr. Pukenas reported having no relevant financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – A 1-day course with simulated intraoperative handoffs improved the rate of failed communications from 30% before the course to 17% immediately after the course, with a further improvement 1 year later to a 13% failure rate in a study of 10 anesthesiology residents.
The course combined simulation-based education, which has been used previously to train residents on postoperative handoffs, and deliberate practice, an educational strategy that has been used previously to teach technical skills to residents. Each resident in the study performed a simulated intraoperative handoff, followed by a debriefing with the whole group and individual feedback on the handoff performance. Participants together discussed barriers to effective communication and created an intraoperative handoff checklist. Each resident then repeated a simulated handoff to practice with the checklist.
One year later, 7 of the 10 residents did another simulated intraoperative handoff that was recorded on video and scored by trained raters using a handoff assessment tool to characterize the type and frequency of communication failures.
Before the course, none of the 10 residents knew the Joint Commission definition of a handoff, and none knew that patient handoff communication was a patient safety goal of the Joint Commission. A year later, all seven residents could accurately define the Joint Commission goal, Dr. Erin W. Pukenas reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
At the beginning of the course, residents had set individual communication goals for handoffs. Forty-six percent said they wanted to develop a more systematic approach to their handoffs, and 31% wanted to be more thorough in their handoffs. A year later, all residents said they had met or exceeded their goals, reported Dr. Pukenas of Rowan University, Camden, N.J.
The study was the first to assess retention of knowledge and skills 1 year after the course was added to the curriculum, she said.
Investigators may next study the effects of simulation-based handoff education and deliberate practice on handoff communications in clinical settings, she said.
The Accreditation Council for Graduate Medical Education requires handoff training for all medical residents.
Dr. Pukenas reported having no relevant financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – A 1-day course with simulated intraoperative handoffs improved the rate of failed communications from 30% before the course to 17% immediately after the course, with a further improvement 1 year later to a 13% failure rate in a study of 10 anesthesiology residents.
The course combined simulation-based education, which has been used previously to train residents on postoperative handoffs, and deliberate practice, an educational strategy that has been used previously to teach technical skills to residents. Each resident in the study performed a simulated intraoperative handoff, followed by a debriefing with the whole group and individual feedback on the handoff performance. Participants together discussed barriers to effective communication and created an intraoperative handoff checklist. Each resident then repeated a simulated handoff to practice with the checklist.
One year later, 7 of the 10 residents did another simulated intraoperative handoff that was recorded on video and scored by trained raters using a handoff assessment tool to characterize the type and frequency of communication failures.
Before the course, none of the 10 residents knew the Joint Commission definition of a handoff, and none knew that patient handoff communication was a patient safety goal of the Joint Commission. A year later, all seven residents could accurately define the Joint Commission goal, Dr. Erin W. Pukenas reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
At the beginning of the course, residents had set individual communication goals for handoffs. Forty-six percent said they wanted to develop a more systematic approach to their handoffs, and 31% wanted to be more thorough in their handoffs. A year later, all residents said they had met or exceeded their goals, reported Dr. Pukenas of Rowan University, Camden, N.J.
The study was the first to assess retention of knowledge and skills 1 year after the course was added to the curriculum, she said.
Investigators may next study the effects of simulation-based handoff education and deliberate practice on handoff communications in clinical settings, she said.
The Accreditation Council for Graduate Medical Education requires handoff training for all medical residents.
Dr. Pukenas reported having no relevant financial disclosures.
On Twitter @sherryboschert
AT THE ASA ANNUAL MEETING
Major finding: The rate of communication failures during simulated intraoperative handoffs decreased from 30% before the course to 17% at course completion and to 13% a year later.
Data source: A prospective study of 10 residents who took a 1-day course on intraoperative handoffs that combined simulations and deliberate practice techniques, 7 of whom repeated a simulated handoff a year later.
Disclosures: Dr. Pukenas reported having no relevant financial disclosures.
Point/Counterpoint – Are SCIP measures efficacious?
POINT: SCIP is both efficacious and effective.
The Surgical Care Improvement Project (SCIP) was a national campaign that set out to reduce surgical mortality and morbidity by 25% by 2010 through recommendations in targeted areas: wound infections, perioperative MIs, and venous thromboembolism. The recommendations have become pay-for-performance measures. There are seven in the area of infectious disease to reduce surgical site infections. There is one measure for reducing perioperative MI: Continue beta-blockers (for patients who are on them) in the perioperative period. For venous thromboembolism prevention, give prophylaxis within 24 hours before to 24 hours after surgery.
It’s key to understand the difference between efficacy and effectiveness. I think we would all agree that the SCIP measures have efficacy. Efficacy trials determine whether an intervention produces the expected result under ideal circumstances. Effectiveness trials measure the degree of beneficial effect under "real world" clinical conditions. The problem with effectiveness trials is that those real-world conditions may change the effect, or they might just change the ability to measure the effect.
I believe that the SCIP measures have proven efficacy because they all are based upon randomized controlled trials that were identified by systematic reviews amenable to meta-analysis. All of these measures are Level 1 recommendations, based on the highest forms of evidence. The studies that Dr. Barash uses to criticize SCIP measures are cohort studies. They do not randomize. There may be unknown confounding variables.
There have been effectiveness trials that show that the SCIP measures do work. One showed a 27% decrease in surgical site infections, another showed a 62% decrease in surgical site infections, and a third showed a 39% decrease in surgical site infections.
Perhaps the strongest endorsement of efficacy of the SCIP measures comes from Dr. Kaveh G. Shojania, who has written several reviews of the efficacy of medical interventions. This guy is like Mikey from the old Life cereal commercials ... he hates everything. He said there were 11 patient safety practices rated most highly in terms of strength of the evidence, and 3 are SCIP measures: appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk, use of perioperative beta-blockers in appropriate patients, and appropriate use of antibiotic prophylaxis in surgical patients (AHRQ Publication No. 01-E058).
Several trials published by pretty good researchers in reputable journals show a lack of effectiveness of SCIP measures. Even those researchers admit to the efficacy of SCIP measures. The lead investigator of the best effectiveness trial, a retrospective cohort study, wrote, "There are several explanations as to why we did not observe an association between timely antibiotic administration and surgical site infection (SSI). The first is that timely antibiotic administration does not diminish SSI risk. This is an unlikely interpretation. There are numerous randomized controlled trials and observational studies that demonstrate the efficacy of prophylactic antibiotics in reducing SSI for various surgical procedures" (Ann. Surg. 2011;254:494-9).
A separate retrospective cohort study showed a decrease in surgical site infection only if two or more SCIP recommendations were followed (JAMA 2010;303:2479-85). Shocking – if you give the wrong antibiotic at the right time, it might not work.
Another retrospective cohort study found no association with adjusted complications and SCIP compliance. Hospitals in the lowest compliance group had patients in lower-income ZIP codes and lower unadjusted complication rates. So, poor people go home and don’t come back, perhaps because of payment considerations. The study didn’t have enough patients; it also used measures that don’t apply to SCIP (Arch. Surg. 2010;145:999-1004).
SCIP did not design these measures for pay-for-performance programs. The intent was to decrease perioperative complications by 25% by 2010. When you start changing the baseline with pay-for-performance, it doesn’t work. In a study by Hawkins et al., the authors tested the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect adherence to guidelines as intended. In a 7-week observational study of elective pediatric surgical cases, adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases in which antibiotic prophylaxis was indicated, compliance was documented in 100% of cases in the electronic medical record; but only 48% of cases adhered to all five guidelines. Lack of adherence was due primarily to dosing or timing errors.
The SCIP measures, however, are based on best evidence. They are tightly linked with the desired outcomes. They are measurable and effectible, as demonstrated in multiple randomized controlled trials. Studies of effectiveness have had variable results due to methodological flaws.
Dr. Lagasse is a professor of anesthesiology and director of quality management at the Yale School of Medicine, New Haven, Conn. He is on the steering committee for the Surgical Care Improvement Project. He reported having no financial disclosures.
COUNTERPOINT: Studies have not shown effectiveness.
When it was created, SCIP did not reflect reality. SCIP started at the U.S. Department of Veterans Affairs, which conducted a 10-year study. They found a 25% relative risk reduction, but that was only a 0.8% absolute risk reduction for the incidence of complications, a drop from about 3.1% to about 2.3% (Arch. Surg. 2002;137:20-27).
It would be great to have randomized controlled trials on the effectiveness of SCIP, but it’s not happening. We’re going to have to go by high-fidelity observational trials, which according to a number of researchers in the field have the same impact as randomized controlled trials.
One study of 35,543 patients in 44 hospitals found a whopping 27% reduction in surgical site infections, but that was only a 0.6% absolute reduction, from about 2.5% to about 1.9% (Am. J. Surg. 2005;190:9-15). There was no significant difference between groups.
Another study showed improved compliance with SCIP measures, but no change in surgical site infection rate (Dis. Colon Rectum 2010;53:24-30). This is the theme in study after study after study.
A 2008 study enrolled 9,195 patients undergoing colorectal, orthopedic, or vascular surgery and looked at SCIP compliance vs. surgical site infection. The SCIP rate correlated with the hospital case mix. If you look at the SCIP rate in terms of antibiotic timing, SCIP is not significant. The study basically showed that variables other than timely antibiotic administration are affecting surgical site infection rates (J. Am. Coll. Surg. 2008;206:814-19).
Hospital performance on process measures may not be a good marker of surgical site infection or the outcome we’re looking at, according to another study, which reported that unmeasured effects may have a larger impact than the measured effects (Health Serv. Res. 2008;43:1464-84).
There is a randomized controlled trial that randomized patients to strict control with the SCIP measures or routine treatment at the hospital. The SCIP-treated patients had nearly twice the incidence of surgical site infections as the patients receiving standard treatment. The authors concluded that combining each of the SCIP factors into one big category doesn’t necessarily work (Arch. Surg. 2011;146:263-9).
Should we be evaluating outcome measures with performance measures (e.g., percent timely antibiotic administration) to determine whether they work or not? One editorial evaluated eight articles with data on 31,448 patients, looking just at antibiotic administration within 1 hour of surgery, a SCIP measure. It found a higher infection rate if antibiotics were administered within 30 minutes of incision (JAMA 2010;303:2527-2528).
There was no significant difference in another study between standard of care and SCIP for venous thromboembolism (Am. J. Surg. 2012;204:591-97). The authors wrote that there is no convincing evidence that improvements in compliance are associated with better outcomes. We see this time and time again.
When people find that SCIP is not working, they turn to other measures to reduce surgical site infection. The Comprehensive Unit-based Safety Program (CUSP) is targeted at a specific problem that a specific hospital is having in managing infections. It’s not coming from Washington; it’s based at the hospital. One study showed that following CUSP, there was a significant reduction in surgical site infections despite the fact that previous to that there was 95% compliance with SCIP standards (J. Am. Coll. Surg. 2012;215:193-200). SCIP was working, but it wasn’t affecting outcome.
Dr. Lagasse and I interpret one key study very differently. He abstracts a sentence from a Limitations section of the study and makes a sweeping generalization out of context. But the study showed no relationship between facility adherence to SCIP and the surgical site infection rate. The authors concluded, "Policies regarding continued SCIP measurement and reporting should be reassessed" (Ann. Surg. 2011;254:494-99).
The largest SCIP study to date from a single entity involved 32,459 patients in the Veterans Affairs medical system. Overall, antibiotics were administered within 28 minutes of surgical incision. Once they adjusted for confounders, they found no significant relationship between surgical site infection and the SCIP measures (JAMA 2013;148:649-57). No one has proven that giving antibiotics within 60 minutes of surgical incision gives you a lower infection rate.
SCIP measures divert resources and divert clinical care. They obscure the nuances of care. They may harm the hospital and the provider, and they raise unnecessary legal risk if an antibiotic is not given within 60 minutes of incision.
Dr. Barash is a professor of anesthesiology at Yale University, New Haven, Conn. He reported having no financial disclosures.
These are excerpts from a debate at the annual meeting of the American Society of Anesthesiologists.
POINT: SCIP is both efficacious and effective.
The Surgical Care Improvement Project (SCIP) was a national campaign that set out to reduce surgical mortality and morbidity by 25% by 2010 through recommendations in targeted areas: wound infections, perioperative MIs, and venous thromboembolism. The recommendations have become pay-for-performance measures. There are seven in the area of infectious disease to reduce surgical site infections. There is one measure for reducing perioperative MI: Continue beta-blockers (for patients who are on them) in the perioperative period. For venous thromboembolism prevention, give prophylaxis within 24 hours before to 24 hours after surgery.
It’s key to understand the difference between efficacy and effectiveness. I think we would all agree that the SCIP measures have efficacy. Efficacy trials determine whether an intervention produces the expected result under ideal circumstances. Effectiveness trials measure the degree of beneficial effect under "real world" clinical conditions. The problem with effectiveness trials is that those real-world conditions may change the effect, or they might just change the ability to measure the effect.
I believe that the SCIP measures have proven efficacy because they all are based upon randomized controlled trials that were identified by systematic reviews amenable to meta-analysis. All of these measures are Level 1 recommendations, based on the highest forms of evidence. The studies that Dr. Barash uses to criticize SCIP measures are cohort studies. They do not randomize. There may be unknown confounding variables.
There have been effectiveness trials that show that the SCIP measures do work. One showed a 27% decrease in surgical site infections, another showed a 62% decrease in surgical site infections, and a third showed a 39% decrease in surgical site infections.
Perhaps the strongest endorsement of efficacy of the SCIP measures comes from Dr. Kaveh G. Shojania, who has written several reviews of the efficacy of medical interventions. This guy is like Mikey from the old Life cereal commercials ... he hates everything. He said there were 11 patient safety practices rated most highly in terms of strength of the evidence, and 3 are SCIP measures: appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk, use of perioperative beta-blockers in appropriate patients, and appropriate use of antibiotic prophylaxis in surgical patients (AHRQ Publication No. 01-E058).
Several trials published by pretty good researchers in reputable journals show a lack of effectiveness of SCIP measures. Even those researchers admit to the efficacy of SCIP measures. The lead investigator of the best effectiveness trial, a retrospective cohort study, wrote, "There are several explanations as to why we did not observe an association between timely antibiotic administration and surgical site infection (SSI). The first is that timely antibiotic administration does not diminish SSI risk. This is an unlikely interpretation. There are numerous randomized controlled trials and observational studies that demonstrate the efficacy of prophylactic antibiotics in reducing SSI for various surgical procedures" (Ann. Surg. 2011;254:494-9).
A separate retrospective cohort study showed a decrease in surgical site infection only if two or more SCIP recommendations were followed (JAMA 2010;303:2479-85). Shocking – if you give the wrong antibiotic at the right time, it might not work.
Another retrospective cohort study found no association with adjusted complications and SCIP compliance. Hospitals in the lowest compliance group had patients in lower-income ZIP codes and lower unadjusted complication rates. So, poor people go home and don’t come back, perhaps because of payment considerations. The study didn’t have enough patients; it also used measures that don’t apply to SCIP (Arch. Surg. 2010;145:999-1004).
SCIP did not design these measures for pay-for-performance programs. The intent was to decrease perioperative complications by 25% by 2010. When you start changing the baseline with pay-for-performance, it doesn’t work. In a study by Hawkins et al., the authors tested the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect adherence to guidelines as intended. In a 7-week observational study of elective pediatric surgical cases, adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases in which antibiotic prophylaxis was indicated, compliance was documented in 100% of cases in the electronic medical record; but only 48% of cases adhered to all five guidelines. Lack of adherence was due primarily to dosing or timing errors.
The SCIP measures, however, are based on best evidence. They are tightly linked with the desired outcomes. They are measurable and effectible, as demonstrated in multiple randomized controlled trials. Studies of effectiveness have had variable results due to methodological flaws.
Dr. Lagasse is a professor of anesthesiology and director of quality management at the Yale School of Medicine, New Haven, Conn. He is on the steering committee for the Surgical Care Improvement Project. He reported having no financial disclosures.
COUNTERPOINT: Studies have not shown effectiveness.
When it was created, SCIP did not reflect reality. SCIP started at the U.S. Department of Veterans Affairs, which conducted a 10-year study. They found a 25% relative risk reduction, but that was only a 0.8% absolute risk reduction for the incidence of complications, a drop from about 3.1% to about 2.3% (Arch. Surg. 2002;137:20-27).
It would be great to have randomized controlled trials on the effectiveness of SCIP, but it’s not happening. We’re going to have to go by high-fidelity observational trials, which according to a number of researchers in the field have the same impact as randomized controlled trials.
One study of 35,543 patients in 44 hospitals found a whopping 27% reduction in surgical site infections, but that was only a 0.6% absolute reduction, from about 2.5% to about 1.9% (Am. J. Surg. 2005;190:9-15). There was no significant difference between groups.
Another study showed improved compliance with SCIP measures, but no change in surgical site infection rate (Dis. Colon Rectum 2010;53:24-30). This is the theme in study after study after study.
A 2008 study enrolled 9,195 patients undergoing colorectal, orthopedic, or vascular surgery and looked at SCIP compliance vs. surgical site infection. The SCIP rate correlated with the hospital case mix. If you look at the SCIP rate in terms of antibiotic timing, SCIP is not significant. The study basically showed that variables other than timely antibiotic administration are affecting surgical site infection rates (J. Am. Coll. Surg. 2008;206:814-19).
Hospital performance on process measures may not be a good marker of surgical site infection or the outcome we’re looking at, according to another study, which reported that unmeasured effects may have a larger impact than the measured effects (Health Serv. Res. 2008;43:1464-84).
There is a randomized controlled trial that randomized patients to strict control with the SCIP measures or routine treatment at the hospital. The SCIP-treated patients had nearly twice the incidence of surgical site infections as the patients receiving standard treatment. The authors concluded that combining each of the SCIP factors into one big category doesn’t necessarily work (Arch. Surg. 2011;146:263-9).
Should we be evaluating outcome measures with performance measures (e.g., percent timely antibiotic administration) to determine whether they work or not? One editorial evaluated eight articles with data on 31,448 patients, looking just at antibiotic administration within 1 hour of surgery, a SCIP measure. It found a higher infection rate if antibiotics were administered within 30 minutes of incision (JAMA 2010;303:2527-2528).
There was no significant difference in another study between standard of care and SCIP for venous thromboembolism (Am. J. Surg. 2012;204:591-97). The authors wrote that there is no convincing evidence that improvements in compliance are associated with better outcomes. We see this time and time again.
When people find that SCIP is not working, they turn to other measures to reduce surgical site infection. The Comprehensive Unit-based Safety Program (CUSP) is targeted at a specific problem that a specific hospital is having in managing infections. It’s not coming from Washington; it’s based at the hospital. One study showed that following CUSP, there was a significant reduction in surgical site infections despite the fact that previous to that there was 95% compliance with SCIP standards (J. Am. Coll. Surg. 2012;215:193-200). SCIP was working, but it wasn’t affecting outcome.
Dr. Lagasse and I interpret one key study very differently. He abstracts a sentence from a Limitations section of the study and makes a sweeping generalization out of context. But the study showed no relationship between facility adherence to SCIP and the surgical site infection rate. The authors concluded, "Policies regarding continued SCIP measurement and reporting should be reassessed" (Ann. Surg. 2011;254:494-99).
The largest SCIP study to date from a single entity involved 32,459 patients in the Veterans Affairs medical system. Overall, antibiotics were administered within 28 minutes of surgical incision. Once they adjusted for confounders, they found no significant relationship between surgical site infection and the SCIP measures (JAMA 2013;148:649-57). No one has proven that giving antibiotics within 60 minutes of surgical incision gives you a lower infection rate.
SCIP measures divert resources and divert clinical care. They obscure the nuances of care. They may harm the hospital and the provider, and they raise unnecessary legal risk if an antibiotic is not given within 60 minutes of incision.
Dr. Barash is a professor of anesthesiology at Yale University, New Haven, Conn. He reported having no financial disclosures.
These are excerpts from a debate at the annual meeting of the American Society of Anesthesiologists.
POINT: SCIP is both efficacious and effective.
The Surgical Care Improvement Project (SCIP) was a national campaign that set out to reduce surgical mortality and morbidity by 25% by 2010 through recommendations in targeted areas: wound infections, perioperative MIs, and venous thromboembolism. The recommendations have become pay-for-performance measures. There are seven in the area of infectious disease to reduce surgical site infections. There is one measure for reducing perioperative MI: Continue beta-blockers (for patients who are on them) in the perioperative period. For venous thromboembolism prevention, give prophylaxis within 24 hours before to 24 hours after surgery.
It’s key to understand the difference between efficacy and effectiveness. I think we would all agree that the SCIP measures have efficacy. Efficacy trials determine whether an intervention produces the expected result under ideal circumstances. Effectiveness trials measure the degree of beneficial effect under "real world" clinical conditions. The problem with effectiveness trials is that those real-world conditions may change the effect, or they might just change the ability to measure the effect.
I believe that the SCIP measures have proven efficacy because they all are based upon randomized controlled trials that were identified by systematic reviews amenable to meta-analysis. All of these measures are Level 1 recommendations, based on the highest forms of evidence. The studies that Dr. Barash uses to criticize SCIP measures are cohort studies. They do not randomize. There may be unknown confounding variables.
There have been effectiveness trials that show that the SCIP measures do work. One showed a 27% decrease in surgical site infections, another showed a 62% decrease in surgical site infections, and a third showed a 39% decrease in surgical site infections.
Perhaps the strongest endorsement of efficacy of the SCIP measures comes from Dr. Kaveh G. Shojania, who has written several reviews of the efficacy of medical interventions. This guy is like Mikey from the old Life cereal commercials ... he hates everything. He said there were 11 patient safety practices rated most highly in terms of strength of the evidence, and 3 are SCIP measures: appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk, use of perioperative beta-blockers in appropriate patients, and appropriate use of antibiotic prophylaxis in surgical patients (AHRQ Publication No. 01-E058).
Several trials published by pretty good researchers in reputable journals show a lack of effectiveness of SCIP measures. Even those researchers admit to the efficacy of SCIP measures. The lead investigator of the best effectiveness trial, a retrospective cohort study, wrote, "There are several explanations as to why we did not observe an association between timely antibiotic administration and surgical site infection (SSI). The first is that timely antibiotic administration does not diminish SSI risk. This is an unlikely interpretation. There are numerous randomized controlled trials and observational studies that demonstrate the efficacy of prophylactic antibiotics in reducing SSI for various surgical procedures" (Ann. Surg. 2011;254:494-9).
A separate retrospective cohort study showed a decrease in surgical site infection only if two or more SCIP recommendations were followed (JAMA 2010;303:2479-85). Shocking – if you give the wrong antibiotic at the right time, it might not work.
Another retrospective cohort study found no association with adjusted complications and SCIP compliance. Hospitals in the lowest compliance group had patients in lower-income ZIP codes and lower unadjusted complication rates. So, poor people go home and don’t come back, perhaps because of payment considerations. The study didn’t have enough patients; it also used measures that don’t apply to SCIP (Arch. Surg. 2010;145:999-1004).
SCIP did not design these measures for pay-for-performance programs. The intent was to decrease perioperative complications by 25% by 2010. When you start changing the baseline with pay-for-performance, it doesn’t work. In a study by Hawkins et al., the authors tested the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect adherence to guidelines as intended. In a 7-week observational study of elective pediatric surgical cases, adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases in which antibiotic prophylaxis was indicated, compliance was documented in 100% of cases in the electronic medical record; but only 48% of cases adhered to all five guidelines. Lack of adherence was due primarily to dosing or timing errors.
The SCIP measures, however, are based on best evidence. They are tightly linked with the desired outcomes. They are measurable and effectible, as demonstrated in multiple randomized controlled trials. Studies of effectiveness have had variable results due to methodological flaws.
Dr. Lagasse is a professor of anesthesiology and director of quality management at the Yale School of Medicine, New Haven, Conn. He is on the steering committee for the Surgical Care Improvement Project. He reported having no financial disclosures.
COUNTERPOINT: Studies have not shown effectiveness.
When it was created, SCIP did not reflect reality. SCIP started at the U.S. Department of Veterans Affairs, which conducted a 10-year study. They found a 25% relative risk reduction, but that was only a 0.8% absolute risk reduction for the incidence of complications, a drop from about 3.1% to about 2.3% (Arch. Surg. 2002;137:20-27).
It would be great to have randomized controlled trials on the effectiveness of SCIP, but it’s not happening. We’re going to have to go by high-fidelity observational trials, which according to a number of researchers in the field have the same impact as randomized controlled trials.
One study of 35,543 patients in 44 hospitals found a whopping 27% reduction in surgical site infections, but that was only a 0.6% absolute reduction, from about 2.5% to about 1.9% (Am. J. Surg. 2005;190:9-15). There was no significant difference between groups.
Another study showed improved compliance with SCIP measures, but no change in surgical site infection rate (Dis. Colon Rectum 2010;53:24-30). This is the theme in study after study after study.
A 2008 study enrolled 9,195 patients undergoing colorectal, orthopedic, or vascular surgery and looked at SCIP compliance vs. surgical site infection. The SCIP rate correlated with the hospital case mix. If you look at the SCIP rate in terms of antibiotic timing, SCIP is not significant. The study basically showed that variables other than timely antibiotic administration are affecting surgical site infection rates (J. Am. Coll. Surg. 2008;206:814-19).
Hospital performance on process measures may not be a good marker of surgical site infection or the outcome we’re looking at, according to another study, which reported that unmeasured effects may have a larger impact than the measured effects (Health Serv. Res. 2008;43:1464-84).
There is a randomized controlled trial that randomized patients to strict control with the SCIP measures or routine treatment at the hospital. The SCIP-treated patients had nearly twice the incidence of surgical site infections as the patients receiving standard treatment. The authors concluded that combining each of the SCIP factors into one big category doesn’t necessarily work (Arch. Surg. 2011;146:263-9).
Should we be evaluating outcome measures with performance measures (e.g., percent timely antibiotic administration) to determine whether they work or not? One editorial evaluated eight articles with data on 31,448 patients, looking just at antibiotic administration within 1 hour of surgery, a SCIP measure. It found a higher infection rate if antibiotics were administered within 30 minutes of incision (JAMA 2010;303:2527-2528).
There was no significant difference in another study between standard of care and SCIP for venous thromboembolism (Am. J. Surg. 2012;204:591-97). The authors wrote that there is no convincing evidence that improvements in compliance are associated with better outcomes. We see this time and time again.
When people find that SCIP is not working, they turn to other measures to reduce surgical site infection. The Comprehensive Unit-based Safety Program (CUSP) is targeted at a specific problem that a specific hospital is having in managing infections. It’s not coming from Washington; it’s based at the hospital. One study showed that following CUSP, there was a significant reduction in surgical site infections despite the fact that previous to that there was 95% compliance with SCIP standards (J. Am. Coll. Surg. 2012;215:193-200). SCIP was working, but it wasn’t affecting outcome.
Dr. Lagasse and I interpret one key study very differently. He abstracts a sentence from a Limitations section of the study and makes a sweeping generalization out of context. But the study showed no relationship between facility adherence to SCIP and the surgical site infection rate. The authors concluded, "Policies regarding continued SCIP measurement and reporting should be reassessed" (Ann. Surg. 2011;254:494-99).
The largest SCIP study to date from a single entity involved 32,459 patients in the Veterans Affairs medical system. Overall, antibiotics were administered within 28 minutes of surgical incision. Once they adjusted for confounders, they found no significant relationship between surgical site infection and the SCIP measures (JAMA 2013;148:649-57). No one has proven that giving antibiotics within 60 minutes of surgical incision gives you a lower infection rate.
SCIP measures divert resources and divert clinical care. They obscure the nuances of care. They may harm the hospital and the provider, and they raise unnecessary legal risk if an antibiotic is not given within 60 minutes of incision.
Dr. Barash is a professor of anesthesiology at Yale University, New Haven, Conn. He reported having no financial disclosures.
These are excerpts from a debate at the annual meeting of the American Society of Anesthesiologists.
Platelet inhibition test helps predict surgical bleeding
SAN FRANCISCO – Preoperative light transmission aggregometry assessments of platelet aggregation may help identify which patients on dual antiplatelet therapy are at greater risk of sustained bleeding from noncardiac surgery, a prospective study of 147 consecutive patients suggests.
The light transmission aggregometry (LTA) assessments of blood drawn immediately before noncardiac surgery were significantly lower in the 32% of patients with sustained bleeding than in the other patients.
All patients were on dual antiplatelet therapy, 95% of them on maintenance therapy with aspirin plus clopidogrel. The timing of the surgery was at the discretion of the surgeons. Treating physicians were blinded to LTA results. The average preoperative washout period for dual antiplatelet therapy was 1.5 days (range, 0-6 days).
The findings of the ongoing study might help define a "bleeding cutoff" measure by LTA to better individualize the timing of surgery, Dr. Wolfgang Toller and his associates suggested in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In general, approximately 5% of patients in their first year of dual antiplatelet therapy undergo noncardiac surgery, which creates a conundrum for management. Discontinuing dual antiplatelet therapy before noncardiac surgery has been associated with a 20% risk of major adverse cardiac events, but there’s a 20%-40% risk of moderate to severe bleeding if dual antiplatelet therapy is continued during noncardiac surgery, said Dr. Toller of the Medical University of Graz, Austria.
The 147 patients in the study underwent vascular surgery (76%), orthopedic surgery (10%), abdominal surgery (7%), or other surgical procedures (7%). All had been on P2Y12 receptor inhibitors within 7 days before surgery.
Investigators used the Chronolog 700 Lumi-Aggregometer to assess platelet aggregation in preoperative blood, using 5 mcm of adenosine diphosphate as the specific inductor for platelet aggregation.
Overall, they found an average 40% maximum change in light transmission from baseline after adding the adenosine diphosphate to blood samples. In patients with increased bleeding, however, the mean maximum change in light transmission was approximately 30% (suggesting less platelet aggregation), compared with a more than 40% change in patients who bled less from the surgery.
The study used a composite definition of increased bleeding that included TIMI (Thrombolysis in Myocardial Infarction) criteria for major or minor bleeding, any postoperative bleeding requiring reoperation, any platelet transfusion, or at least two packed red blood cells more than the average surgery-specific transfusion requirements at the surgical site.
Dr. Toller reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Preoperative light transmission aggregometry assessments of platelet aggregation may help identify which patients on dual antiplatelet therapy are at greater risk of sustained bleeding from noncardiac surgery, a prospective study of 147 consecutive patients suggests.
The light transmission aggregometry (LTA) assessments of blood drawn immediately before noncardiac surgery were significantly lower in the 32% of patients with sustained bleeding than in the other patients.
All patients were on dual antiplatelet therapy, 95% of them on maintenance therapy with aspirin plus clopidogrel. The timing of the surgery was at the discretion of the surgeons. Treating physicians were blinded to LTA results. The average preoperative washout period for dual antiplatelet therapy was 1.5 days (range, 0-6 days).
The findings of the ongoing study might help define a "bleeding cutoff" measure by LTA to better individualize the timing of surgery, Dr. Wolfgang Toller and his associates suggested in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In general, approximately 5% of patients in their first year of dual antiplatelet therapy undergo noncardiac surgery, which creates a conundrum for management. Discontinuing dual antiplatelet therapy before noncardiac surgery has been associated with a 20% risk of major adverse cardiac events, but there’s a 20%-40% risk of moderate to severe bleeding if dual antiplatelet therapy is continued during noncardiac surgery, said Dr. Toller of the Medical University of Graz, Austria.
The 147 patients in the study underwent vascular surgery (76%), orthopedic surgery (10%), abdominal surgery (7%), or other surgical procedures (7%). All had been on P2Y12 receptor inhibitors within 7 days before surgery.
Investigators used the Chronolog 700 Lumi-Aggregometer to assess platelet aggregation in preoperative blood, using 5 mcm of adenosine diphosphate as the specific inductor for platelet aggregation.
Overall, they found an average 40% maximum change in light transmission from baseline after adding the adenosine diphosphate to blood samples. In patients with increased bleeding, however, the mean maximum change in light transmission was approximately 30% (suggesting less platelet aggregation), compared with a more than 40% change in patients who bled less from the surgery.
The study used a composite definition of increased bleeding that included TIMI (Thrombolysis in Myocardial Infarction) criteria for major or minor bleeding, any postoperative bleeding requiring reoperation, any platelet transfusion, or at least two packed red blood cells more than the average surgery-specific transfusion requirements at the surgical site.
Dr. Toller reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Preoperative light transmission aggregometry assessments of platelet aggregation may help identify which patients on dual antiplatelet therapy are at greater risk of sustained bleeding from noncardiac surgery, a prospective study of 147 consecutive patients suggests.
The light transmission aggregometry (LTA) assessments of blood drawn immediately before noncardiac surgery were significantly lower in the 32% of patients with sustained bleeding than in the other patients.
All patients were on dual antiplatelet therapy, 95% of them on maintenance therapy with aspirin plus clopidogrel. The timing of the surgery was at the discretion of the surgeons. Treating physicians were blinded to LTA results. The average preoperative washout period for dual antiplatelet therapy was 1.5 days (range, 0-6 days).
The findings of the ongoing study might help define a "bleeding cutoff" measure by LTA to better individualize the timing of surgery, Dr. Wolfgang Toller and his associates suggested in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In general, approximately 5% of patients in their first year of dual antiplatelet therapy undergo noncardiac surgery, which creates a conundrum for management. Discontinuing dual antiplatelet therapy before noncardiac surgery has been associated with a 20% risk of major adverse cardiac events, but there’s a 20%-40% risk of moderate to severe bleeding if dual antiplatelet therapy is continued during noncardiac surgery, said Dr. Toller of the Medical University of Graz, Austria.
The 147 patients in the study underwent vascular surgery (76%), orthopedic surgery (10%), abdominal surgery (7%), or other surgical procedures (7%). All had been on P2Y12 receptor inhibitors within 7 days before surgery.
Investigators used the Chronolog 700 Lumi-Aggregometer to assess platelet aggregation in preoperative blood, using 5 mcm of adenosine diphosphate as the specific inductor for platelet aggregation.
Overall, they found an average 40% maximum change in light transmission from baseline after adding the adenosine diphosphate to blood samples. In patients with increased bleeding, however, the mean maximum change in light transmission was approximately 30% (suggesting less platelet aggregation), compared with a more than 40% change in patients who bled less from the surgery.
The study used a composite definition of increased bleeding that included TIMI (Thrombolysis in Myocardial Infarction) criteria for major or minor bleeding, any postoperative bleeding requiring reoperation, any platelet transfusion, or at least two packed red blood cells more than the average surgery-specific transfusion requirements at the surgical site.
Dr. Toller reported having no financial disclosures.
On Twitter @sherryboschert
AT THE ASA ANNUAL MEETING
Major finding: The mean maximum change in light transmission on LTA assessment of preoperative blood was approximately 30% in patients with increased bleeding from surgery, significantly lower than the more than 40% change in those who bled less.
Data source: Prospective study of 147 patients on dual antiplatelet therapy who underwent noncardiac surgery at one institution.
Disclosures: Dr. Toller reported having no financial disclosures.
Inadequate neuromuscular blockade common during surgery
SAN FRANCISCO – Patients under general anesthesia may be getting insufficient neuromuscular blockade in 1%-45% of operations, depending on the definition, according to several studies presented in a joint session at the annual meeting of the American Society of Anesthesiologists.
Regardless of the exact definition, the findings suggest that the problem of insufficient blockade is considerably more common than expected, the anesthesiologists in attendance agreed.
A lack of clinical guidelines for neuromuscular blockade probably contributes to the problem, some speakers suggested. There is no established definition of insufficient neuromuscular blockade, which has been associated in prior studies with compromised surgical visualization, impaired ventilation leading to barotraumas, direct injury through unexpected movement, and other complications.
Investigators presented their results in posters and in a joint discussion session at the meeting. All studies were sponsored by Merck, which markets a neuromuscular blocking agent (rocuronium bromide, or Zemuron) and is seeking U.S. approval for a drug that rapidly reverses neuromuscular blockade (sugammadex, or Bridion).
One percent of 129,209 adults who underwent general anesthesia and received a nondepolarizing neuromuscular blockade agent in 2005-2013 experienced insufficient blockade in a way that interrupted surgery, either through undesired patient movement (0.3%) or an explicit request from the surgeon for additional muscle relaxation and administration of more neuromuscular blockade (0.7%), Dr. Timur Dubovoy and his associates reported.
They also found indirect evidence of insufficient neuromuscular blockade through two other criteria that were much more common, said Dr. Dubovoy of the University of Michigan, Ann Arbor. Anesthesiologists gave more neuromuscular blockade after documenting twitches on peripheral nerve stimulation (train-of-four monitoring) in 39% of patients, indicative of unintended recovery from neuromuscular blockade. Large or even "excessive" maintenance doses were given to 45% of patients, consistent with insufficient neuromuscular blockade, he said.
Those kinds of events typically don’t interrupt a procedure but can lead to residual neuromuscular blockade due to excessive dosing, potentially increasing complications and delaying recovery after anesthesia. The study looked only at the incidence of insufficient neuromuscular blockade, however, not outcomes.
"Current use of nondepolarizing neuromuscular blockade agents and subjective tactile train-of-four monitoring frequently exposes patients to inadequate neuromuscular blockade," Dr. Dubovoy said.
In a separate study, insufficient neuromuscular blockade affected 21%-28% of 48,315 adults undergoing abdominal, laparoscopic, and interventional neurovascular procedures at the Cleveland Clinic in 2005-2013, Dr. Brian D. Hesler and his associates reported.
"Our results suggest that insufficient block is relatively common, even in operations that are generally thought to require muscle relaxation," said Dr. Hesler of the Cleveland Clinic. "It is difficult to separate inadequate anesthesia from inadequate neuromuscular block, and both probably contributed in many cases."
He and his associates formed a panel of seven experienced anesthesiologists to identify anesthesiology actions that are indicative of episodes of insufficient neuromuscular block and searched for those criteria in patient records, with a three-person adjudication committee approving the search criteria through a random sample of at least 50 charts for each criterion.
Overall, 28% of operations had evidence of insufficient neuromuscular blockade, or 21% if the investigators excluded cases identified solely by electromyogram criteria.
In a separate analysis of the same cohort, Dr. Hesler and his associates searched for comments in the anesthetic records and found that insufficient blockade usually was identified more than 30 minutes before emergence, defined as the time when maintenance anesthesia was discontinued (106 cases), but 18% of the time it occurred 15-30 minutes before emergence (9 cases) or less than 15 minutes before emergence (14 cases).
The closer to the end of surgery, the more likely the anesthesiologist was to respond by deepening anesthesia instead of redosing the neuromuscular blocking agent, with other sedatives (opioids) used at a consistent rate in each time period.
A separate prospective, observational study of 448 patients undergoing elective laparoscopic or open abdominal surgical procedures at eight Canadian centers in 2011-2012 stratified residual neuromuscular blockade by train-of-four (TOF) ratios.
Lower TOF ratios at tracheal extubation and at arrival in the postanesthesia care unit (PACU) were associated with greater risk for complications and greater use of perioperative resources, Dr. Dolores McKeen and her associates reported.
Every 0.1-increment increase in the TOF ratio at tracheal extubation was associated with a 30% reduction in the odds of needing placement of an oral or nasal airway due to upper airway obstruction from the time of patient extubation to PACU discharge. Each 0.1-increment increase in the TOF ratio at tracheal extubation also was associated with 3% fewer bed visits by nurses, said Dr. McKeen of Dalhousie University, Halifax, N.S. Similar results were seen for TOF ratios upon arrival at the PACU.
This suggests that "more effective strategies to prevent and/or manage residual neuromuscular blockade are required to minimize the impact on the patient and health care provider," she said.
The incidence of postoperative residual neuromuscular blockade was 19% for patients with a TOF ratio less than 0.6 at tracheal extubation, 12% with a ratio of 0.6-0.7, 9% with a ratio of 0.7-0.8, 16% with a ratio of 0.8-0.9, and 44% with a ratio of 0.9 or greater. The incidence of residual blockade was 8% for patients with a TOF ratio less than 0.6 upon arrival to the PACU, 7% with a ratio of 0.6-0.7, 14% with a ratio of 0.7-0.8, 16% with a ratio of 0.8-0.9, and 56% with a ratio of 0.9 or greater.
In the United States, neostigmine, an acetylcholinesterase inhibitor, is the most common means of reversing neuromuscular blocking agents, according to Scott Devine, Ph.D., of Merck. Giving neostigmine too early can be ineffective, and giving it too late might induce skeletal muscle weakness.
He and his associates analyzed data from the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry (NACOR) on 113,276 procedures utilizing rocuronium or vecuronium that were reversed with neostigmine in 2010-2012. The reversal agent was given a mean of 63 minutes after the last dose of a neuromuscular blocking agent, 7 minutes before surgical site closure, 14 minutes prior to emergence, and 29 minutes before the end of anesthesia time, though each administration time had a wide range, he reported.
A substantial number of patients would have spontaneously recovered from the effects of the neuromuscular blockers after 63 minutes, suggesting that neostigmine often may be given later than needed, he said. If neostigmine is given 7 minutes before surgical site closure, reversal of neuromuscular blockade could be well underway, resulting in increased muscle tension during surgical site closure, which could increase the risk of complications such as dehiscence or postsurgical hernias, he added.
The large variability in practice may be due to multiple factors and deserves further research, he said.
Merck, which markets a neuromuscular blockade agent, sponsored the studies and supplied at least one investigator for each study.
[email protected] On Twitter @sherryboschert
One part of what we anesthesiologists do, other than keeping patients asleep and pain free, is to have them in a condition so that surgeons can do their operations optimally. If patients are not relaxed, and if muscles are not relaxed, that makes the surgical conditions more difficult, which could potentially lead to longer duration of surgery, more complications, and things like that. So this topic is actually very important to surgeons.
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In these studies, the neuromuscular blockade frequently seems to be insufficient, which is a little bit of a surprise. We hear from our surgery colleagues fairly often during surgery, "Give more muscle relaxants," because they have their hands in the field and they feel what’s going on. But anesthesiologists haven’t always agreed that it’s necessary to give more muscle relaxants, because we thought surgeons overestimated the conditions. It does seem that insufficient muscle relaxation is much more common than we had thought.
Many of these studies come from the Cleveland Clinic, so we’ve gone through their data in detail. We probably will be a little bit more liberal with muscle relaxation, which is difficult. If you overrelax patients, then it takes us longer to extubate them, which means we don’t get out of the OR before the surgeon comes to start the next case. So it’s a give and take.
That’s why to a certain extent it’s important that there are drugs available that promptly, within seconds, reverse our muscle relaxants. But they are not available in the United States yet. We are still waiting. Europe, South America – everybody is already using them.
It’s important for anesthesia and surgery to work together and see whether any of this actually does improve intermediate- or long-term outcomes of patients. That’s ultimately the goal.
Dr. Andrea Kurz is a professor and vice-chair of the Anesthesiology Institute at the Cleveland Clinic. She gave these remarks in an interview. Dr. Kurz reported having no financial disclosures.
One part of what we anesthesiologists do, other than keeping patients asleep and pain free, is to have them in a condition so that surgeons can do their operations optimally. If patients are not relaxed, and if muscles are not relaxed, that makes the surgical conditions more difficult, which could potentially lead to longer duration of surgery, more complications, and things like that. So this topic is actually very important to surgeons.
|
|
In these studies, the neuromuscular blockade frequently seems to be insufficient, which is a little bit of a surprise. We hear from our surgery colleagues fairly often during surgery, "Give more muscle relaxants," because they have their hands in the field and they feel what’s going on. But anesthesiologists haven’t always agreed that it’s necessary to give more muscle relaxants, because we thought surgeons overestimated the conditions. It does seem that insufficient muscle relaxation is much more common than we had thought.
Many of these studies come from the Cleveland Clinic, so we’ve gone through their data in detail. We probably will be a little bit more liberal with muscle relaxation, which is difficult. If you overrelax patients, then it takes us longer to extubate them, which means we don’t get out of the OR before the surgeon comes to start the next case. So it’s a give and take.
That’s why to a certain extent it’s important that there are drugs available that promptly, within seconds, reverse our muscle relaxants. But they are not available in the United States yet. We are still waiting. Europe, South America – everybody is already using them.
It’s important for anesthesia and surgery to work together and see whether any of this actually does improve intermediate- or long-term outcomes of patients. That’s ultimately the goal.
Dr. Andrea Kurz is a professor and vice-chair of the Anesthesiology Institute at the Cleveland Clinic. She gave these remarks in an interview. Dr. Kurz reported having no financial disclosures.
One part of what we anesthesiologists do, other than keeping patients asleep and pain free, is to have them in a condition so that surgeons can do their operations optimally. If patients are not relaxed, and if muscles are not relaxed, that makes the surgical conditions more difficult, which could potentially lead to longer duration of surgery, more complications, and things like that. So this topic is actually very important to surgeons.
|
|
In these studies, the neuromuscular blockade frequently seems to be insufficient, which is a little bit of a surprise. We hear from our surgery colleagues fairly often during surgery, "Give more muscle relaxants," because they have their hands in the field and they feel what’s going on. But anesthesiologists haven’t always agreed that it’s necessary to give more muscle relaxants, because we thought surgeons overestimated the conditions. It does seem that insufficient muscle relaxation is much more common than we had thought.
Many of these studies come from the Cleveland Clinic, so we’ve gone through their data in detail. We probably will be a little bit more liberal with muscle relaxation, which is difficult. If you overrelax patients, then it takes us longer to extubate them, which means we don’t get out of the OR before the surgeon comes to start the next case. So it’s a give and take.
That’s why to a certain extent it’s important that there are drugs available that promptly, within seconds, reverse our muscle relaxants. But they are not available in the United States yet. We are still waiting. Europe, South America – everybody is already using them.
It’s important for anesthesia and surgery to work together and see whether any of this actually does improve intermediate- or long-term outcomes of patients. That’s ultimately the goal.
Dr. Andrea Kurz is a professor and vice-chair of the Anesthesiology Institute at the Cleveland Clinic. She gave these remarks in an interview. Dr. Kurz reported having no financial disclosures.
SAN FRANCISCO – Patients under general anesthesia may be getting insufficient neuromuscular blockade in 1%-45% of operations, depending on the definition, according to several studies presented in a joint session at the annual meeting of the American Society of Anesthesiologists.
Regardless of the exact definition, the findings suggest that the problem of insufficient blockade is considerably more common than expected, the anesthesiologists in attendance agreed.
A lack of clinical guidelines for neuromuscular blockade probably contributes to the problem, some speakers suggested. There is no established definition of insufficient neuromuscular blockade, which has been associated in prior studies with compromised surgical visualization, impaired ventilation leading to barotraumas, direct injury through unexpected movement, and other complications.
Investigators presented their results in posters and in a joint discussion session at the meeting. All studies were sponsored by Merck, which markets a neuromuscular blocking agent (rocuronium bromide, or Zemuron) and is seeking U.S. approval for a drug that rapidly reverses neuromuscular blockade (sugammadex, or Bridion).
One percent of 129,209 adults who underwent general anesthesia and received a nondepolarizing neuromuscular blockade agent in 2005-2013 experienced insufficient blockade in a way that interrupted surgery, either through undesired patient movement (0.3%) or an explicit request from the surgeon for additional muscle relaxation and administration of more neuromuscular blockade (0.7%), Dr. Timur Dubovoy and his associates reported.
They also found indirect evidence of insufficient neuromuscular blockade through two other criteria that were much more common, said Dr. Dubovoy of the University of Michigan, Ann Arbor. Anesthesiologists gave more neuromuscular blockade after documenting twitches on peripheral nerve stimulation (train-of-four monitoring) in 39% of patients, indicative of unintended recovery from neuromuscular blockade. Large or even "excessive" maintenance doses were given to 45% of patients, consistent with insufficient neuromuscular blockade, he said.
Those kinds of events typically don’t interrupt a procedure but can lead to residual neuromuscular blockade due to excessive dosing, potentially increasing complications and delaying recovery after anesthesia. The study looked only at the incidence of insufficient neuromuscular blockade, however, not outcomes.
"Current use of nondepolarizing neuromuscular blockade agents and subjective tactile train-of-four monitoring frequently exposes patients to inadequate neuromuscular blockade," Dr. Dubovoy said.
In a separate study, insufficient neuromuscular blockade affected 21%-28% of 48,315 adults undergoing abdominal, laparoscopic, and interventional neurovascular procedures at the Cleveland Clinic in 2005-2013, Dr. Brian D. Hesler and his associates reported.
"Our results suggest that insufficient block is relatively common, even in operations that are generally thought to require muscle relaxation," said Dr. Hesler of the Cleveland Clinic. "It is difficult to separate inadequate anesthesia from inadequate neuromuscular block, and both probably contributed in many cases."
He and his associates formed a panel of seven experienced anesthesiologists to identify anesthesiology actions that are indicative of episodes of insufficient neuromuscular block and searched for those criteria in patient records, with a three-person adjudication committee approving the search criteria through a random sample of at least 50 charts for each criterion.
Overall, 28% of operations had evidence of insufficient neuromuscular blockade, or 21% if the investigators excluded cases identified solely by electromyogram criteria.
In a separate analysis of the same cohort, Dr. Hesler and his associates searched for comments in the anesthetic records and found that insufficient blockade usually was identified more than 30 minutes before emergence, defined as the time when maintenance anesthesia was discontinued (106 cases), but 18% of the time it occurred 15-30 minutes before emergence (9 cases) or less than 15 minutes before emergence (14 cases).
The closer to the end of surgery, the more likely the anesthesiologist was to respond by deepening anesthesia instead of redosing the neuromuscular blocking agent, with other sedatives (opioids) used at a consistent rate in each time period.
A separate prospective, observational study of 448 patients undergoing elective laparoscopic or open abdominal surgical procedures at eight Canadian centers in 2011-2012 stratified residual neuromuscular blockade by train-of-four (TOF) ratios.
Lower TOF ratios at tracheal extubation and at arrival in the postanesthesia care unit (PACU) were associated with greater risk for complications and greater use of perioperative resources, Dr. Dolores McKeen and her associates reported.
Every 0.1-increment increase in the TOF ratio at tracheal extubation was associated with a 30% reduction in the odds of needing placement of an oral or nasal airway due to upper airway obstruction from the time of patient extubation to PACU discharge. Each 0.1-increment increase in the TOF ratio at tracheal extubation also was associated with 3% fewer bed visits by nurses, said Dr. McKeen of Dalhousie University, Halifax, N.S. Similar results were seen for TOF ratios upon arrival at the PACU.
This suggests that "more effective strategies to prevent and/or manage residual neuromuscular blockade are required to minimize the impact on the patient and health care provider," she said.
The incidence of postoperative residual neuromuscular blockade was 19% for patients with a TOF ratio less than 0.6 at tracheal extubation, 12% with a ratio of 0.6-0.7, 9% with a ratio of 0.7-0.8, 16% with a ratio of 0.8-0.9, and 44% with a ratio of 0.9 or greater. The incidence of residual blockade was 8% for patients with a TOF ratio less than 0.6 upon arrival to the PACU, 7% with a ratio of 0.6-0.7, 14% with a ratio of 0.7-0.8, 16% with a ratio of 0.8-0.9, and 56% with a ratio of 0.9 or greater.
In the United States, neostigmine, an acetylcholinesterase inhibitor, is the most common means of reversing neuromuscular blocking agents, according to Scott Devine, Ph.D., of Merck. Giving neostigmine too early can be ineffective, and giving it too late might induce skeletal muscle weakness.
He and his associates analyzed data from the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry (NACOR) on 113,276 procedures utilizing rocuronium or vecuronium that were reversed with neostigmine in 2010-2012. The reversal agent was given a mean of 63 minutes after the last dose of a neuromuscular blocking agent, 7 minutes before surgical site closure, 14 minutes prior to emergence, and 29 minutes before the end of anesthesia time, though each administration time had a wide range, he reported.
A substantial number of patients would have spontaneously recovered from the effects of the neuromuscular blockers after 63 minutes, suggesting that neostigmine often may be given later than needed, he said. If neostigmine is given 7 minutes before surgical site closure, reversal of neuromuscular blockade could be well underway, resulting in increased muscle tension during surgical site closure, which could increase the risk of complications such as dehiscence or postsurgical hernias, he added.
The large variability in practice may be due to multiple factors and deserves further research, he said.
Merck, which markets a neuromuscular blockade agent, sponsored the studies and supplied at least one investigator for each study.
[email protected] On Twitter @sherryboschert
SAN FRANCISCO – Patients under general anesthesia may be getting insufficient neuromuscular blockade in 1%-45% of operations, depending on the definition, according to several studies presented in a joint session at the annual meeting of the American Society of Anesthesiologists.
Regardless of the exact definition, the findings suggest that the problem of insufficient blockade is considerably more common than expected, the anesthesiologists in attendance agreed.
A lack of clinical guidelines for neuromuscular blockade probably contributes to the problem, some speakers suggested. There is no established definition of insufficient neuromuscular blockade, which has been associated in prior studies with compromised surgical visualization, impaired ventilation leading to barotraumas, direct injury through unexpected movement, and other complications.
Investigators presented their results in posters and in a joint discussion session at the meeting. All studies were sponsored by Merck, which markets a neuromuscular blocking agent (rocuronium bromide, or Zemuron) and is seeking U.S. approval for a drug that rapidly reverses neuromuscular blockade (sugammadex, or Bridion).
One percent of 129,209 adults who underwent general anesthesia and received a nondepolarizing neuromuscular blockade agent in 2005-2013 experienced insufficient blockade in a way that interrupted surgery, either through undesired patient movement (0.3%) or an explicit request from the surgeon for additional muscle relaxation and administration of more neuromuscular blockade (0.7%), Dr. Timur Dubovoy and his associates reported.
They also found indirect evidence of insufficient neuromuscular blockade through two other criteria that were much more common, said Dr. Dubovoy of the University of Michigan, Ann Arbor. Anesthesiologists gave more neuromuscular blockade after documenting twitches on peripheral nerve stimulation (train-of-four monitoring) in 39% of patients, indicative of unintended recovery from neuromuscular blockade. Large or even "excessive" maintenance doses were given to 45% of patients, consistent with insufficient neuromuscular blockade, he said.
Those kinds of events typically don’t interrupt a procedure but can lead to residual neuromuscular blockade due to excessive dosing, potentially increasing complications and delaying recovery after anesthesia. The study looked only at the incidence of insufficient neuromuscular blockade, however, not outcomes.
"Current use of nondepolarizing neuromuscular blockade agents and subjective tactile train-of-four monitoring frequently exposes patients to inadequate neuromuscular blockade," Dr. Dubovoy said.
In a separate study, insufficient neuromuscular blockade affected 21%-28% of 48,315 adults undergoing abdominal, laparoscopic, and interventional neurovascular procedures at the Cleveland Clinic in 2005-2013, Dr. Brian D. Hesler and his associates reported.
"Our results suggest that insufficient block is relatively common, even in operations that are generally thought to require muscle relaxation," said Dr. Hesler of the Cleveland Clinic. "It is difficult to separate inadequate anesthesia from inadequate neuromuscular block, and both probably contributed in many cases."
He and his associates formed a panel of seven experienced anesthesiologists to identify anesthesiology actions that are indicative of episodes of insufficient neuromuscular block and searched for those criteria in patient records, with a three-person adjudication committee approving the search criteria through a random sample of at least 50 charts for each criterion.
Overall, 28% of operations had evidence of insufficient neuromuscular blockade, or 21% if the investigators excluded cases identified solely by electromyogram criteria.
In a separate analysis of the same cohort, Dr. Hesler and his associates searched for comments in the anesthetic records and found that insufficient blockade usually was identified more than 30 minutes before emergence, defined as the time when maintenance anesthesia was discontinued (106 cases), but 18% of the time it occurred 15-30 minutes before emergence (9 cases) or less than 15 minutes before emergence (14 cases).
The closer to the end of surgery, the more likely the anesthesiologist was to respond by deepening anesthesia instead of redosing the neuromuscular blocking agent, with other sedatives (opioids) used at a consistent rate in each time period.
A separate prospective, observational study of 448 patients undergoing elective laparoscopic or open abdominal surgical procedures at eight Canadian centers in 2011-2012 stratified residual neuromuscular blockade by train-of-four (TOF) ratios.
Lower TOF ratios at tracheal extubation and at arrival in the postanesthesia care unit (PACU) were associated with greater risk for complications and greater use of perioperative resources, Dr. Dolores McKeen and her associates reported.
Every 0.1-increment increase in the TOF ratio at tracheal extubation was associated with a 30% reduction in the odds of needing placement of an oral or nasal airway due to upper airway obstruction from the time of patient extubation to PACU discharge. Each 0.1-increment increase in the TOF ratio at tracheal extubation also was associated with 3% fewer bed visits by nurses, said Dr. McKeen of Dalhousie University, Halifax, N.S. Similar results were seen for TOF ratios upon arrival at the PACU.
This suggests that "more effective strategies to prevent and/or manage residual neuromuscular blockade are required to minimize the impact on the patient and health care provider," she said.
The incidence of postoperative residual neuromuscular blockade was 19% for patients with a TOF ratio less than 0.6 at tracheal extubation, 12% with a ratio of 0.6-0.7, 9% with a ratio of 0.7-0.8, 16% with a ratio of 0.8-0.9, and 44% with a ratio of 0.9 or greater. The incidence of residual blockade was 8% for patients with a TOF ratio less than 0.6 upon arrival to the PACU, 7% with a ratio of 0.6-0.7, 14% with a ratio of 0.7-0.8, 16% with a ratio of 0.8-0.9, and 56% with a ratio of 0.9 or greater.
In the United States, neostigmine, an acetylcholinesterase inhibitor, is the most common means of reversing neuromuscular blocking agents, according to Scott Devine, Ph.D., of Merck. Giving neostigmine too early can be ineffective, and giving it too late might induce skeletal muscle weakness.
He and his associates analyzed data from the Anesthesia Quality Institute’s National Anesthesia Clinical Outcomes Registry (NACOR) on 113,276 procedures utilizing rocuronium or vecuronium that were reversed with neostigmine in 2010-2012. The reversal agent was given a mean of 63 minutes after the last dose of a neuromuscular blocking agent, 7 minutes before surgical site closure, 14 minutes prior to emergence, and 29 minutes before the end of anesthesia time, though each administration time had a wide range, he reported.
A substantial number of patients would have spontaneously recovered from the effects of the neuromuscular blockers after 63 minutes, suggesting that neostigmine often may be given later than needed, he said. If neostigmine is given 7 minutes before surgical site closure, reversal of neuromuscular blockade could be well underway, resulting in increased muscle tension during surgical site closure, which could increase the risk of complications such as dehiscence or postsurgical hernias, he added.
The large variability in practice may be due to multiple factors and deserves further research, he said.
Merck, which markets a neuromuscular blockade agent, sponsored the studies and supplied at least one investigator for each study.
[email protected] On Twitter @sherryboschert
AT THE ASA ANNUAL MEETING
Major finding: The incidence of inadequate neuromuscular blockade during surgery ranged from 1% to 45%, depending on the definition.
Data source: Multiple retrospective studies of adults undergoing surgery with general anesthesia who received neuromuscular blocking agents.
Disclosures: Merck, which markets a neuromuscular blockade reversal agent, sponsored the studies and supplied at least one investigator for each study.
Adding melatonin to alprazolam boosts preoperative anxiolysis
SAN FRANCISCO – Adding melatonin to alprazolam significantly decreased preoperative anxiety, compared with either medication alone or with placebo, in a randomized, double-blind trial of 80 patients.
Adult patients undergoing laparoscopic cholecystectomy who reported a preoperative anxiety level of at least 3 cm on a 10-cm Visual Analog Scale (VAS) had average anxiety scores of 5 cm before being randomized to preoperative medication with alprazolam 0.5 mg, melatonin 3 mg, both drugs, or placebo (with 20 patients in each group).
After 1 hour spent in a quiet room following the premedication, VAS scores had fallen by an average of 3 cm in the two-drug group, significantly more than average 2-cm reductions with either drug alone, or a 1-cm decline on placebo, Dr. Krishna Pokharel and her associates reported.
Adding melatonin did not seem to worsen the sedative or amnesiac effects of alprazolam, she reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In the past, some of her patients who had been premedicated with a benzodiazepine before general anesthesia and surgery sometimes became aroused during the procedure, perhaps because benzodiazepines suppress endogenous melatonin levels, Dr. Pokharel said. She hypothesized that adding melatonin might help, and the study results have convinced her institution to routinely add melatonin to alprazolam for surgical premedication in anxious patients, said Dr. Pokharel of B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Patients were shown different pictures during assessments of anxiety and sedation at various time points before surgery. At 24 hours after surgery, 10 patients on alprazolam plus melatonin could recall the picture they saw 1 hour after taking the presurgical medication, compared with 9 patients on alprazolam alone, 18 patients on melatonin alone, and 16 patients on placebo, the poster reported.
In other results, average scores on a 5-point scale for sedation at 1 hour were 0.5 with melatonin, 1 for each group using alprazolam, and 0 with placebo, among other secondary outcomes. At 24 hours after surgery, five patients in the two-drug group could not remember being transferred to the OR, compared with four patients on alprazolam, one patient on melatonin, and none of the patients on placebo.
All groups scored 2 on a 3-point scale for orientation 1 hour after taking the premedication. The amount of propofol needed to achieve a loss of response to verbal commands at the time of general anesthesia induction averaged 66 mg in the alprazolam plus melatonin group, 59 mg after alprazolam alone, 79 mg after melatonin alone, and 76 mg on placebo.
No patients developed serious adverse events.
Dr. Pokharel reported having no financial disclosures.
On Twitter @sherryboschert
laparoscopic cholecystectomy, Visual Analog Scale, VAS, anxiety, Dr. Krishna Pokharel, the American Society of Anesthesiologists, benzodiazepines,
SAN FRANCISCO – Adding melatonin to alprazolam significantly decreased preoperative anxiety, compared with either medication alone or with placebo, in a randomized, double-blind trial of 80 patients.
Adult patients undergoing laparoscopic cholecystectomy who reported a preoperative anxiety level of at least 3 cm on a 10-cm Visual Analog Scale (VAS) had average anxiety scores of 5 cm before being randomized to preoperative medication with alprazolam 0.5 mg, melatonin 3 mg, both drugs, or placebo (with 20 patients in each group).
After 1 hour spent in a quiet room following the premedication, VAS scores had fallen by an average of 3 cm in the two-drug group, significantly more than average 2-cm reductions with either drug alone, or a 1-cm decline on placebo, Dr. Krishna Pokharel and her associates reported.
Adding melatonin did not seem to worsen the sedative or amnesiac effects of alprazolam, she reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In the past, some of her patients who had been premedicated with a benzodiazepine before general anesthesia and surgery sometimes became aroused during the procedure, perhaps because benzodiazepines suppress endogenous melatonin levels, Dr. Pokharel said. She hypothesized that adding melatonin might help, and the study results have convinced her institution to routinely add melatonin to alprazolam for surgical premedication in anxious patients, said Dr. Pokharel of B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Patients were shown different pictures during assessments of anxiety and sedation at various time points before surgery. At 24 hours after surgery, 10 patients on alprazolam plus melatonin could recall the picture they saw 1 hour after taking the presurgical medication, compared with 9 patients on alprazolam alone, 18 patients on melatonin alone, and 16 patients on placebo, the poster reported.
In other results, average scores on a 5-point scale for sedation at 1 hour were 0.5 with melatonin, 1 for each group using alprazolam, and 0 with placebo, among other secondary outcomes. At 24 hours after surgery, five patients in the two-drug group could not remember being transferred to the OR, compared with four patients on alprazolam, one patient on melatonin, and none of the patients on placebo.
All groups scored 2 on a 3-point scale for orientation 1 hour after taking the premedication. The amount of propofol needed to achieve a loss of response to verbal commands at the time of general anesthesia induction averaged 66 mg in the alprazolam plus melatonin group, 59 mg after alprazolam alone, 79 mg after melatonin alone, and 76 mg on placebo.
No patients developed serious adverse events.
Dr. Pokharel reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Adding melatonin to alprazolam significantly decreased preoperative anxiety, compared with either medication alone or with placebo, in a randomized, double-blind trial of 80 patients.
Adult patients undergoing laparoscopic cholecystectomy who reported a preoperative anxiety level of at least 3 cm on a 10-cm Visual Analog Scale (VAS) had average anxiety scores of 5 cm before being randomized to preoperative medication with alprazolam 0.5 mg, melatonin 3 mg, both drugs, or placebo (with 20 patients in each group).
After 1 hour spent in a quiet room following the premedication, VAS scores had fallen by an average of 3 cm in the two-drug group, significantly more than average 2-cm reductions with either drug alone, or a 1-cm decline on placebo, Dr. Krishna Pokharel and her associates reported.
Adding melatonin did not seem to worsen the sedative or amnesiac effects of alprazolam, she reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.
In the past, some of her patients who had been premedicated with a benzodiazepine before general anesthesia and surgery sometimes became aroused during the procedure, perhaps because benzodiazepines suppress endogenous melatonin levels, Dr. Pokharel said. She hypothesized that adding melatonin might help, and the study results have convinced her institution to routinely add melatonin to alprazolam for surgical premedication in anxious patients, said Dr. Pokharel of B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Patients were shown different pictures during assessments of anxiety and sedation at various time points before surgery. At 24 hours after surgery, 10 patients on alprazolam plus melatonin could recall the picture they saw 1 hour after taking the presurgical medication, compared with 9 patients on alprazolam alone, 18 patients on melatonin alone, and 16 patients on placebo, the poster reported.
In other results, average scores on a 5-point scale for sedation at 1 hour were 0.5 with melatonin, 1 for each group using alprazolam, and 0 with placebo, among other secondary outcomes. At 24 hours after surgery, five patients in the two-drug group could not remember being transferred to the OR, compared with four patients on alprazolam, one patient on melatonin, and none of the patients on placebo.
All groups scored 2 on a 3-point scale for orientation 1 hour after taking the premedication. The amount of propofol needed to achieve a loss of response to verbal commands at the time of general anesthesia induction averaged 66 mg in the alprazolam plus melatonin group, 59 mg after alprazolam alone, 79 mg after melatonin alone, and 76 mg on placebo.
No patients developed serious adverse events.
Dr. Pokharel reported having no financial disclosures.
On Twitter @sherryboschert
laparoscopic cholecystectomy, Visual Analog Scale, VAS, anxiety, Dr. Krishna Pokharel, the American Society of Anesthesiologists, benzodiazepines,
laparoscopic cholecystectomy, Visual Analog Scale, VAS, anxiety, Dr. Krishna Pokharel, the American Society of Anesthesiologists, benzodiazepines,
AT THE ASA ANNUAL MEETING
Major finding: Anxiety VAS scores at 60 minutes, compared with baseline, fell by 3 cm with melatonin plus alprazolam, 2 cm with either drug alone, or 1 cm with placebo.
Data source: A prospective, randomized, controlled trial of 80 adults undergoing laparoscopic cholecystectomy at one hospital.
Disclosures: Dr. Pokharel reported having no financial disclosures.
