BEST ANESTHESIOLOGY PAPERS OF 2015

WAS February 27, 2016

Best Papers of 2015 Alana M. Flexman, MD FRCPC Clinical Assistant Professor Department of Anesthesiology and Perioperative Care Vancouver General Hospital University of British Columbia

Whistler Anesthesiology Summit February 27, 2016


Disclosures • Research grants:

² Canadian Anesthesiologists’ Society ² Hospira, Inc ² Masimo, Inc

• Honoraria ² Hospira, Inc


Paper selecGon

• Clinical Focus • General Appeal • Past 12 months • 5 papers selected

Objec&ve: To review influen&al publica&ons from the past year


Survey says… Premedication with lorazepam results in which of the following:

A.  Improved patient satisfaction B.  Similar time to extubation C.  Reduced intraoperative hypotension D.  Slower recovery of early cognition


Szamburski et al

Szamburski et al, JAMA 2015; 313: 916-‐925.


Szamburski et al


To assess the efficacy of preoperative sedation in influencing a patient’s perioperative experience


Szamburski et al


N=1062 randomized Elective surgery, GA

N=354 Lorazepam

2.5 mg

N=354 No Premed

N=354 Placebo

Primary Outcome: Patient Satisfaction (EVAN-G) Secondary Outcomes: PQRS, cooperation, anxiety, pain, well-being, quality of sleep & recover, time to extubation


Szamburski et al


Lorazepam No premed

Placebo P-Value

Overall satisfaction

72 73 71 0.38

Time to extubation

17 min 12 min 13 min <0.001

Amnesia 24% 6% 6% <0.001 Anxiety in OR (VAS)

35 38 44 0.001*

Pain satisfaction

68 66 53 0.01


Szamburski et al



Szamburski et al


• Sedation with lorazepam did NOT improve self-reported patient experience the day of surgery • But reduced anxiety on arrival to OR

• Sedation was associated with 4 min prolongation of extubation time and lower rate of early cognitive recovery


Szamburski et al


Rou&ne premedica&on with lorazepam


Survey says… In the management of acute STEMI, providing supplemental oxygen to normoxic patients results in:

A.  Worse patient outcomes B.  No effect on patient outcomes C.  Improved patient outcomes


Stub et al

Stub et al, CirculaGon 2015;131:2143-‐2150.


Stub et al


• AMA: : no clear recommendation • 90% receive supplemental oxygen Beasley et al, J R Soc Med 2007;100:130-‐133.


Stub et al


Compare supplemental oxygen therapy with no oxygen therapy in normoxic patients with STEMI to determine its effect on myocardial infarct size


Stub et al


Primary Outcome: Myocardial injury (peak cTnI & CK) Secondary Outcomes: ST-‐segment resoluGon, mortality, major adverse cardiac events, infarct size at 6 months

N=470 enrolled, 441 completed STEMI, SpO2 >94%

Supplemental O2 8 L/min N=218

No O2 unless SpO2 <94% N=223


Stub et al


• 7% of No Oxygen group required O2

• SpO2 higher in Supplemental O2 group • Baseline characteristics, hemodynamics and procedures similar


Stub et al


Outcome Oxygen No Oxygen P-value

Mean peak TnI 57.4 48.0 0.18 Mean peak CK 1948 1543 0.01 Mean infarct size 14.6 10.2 0.06 ST resolution 62% 70% 0.10 Recurrent MI 5.5% 0.9% 0.006 Death 1.8% 4.5% 0.11 Major arrhythmias 40% 31% 0.05


Stub et al



Stub et al


• Routine oxygen therapy not associated with reduction in symptoms or infarct size

• Routine high-flow oxygen may be accompanied by harm


Stub et al


Supplemental O2 in normoxia for STEMI?

(cardiac ischemia?)


Survey says…

Jorgenson et al, JAMA 2014;312(3):269-‐277.

Which of the following is most effective in reducing intravascular catheter-associated infections?

A. Chlorhexidine-alcohol B.  Iodine C.  Iodine-alcohol D. Skin scrubbing before insertion


Mimoz et al

Mimoz et al, Lancet 2015;386:2069-‐2077.


Mimoz et al


1)  To compare the efficacy of chlorhexidine-alcohol vs providone iodine-alcohol to prevent short-term catheter-related infections

2)  To determine the effect of skin scrubbing with antiseptic detergent on catheter colonisation


Mimoz et al


N=2349 enrolled ICU requiring CVL or arterial line >48h

Iodine-alcohol & scrubbing N=1286

catheters

Iodine-alcohol & no

scrubbing N=1326

catheters

Chlorhex-alcohol & scrubbing N=1270 catheters

Chlorhex- alcohol & no

scrubbing N=1277

catheters

Primary Outcome: Incidence of catheter-‐related infecGons Secondary Outcomes: Incidence of catheter colonisaGon


Mimoz et al


• Groups similar with respect to: • Demographics • History of immune deficiency/disease • Metastatic cancer • Indication for admission • Type of line inserted • Operator experience

WAS February 27, 2016 Mimoz et al, Lancet 2015;386:2069-‐2077.


NNT 78 catheters in place for a mean of 8 days to prevent 1

infection


Less catheter-related blood infections with chlorhexidine


No benefit to scrubbing


Mimoz et al


• No difference in ICU length of stay or mortality between the preps

• No difference in incidence of colonisation with scrubbing

• Higher rate of severe skin reactions with chlorhexidine-alcohol (3% vs 1%, p=0.0017)


Mimoz et al


1 infection=€19583 ($39346.89)

Chlorhexidine for 78 catheters=€227 ($456.14)


Mimoz et al


• Chlorhexidine-alcohol combination should now be standard of skin preparation before major intravascular catheter insertion

• Scrubbing of the skin with detergent should not be standard


Pollack et al

Pollack et al, NEJM 2015; 373: 511-‐20.

Chlorhexidine-‐alcohol ✔


Survey says… Which of the following is NOT associated with increased perioperative mortality:

A.  Age > 65 years B.  Case start after 4:00pm C.  ASA physical status > 3 D.  Male gender E.  Age <1 year


Whitlock et al

Whitlock et al, Anesthesiology 2015;123:1312-‐1321.


Whitlock et al


• Predictors of postoperative mortality across broad surgical populations unclear

• National Anesthesia Clinical Outcomes Registry (NACOR)


Whitlock et al


To identify factors associated with perioperative mortality using the NACOR dataset


Whitlock et al


Entire NACOR Dataset 18 487 093

Outcome eligible 2 948 842 cases

Missing data 17383 cases

Obstetric 65318 cases

Final Dataset 2 866 141

cases

No outcome 15 538 251 cases


Whitlock et al


Predictor variables: PracGce/facility type

PaGent factors (age, sex, ASA) Emergency/elecGve

Procedure factors (type) Anesthesia factors (type)

Case start Gme and duraGon

Primary Outcome: Death within 48 hours of inducGon


Whitlock et al







Multivariate regression


Whitlock et al







Sensitivity analyses Multivariate regression


Whitlock et al


Variables independently associated with mortality

Increasing ASA

Emergency case

Age < 1 year

Age > 65 years

Cases beginning between 4:00pm and 6:59am


Whitlock et al



Whitlock et al



Whitlock et al


• Confirmed association with known predictors of outcome (e.g. ASA class, age)

• Increased mortality in cases starting after 4pm • Potentially modifiable risk factor

NEW


Minimize surgery aIer 4:00pm?

✔

Whitlock et al



Survey says… In patients with atrial fibrillation, bridging warfarin with LMW heparin around surgery:

A.  Reduces the risk of stroke B.  Increases the risk of bleeding C.  Reduces the risk of DVT/PE D.  Reduces the risk of death


DoukeGs et al

DoukeGs et al, NEJM 2015;373:823-‐33.


DoukeGs et al



DoukeGs et al


N=1884 randomized Afib on Warfarin

Bridging (Dalteparin)

No bridging (Placebo)

Primary Efficacy Outcome: Arterial thromboembolism Primary Safety Outcome: Major bleeding


DoukeGs et al


Patients: • Mean CHADS2 score: 2.3 • 34% on ASA • 3.7% on Clopidogrel • 31% CHF or LV dysfunction


DoukeGs et al


Outcome No Bridging Bridging P-‐value

Arterial thromboembolism 0.4% 0.3% 0.73 (0.01 Non-‐Inf)

Major Bleeding 1.3% 3.2% 0.005

Death 0.5% 0.4% 0.88

Myocardial Infarc&on 0.8% 1.6% 0.10

DVT/PE 0% 0.1% 0.25

Minor Bleeding 12% 20.9% <0.001


DoukeGs et al


• Discontinuing warfarin without bridging was non-inferior to bridging in preventing arterial thromboembolism

• Bridging led to increased major and minor bleeding

• No difference in MI, VTE, death • Net benefit in avoiding bridging


DoukeGs et al


Rou&ne bridging for atrial fibrilla&on


References 1.  Maurice-Szamburski A, Auquier P, Viarre-Oreal V, Cuvillon P, Carles M, Ripart

J, et al. Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial. JAMA. 2015 Mar 3;313(9):916-25.

2.  Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50.

3.  Mimoz O, Lucet JC, Kerforne T, Pascal J, Souweine B, Goudet V, et al. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet. 2015 Nov 21;386(10008):2069-77.

4.  Whitlock EL, Feiner JR, Chen LL. Perioperative Mortality, 2010 to 2014: A Retrospective Cohort Study Using the National Anesthesia Clinical Outcomes Registry. Anesthesiology. 2015 Dec;123(6):1312-21.

5.  Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-33.

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BEST ANESTHESIOLOGY PAPERS OF 2015