Perioperative medicine training resources: U3M1: Perioperative optimisation protocols

Leaders of a health service organisation set up and maintain systems and processes to support effective communication with patients, carers and families; between multidisciplinary teams and clinicians; and across health service organisations. The workforce uses these systems to effectively communicate to ensure safety.

Abstract
Anaemia is a common finding in patients presenting for major elective surgery and is associated with poor outcomes including death and complications. Iron deficiency is the leading cause of perioperative anaemia. Intravenous (i.v.) iron is considered to be an effective and safe treatment for iron deficiency anaemia and is recommended by expert opinion for treatment of preoperative anaemia, although evidence from clinical trials is lacking. The PREVENTT trial was a large multicentre trial investigating the effects of i.v. iron on red cell transfusion, death, complications and quality of life in 487 patients undergoing major abdominal surgery. The principal finding of this multicentre randomised placebo controlled trial was that there was no difference in the co-primary outcomes of blood transfusion or death, or the number of transfusion episodes, within 30 days after surgery, in patients that received preoperative i.v. iron therapy compared to placebo. The major inferential differences in this independent discussion relate to the limitations of the PREVENTT trial and its implications for future practice. Although PREVENTT represents the best evidence available to guide perioperative use of i.v. iron, it is likely that the study was underpowered. In the context of already widespread adoption of preoperative i.v. iron therapy, many clinicians may have felt they lacked equipoise. In light of the PREVENTT study routine use of i.v. iron in patients undergoing elective abdominal surgery cannot be recommended. Further research should define the optimum red cell transfusion strategy for patients undergoing surgery and idenify other surgical groups who may benefit from this intervention.

Abstract
The rate of postoperative recovery is determined by pain, stress-induced organ dysfunction, and limitations in conventional postoperative care. We attempted to provide "stress-free" colonic resection for neoplastic disease in eight elderly high-risk patients by a combination of laparoscopically assisted surgery, epidural analgesia, and early oral nutrition and mobilisation. Effective pain relief allowed early mobilisation, and hospital stay was reduced to 2 days without nausea, vomiting, or ileus. Postoperative fatigue and impairment in functional activity were avoided. Major advances in postoperative recovery can be achieved by early aggressive perioperative care in elderly high-risk patients undergoing colonic surgery.

Abstract
Purpose of Review
The purpose of this article is to provide a brief review of the preoperative pulmonary evaluation of patients undergoing non-thoracic surgery, focusing on risk factor identification, assessment of specific high-risk populations, and strategies to minimize postoperative pulmonary complications (PPCs).

Recent Findings
Along with traditional risk factors, recent risk stratification indices have been developed and validated to help quantify risk of PPCs. Careful history and physical examination are key elements in the pulmonary evaluation of all pre-surgical patients. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk and require more intensive optimization and perioperative monitoring. Well-controlled asthma has not been associated with increased risk of PPCs but the potential for life-threatening bronchospasm and status asthmaticus cannot be ignored. In general, the literature does not support delaying surgery for preoperative diagnosis and management of obstructive sleep apnea (OSA). Exceptions to this rule are patients presenting with evidence of obesity-hypoventilation syndrome or pulmonary hypertension. Recent literature provides more evidence of benefits of regional anesthesia and analgesia to decrease the risk of pulmonary complications, particularly in COPD patients.

Summary
PPCs are major contributors to perioperative morbidity and mortality. A thorough preoperative evaluation must identify high-risk patients, optimize chronic and acute respiratory diseases, and establish a clear perioperative plan to minimize PPCs.

Keywords: complications; myasthenia gravis; perioperative care.

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Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494-1503. doi:10.1056/NEJMoa1401105
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Your search for Devereaux PJ, Mrkobrada M, Sessler DI, Leslie K, Alonso-Coello P, Kurz A, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494-1503. doi:10.1056/NEJMoa1401105 retrieved no results.
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Title & authors
Randomized Controlled Trial N Engl J Med
. 2014 Apr 17;370(16):1494-503. doi: 10.1056/NEJMoa1401105. Epub 2014 Mar 31.
Aspirin in patients undergoing noncardiac surgery
BrowZine Journal Cover
P J Devereaux 1, Marko Mrkobrada, Daniel I Sessler, Kate Leslie, Pablo Alonso-Coello, Andrea Kurz, Juan Carlos Villar, Alben Sigamani, Bruce M Biccard, Christian S Meyhoff, Joel L Parlow, Gordon Guyatt, Andrea Robinson, Amit X Garg, Reitze N Rodseth, Fernando Botto, Giovanna Lurati Buse, Denis Xavier, Matthew T V Chan, Maria Tiboni, Deborah Cook, Priya A Kumar, Patrice Forget, German Malaga, Edith Fleischmann, Mohammed Amir, John Eikelboom, Richard Mizera, David Torres, C Y Wang, Tomas VanHelder, Pilar Paniagua, Otavio Berwanger, Sadeesh Srinathan, Michelle Graham, Laura Pasin, Yannick Le Manach, Peggy Gao, Janice Pogue, Richard Whitlock, André Lamy, Clive Kearon, Colin Baigent, Clara Chow, Shirley Pettit, Susan Chrolavicius, Salim Yusuf; POISE-2 Investigators
Collaborators, Affiliations expand
PMID: 24679062 DOI: 10.1056/NEJMoa1401105
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Abstract
Background: There is substantial variability in the perioperative administration of aspirin in patients undergoing noncardiac surgery, both among patients who are already on an aspirin regimen and among those who are not.

Methods: Using a 2-by-2 factorial trial design, we randomly assigned 10,010 patients who were preparing to undergo noncardiac surgery and were at risk for vascular complications to receive aspirin or placebo and clonidine or placebo. The results of the aspirin trial are reported here. The patients were stratified according to whether they had not been taking aspirin before the study (initiation stratum, with 5628 patients) or they were already on an aspirin regimen (continuation stratum, with 4382 patients). Patients started taking aspirin (at a dose of 200 mg) or placebo just before surgery and continued it daily (at a dose of 100 mg) for 30 days in the initiation stratum and for 7 days in the continuation stratum, after which patients resumed their regular aspirin regimen. The primary outcome was a composite of death or nonfatal myocardial infarction at 30 days.

Results: The primary outcome occurred in 351 of 4998 patients (7.0%) in the aspirin group and in 355 of 5012 patients (7.1%) in the placebo group (hazard ratio in the aspirin group, 0.99; 95% confidence interval [CI], 0.86 to 1.15; P=0.92). Major bleeding was more common in the aspirin group than in the placebo group (230 patients [4.6%] vs. 188 patients [3.8%]; hazard ratio, 1.23; 95% CI, 1.01, to 1.49; P=0.04). The primary and secondary outcome results were similar in the two aspirin strata.

Conclusions: Administration of aspirin before surgery and throughout the early postsurgical period had no significant effect on the rate of a composite of death or nonfatal myocardial infarction but increased the risk of major bleeding. (Funded by the Canadian Institutes of Health Research and others; POISE-2 ClinicalTrials.gov number, NCT01082874.).

Abstract
The hematologic system is responsible for several of the body's most critical functions, including delivery of oxygen and nutrients to tissues, clearance of toxic metabolic byproducts, defense against offending pathogens, and maintenance of hemostasis in the setting of trauma. Its exquisite complexity is difficult to overstate and poses a great challenge to review in short form. This article provides highlights and clinical pearls in managing patients suffering from some of the most common hematologic afflictions encountered in the perioperative setting.

Full citation:
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):e278-e333.

Abstract
Perioperative acute kidney injury (AKI) is associated with an increased morbidity and mortality. The incidence of AKI varies depending on preoperative risk factors and the surgical setting. Preoperative risk stratification is critical for informed consent and perioperative planning. Perioperative renal protection strategies are potentially invaluable in the prevention of AKI. Current advances in the development of biomarkers may offer the opportunity for early diagnosis and the implementation of therapeutic strategies. Increased awareness and concerted efforts by all perioperative physicians are needed to provide an improved outcome for surgical patients.

Abstract
Background: Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients.

Objectives: To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs.

Design: This was a prospective international 1-week observational study using the 'Assess Respiratory Risk in Surgical Patients in Catalonia risk score' (ARISCAT score) for PPC for risk stratification.

Patients and setting: Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries.

Main outcome measures: The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes.

Results: A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure.

Conclusion: The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome.

Abstract
Postoperative pulmonary complications are common and cause increased mortality and hospital stay. Smoking and respiratory diseases including asthma, chronic obstructive pulmonary disease and obstructive sleep apnoea are associated with developing postoperative pulmonary complications. Independent risk factors for such complications also include low pre-operative oxygen saturation, or a recent respiratory infection. Postponing surgery in patients who have respiratory infections or inadequately treated respiratory disease, until these can be fully treated, should, therefore, reduce postoperative pulmonary complications. There is evidence from several studies that pre-operative smoking cessation reduces such complications, with no agreed duration at which the benefits become significant; the longer the abstinence, the greater the benefit. Intensive smoking cessation programmes are more effective, and there are long-term benefits, as many patients become permanent non-smokers following their surgery. Supervised exercise programmes normally last 6-8 weeks, and although they reduce overall complications, the evidence of benefit for postoperative pulmonary complications is mixed. High-intensity interval training can improve fitness in just 2 weeks, and so may be more useful for surgical patients. Specific respiratory pre-operative interventions, such as deep breathing exercises and incentive spirometry, can help when used as components of a package of respiratory care. Pre-operative inspiratory muscle training programmes that involve inspiration against a predetermined respiratory load may also reduce some postoperative pulmonary complications. Pre-operative exercise programmes are recommended for patients having major surgery, or in those where pre-operative testing has shown low levels of cardiorespiratory fitness; interval training or respiratory interventions are more feasible as these reduce complications after a shorter pre-operative intervention.

Thyroid disease has been long recognized: goitres were first described by the Chinese in 2700 BC. Thyroid surgery was first described in the 12th Century, but for many years the operations were so prone to complications that it prompted Samuel Gross to write in 1848:

‘Can the thyroid in the state of enlargement be removed? Emphatically experience answers no…every stroke of the knife will be followed by a torrent of blood and lucky…if his victims lived long enough for him to finish his horrid butchery. No honest and sensible surgeon would ever engage in it’.

In the UK, Stanley Rowbotham pioneered anaesthesia for thyroid surgery in the 1940s. He combined local anaesthesia with light general anaesthesia, and even attempted to make the patient strain to test haemostatic sutures using one breath of ether.1

Anaesthesia for thyroid surgery requires an anaesthetist who is experienced in the recognition, assessment, and management of a potentially difficult, shared airway, in a patient who may also have significant co-morbidity.

Complexity of the procedure may vary from excision of a simple nodule to removal of retrosternal goitre to relieve tracheal compression. The latter can be excised through a standard collar incision, but it may be necessary to split the sternum to access the inferior pole of the enlarged gland. Although blood loss is usually minimal, there is potential for major haemorrhage from large blood vessels closely related to the gland, particularly if the thyroid extends retrosternally.

Abstract
Carcinoid tumors are uncommon, slow-growing neoplasms. These tumors are capable of secreting numerous bioactive substances, which results in significant potential challenges in the management of patients afflicted with carcinoid syndrome. Over the past two decades, both surgical and medical therapeutic options have broadened, resulting in improved outcomes. The pathophysiology, clinical signs and symptoms, diagnosis, treatment options, and perioperative management, including anesthetic considerations, of carcinoid syndrome are presented.

Abstract
Guidelines are presented for the organisational and clinical peri-operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri-operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

Abstract
This article reviews neurologic problems that have been categorized into two groups: parenchymal and vascular disease. Each disease has a brief summary of key clinical points, followed by recommended management strategies. The neurologic diseases most frequently encountered by the medical consultant are presented.

Abstract
Postoperative pulmonary complications (PPCs) are common, costly, and increase patient mortality. Changes to the respiratory system occur immediately on induction of general anaesthesia: respiratory drive and muscle function are altered, lung volumes reduced, and atelectasis develops in > 75% of patients receiving a neuromuscular blocking drug. The respiratory system may take 6 weeks to return to its preoperative state after general anaesthesia for major surgery. Risk factors for PPC development are numerous, and clinicians should be aware of non-modifiable and modifiable factors in order to recognize those at risk and optimize their care. Many validated risk prediction models are described. These have been useful for improving our understanding of PPC development, but there remains inadequate consensus for them to be useful clinically. Preventative measures include preoperative optimization of co-morbidities, smoking cessation, and correction of anaemia, in addition to intraoperative protective ventilation strategies and appropriate management of neuromuscular blocking drugs. Protective ventilation includes low tidal volumes, which must be calculated according to the patient's ideal body weight. Further evidence for the most beneficial level of PEEP is required, and on-going randomized trials will hopefully provide more information. When PEEP is used, it may be useful to precede this with a recruitment manoeuvre if atelectasis is suspected. For high-risk patients, surgical time should be minimized. After surgery, nasogastric tubes should be avoided and analgesia optimized. A postoperative mobilization, chest physiotherapy, and oral hygiene bundle reduces PPCs.

_Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results. This randomised controlled trial, done in 190 hospitals in 23 countries, was designed to investigate the effects of perioperative beta blockers.Methods_ We randomly assigned 8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate (n=4174) or placebo (n=4177), by a computerised randomisation phone service. Study treatment was started 2-4 h before surgery and continued for 30 days. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00182039.Findings_ All 8351 patients were included in analyses

Abstract
Background: Adverse cardiac events are common after vascular surgery. We hypothesized that perioperative statin therapy would improve postoperative outcomes.

Methods: In this double-blind, placebo-controlled trial, we randomly assigned patients who had not previously been treated with a statin to receive, in addition to a beta-blocker, either 80 mg of extended-release fluvastatin or placebo once daily before undergoing vascular surgery. Lipid, interleukin-6, and C-reactive protein levels were measured at the time of randomization and before surgery. The primary end point was the occurrence of myocardial ischemia, defined as transient electrocardiographic abnormalities, release of troponin T, or both, within 30 days after surgery. The secondary end point was the composite of death from cardiovascular causes and myocardial infarction.

Results: A total of 250 patients were assigned to fluvastatin, and 247 to placebo, a median of 37 days before vascular surgery. Levels of total cholesterol, low-density lipoprotein cholesterol, interleukin-6, and C-reactive protein were significantly decreased in the fluvastatin group but were unchanged in the placebo group. Postoperative myocardial ischemia occurred in 27 patients (10.8%) in the fluvastatin group and in 47 (19.0%) in the placebo group (hazard ratio, 0.55; 95% confidence interval [CI], 0.34 to 0.88; P=0.01). Death from cardiovascular causes or myocardial infarction occurred in 12 patients (4.8%) in the fluvastatin group and 25 patients (10.1%) in the placebo group (hazard ratio, 0.47; 95% CI, 0.24 to 0.94; P=0.03). Fluvastatin therapy was not associated with a significant increase in the rate of adverse events.

Conclusions: In patients undergoing vascular surgery, perioperative fluvastatin therapy was associated with an improvement in postoperative cardiac outcome. (Current Controlled Trials number, ISRCTN83738615.)

Abstract
Background: A "teachable moment" is an event that motivates spontaneous behavior change. Some evidence suggests that major surgery for a smoking-related illness can serve as a teachable moment for smoking cessation. This study tested the hypotheses that surgery increases the likelihood of smoking cessation and that cessation is more likely after major surgical procedures compared with outpatient surgery.

Methods: Secondary analyses were performed of longitudinal biennial survey data (1992-2004) from the nationally representative Health and Retirement Study of U.S. adults older than 50 yr, determining the relationship between the incidence of smoking cessation and the occurrence of surgery.

Results: Five thousand four hundred ninety-eight individuals reported current smoking at enrollment, and 2,444 of them (44.5%) quit smoking during the period of examination. The incidence of quitting in smokers undergoing major surgery was 20.6/100 person-years of follow-up and 10.2/100 person-years in those undergoing outpatient surgery. In a multivariate negative binomial regression model, the incidence rate ratio of quitting associated with major surgery was 2.02 (95% CI: 1.67-2.44) and that of those associated with outpatient surgery was 1.28 (95% CI: 1.09-1.50). Estimates derived from national surgical utilization data show that approximately 8% of all quit events in the United States annually can be attributed to the surgical procedures analyzed.

Conclusions: Undergoing surgery is associated with an increased likelihood of smoking cessation in the older U.S. population. Cessation is more likely in association with major procedures compared with outpatient surgery. These data support the concept that surgery is a teachable moment for smoking cessation.

Abstract
Oesophagectomy is a technically-demanding operation associated with a high level of morbidity. We analysed the association of pre-operative variables, including those from cardiopulmonary exercise testing, with complications (logistic regression) and survival and length of stay (Cox regression) after scheduled transthoracic oesophagectomy in 273 adults, in isolation and on multivariate testing (maximum Akaike information criterion). On multivariate analysis, any postoperative complication was associated with ventilatory equivalents for carbon dioxide, odds ratio (95%CI) 1.088 (1.02-1.17), p = 0.018. Cardiorespiratory complications were associated with FEV1 and pre-operative background survival (in an analogous group without cancer), odds ratios (95%CI) 0.55 (0.37-0.80), p = 0.002 and 0.89 (0.82-0.96), p = 0.004, respectively. Survival was associated with the ratio of expected-to-observed ventilatory equivalents for carbon dioxide and predicted postoperative survival, hazard ratios (95%CI) 0.17 (0.03-0.91), p = 0.039 and 0.96 (0.90-1.01), p = 0.076. Length of hospital stay was associated with FVC, hazard ratio (95%CI) 1.38 (1.17-1.63), p < 0.0001.

Abstract
Background: Pulmonary rehabilitation is recognized as a core component of the management of individuals with chronic respiratory disease. Since the 2006 American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement on Pulmonary Rehabilitation, there has been considerable growth in our knowledge of its efficacy and scope.

Purpose: The purpose of this Statement is to update the 2006 document, including a new definition of pulmonary rehabilitation and highlighting key concepts and major advances in the field.

Methods: A multidisciplinary committee of experts representing the ATS Pulmonary Rehabilitation Assembly and the ERS Scientific Group 01.02, "Rehabilitation and Chronic Care," determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant clinical and scientific expertise. The final content of this Statement was agreed on by all members.

Results: An updated definition of pulmonary rehabilitation is proposed. New data are presented on the science and application of pulmonary rehabilitation, including its effectiveness in acutely ill individuals with chronic obstructive pulmonary disease, and in individuals with other chronic respiratory diseases. The important role of pulmonary rehabilitation in chronic disease management is highlighted. In addition, the role of health behavior change in optimizing and maintaining benefits is discussed.

Conclusions: The considerable growth in the science and application of pulmonary rehabilitation since 2006 adds further support for its efficacy in a wide range of individuals with chronic respiratory disease.

Abstract
Von Willebrand disease (VWD) is a common bleeding disorder, affecting male and female individuals equally, that often manifests in mucosal bleeding. VWD can be secondary to a quantitative (Type 1 and Type 3) or qualitative (Type 2) defects in Von Willebrand factor (VWF). Initial testing includes VWF antigen, as well as a platelet binding assay to differentiate between qualitative and quantitative defects. Further subtyping requires additional testing and is needed to ensure appropriate treatment. Desmopressin, antifibrinolytics, hormonal treatments for heavy menstrual bleeding, and VWF concentrates are commonly used in the treatment of VWD.

Abstract
Multiple clinical factors and now serum biomarkers may aid with risk stratification in vascular surgical patients. Herein, we review and update the clinical risk models, biomarker data, and currently used noninvasive cardiac stress tests. We also review the most recent American Heart Association guideline changes, and suggest a pathway for risk stratification.