January - February 2023

Anesthesia Analgesia

Submitted January 2023 by Dr David Sainsbury

Read by 241 Journal Watch subscribers

Summary
This was a retrospective cohort study of opioid-naïve patients aged 12-21 undergoing surgery. The study used insurance claim data to examine the healthcare usage of the patients and the association with prolonged opioid use after surgery (POUS). POUS was defined as one or more opioid prescriptions dispensed between 91 and 180 days
after the incident surgical procedure and the association with health care utilisation up to 730 days after the surgical encounter. The study found that the patients in the POUS group had greater health care utilisation including LOS, inpatient, outpatient and emergency department visits. This was associated with a mean increase in cost of US$4604.

Discussion
The authors’ conclusions that POUS is associated with increased health care utilisation is probably correct. Despite being a retrospective study, its major strength, like many similar studies, is the sheer wealth of data that the US insurance providers collect. This included 126,338 patients over the course of 16 years with each patient ‘followed up’ for 2 years post-procedure. The authors highlighted that the POUS cohort are more complex at baseline with
more pain problems, mental health challenges and chronic illnesses. These are a group of patients who are likely to struggle with any surgical procedure although the increased healthcare use remained after taking these baseline characteristics into consideration.

There is a dearth of procedural information and post-procedure clinical information such as whether the patients were developing a persistent post-surgical pain state for which they felt opioid use was appropriate. There have been multiple studies in the US looking at how exposure to opioids even for routine procedures can lead on to chronic opioid use. This has variably been called chronic or persistent opioid use seemingly to facilitate research in this area. However, these terms can be problematic as they do not represent a clinical entity.

In this study, the lack of context also means we have no idea what POUS and the increased healthcare usage actually represents. This failure to identify modifiable patient and system factors means this information is of limited use for most clinicians other than to serve as a reminder that ‘normal’ peri-operative exposure to opioids in our vulnerable young patients can lead to aberrant opioid use.

It is also worth noting the massive amount of opioid these POUS adolescents and young adults were prescribed; across the study there was a mean of 20 days’ supply with a mean morphine equivalent of nearly 1100 mg. It would have been interesting to see how those prescribing practices might have contributed to POUS and to take the opportunity to remind prescribers of their responsibility to ensure good opioid stewardship.

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Anaesthesia & Intensive Care Medicine

Submitted January 2023 by Dr David Sainsbury

Read by 255 Journal Watch subscribers

This is an educational article discussing the management of mainly post-surgical pain in neonates from a group of authors based at Alder Hey Children’s Hospital in the UK. It has sections on physiology, pain assessment, non-pharmacological approaches, pharmacological approaches, and regional anaesthesia. It reads more as a report of their local practice than a review. It is useful as it provides a framework for assessment and management including
dosages used for nurse-controlled analgesia programs and various regional blocks, which are not always easily accessible.

They also report on and encourage the use of PR codeine in this age group. It appears to be something they have been able to make work for them in their institution, but they present it without any data to support this practice. Either side of this is an acknowledgment of the UK’s prohibition on the use of codeine in under-12s and the challenges of morphine use in neonates.

The article could have been more comprehensive by re-iterating the pharmacokinetic differences in this age group (these are briefly covered while discussing morphine), reviewing fentanyl and a-2 agonists in more detail, and discussing management of procedural pain/skin-breaking procedures; a significant source of pain and distress in this age group and something which we contribute to as anaesthetists.

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European Journal of Anaesthesiology

Submitted January 2023 by Dr Don Hannah

Read by 274 Journal Watch subscribers

Methods
A group was appointed to develop guidelines on the peri-operative management of neuromuscular blockade. Clinical queries were developed in the form of three Population/Intervention/Comparison/Outcome (PICO) groups. The literature was searched from 1995 to 2021 and authors were able to add papers they thought were appropriate. All papers underwent screening for bias.

PICO groups and findings
1. Is the use of myorelaxants necessary to facilitate tracheal intubation in adults?
1.1. Pooled data patients (447) showed 38% intubated with a relaxant-free induction regimen experienced pharyngeal or laryngeal injury compared to 27% when neuromuscular relaxants were used pharyngeal or laryngeal injury
1.2. The incidence of poor intubation conditions was 27% in the group without muscle relaxants vs. 3% with paralysis
2. Does the intensity of neuromuscular blockade influence a patient’s outcome in abdominal surgery (i.e. laparotomy or laparoscopy)?
2.1. The majority of surgeries studied were laparoscopic procedures
2.2. Deep blockade resulted in better conditions, but the authors stressed that this is controversial and multifactorial
2.3. Studies were too heterogeneous to give results on post operative pain or other adverse outcomes
3. What are the strategies for the diagnosis and treatment of residual neuromuscular paralysis?
3.1. The pooled incidence of residual paralysis was similar in the qualitative NMM (0.306) when no NMM was used (0.331). The use of a quantitative NMM resulted in an incidence of residual paralysis of 0.115 (95% CI: 0.057 to 0.188)
3.2. Confirmed that residual paralysis is more common after neostigmine-based reversal of deep to moderate NMB compared with than after sugammadex (24% vs 2%)
3.3. Found that a significant number of cases reversed with neostigmine at TOF=4 still had a TOF ratio <0.9 at 10-20min later

I was quite surprised to find that this was the first European Society of Anaesthesiology and Intensive Care (ESAIC)
guideline on peri-operative management of neuromuscular blockade. Few readers will find anything controversial in this paper. It does provide good evidence for requesting quantitative neuromuscular monitors in each theatre and appropriate access to sugammadex as required.

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Anesthesiology

Submitted January 2023 by Dr Don Hannah

Read by 276 Journal Watch subscribers

This update focuses primarily on the method and site of neuromuscular monitoring and the process of antagonising neuromuscular blockade to reduce residual neuromuscular blockade.

Methods
Delineation of methods was clear and exhaustive. The presentation of supplemental digital content aids in a more comprehensive understanding of the data. The major shortcoming is the explicit exclusion of non-English literature.

The recommendations made are as follows:
• When neuromuscular blocking drugs are administered, we recommend (strong) against clinical assessment alone to avoid residual neuromuscular blockade, due to the insensitivity of the assessment (moderate evidence)
• A large multinational prospective cohort study did not detect a difference in a composite pulmonary complication outcome (respiratory failure, hypoxia, pulmonary infection or infiltrates, atelectasis, aspiration pneumonia, bronchospasm, or pulmonary oedema) in patients with quantitative versus qualitative assessment
• Two of the three randomised studies reported a lower incidence of hypoxia with quantitative monitoring‚ one no events: low strength of evidence)
• Recommend (strong) confirming a train-of-four ratio greater than or equal to 0.9 before extubation (moderate evidence)
• When sugammadex was used and a train-of-four ratio (ToF) greater than or equal to 0.9 was confirmed before extubation, the pooled incidence of residual neuromuscular blockade was 0.5% compared to 2.2% without ToF. With neostigmine, the incidence was 5.3% and 44.9% respectively, with and without confirmation
• Strong recommendation for using the adductor pollicis muscle for neuromuscular monitoring (moderate evidence)
• Time to reach train-of-four ratio greater than or equal to 0.9 at the adductor pollicis muscle was longer compared with eye muscles and flexor hallucis brevis.
• Measurements obtained at sites with longer recovery times helps guarantee full neuromuscular function on reversal.
• Strong recommendation for using sugammadex over neostigmine at deep, moderate, and shallow depths of neuromuscular blockade induced by rocuronium or vecuronium, to avoid residual neuromuscular blockade (moderate evidence)
• The incidence of residual neuromuscular blockade was lower and time to recovery was shorter with sugammadex compared to neostigmine. However, there were no differences in re-paralysis and reintubation rates
• No differences in tachycardia, bradycardia or arrhythmias when comparing neostigmine to sugammadex
• Low evidence of slightly lower rates of reintubation, postoperative hypoxia and pneumonia with sugammadex compared to neostigmine
• Pooled anaphylaxis rates of 1.4/10,000 for sugammadex and 0.3/10,000 for neostigmine. (similar to Orihara et al BJA 2020 Feb;124(2):154-163)

A tension always exists with literature of this type between raw presentation of data, which often offers little guidance, and interpretation of data, which can appear biased or be promoting a particular agenda. This paper leans towards the latter but presents enough information for the reader to decide if the conclusions are valid or should change their practice.

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Anesthesiology

Submitted January 2023 by Dr Don Hannah

Read by 275 Journal Watch subscribers

This was an update of previous guidelines aimed at addressing the ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and paediatric fasting duration.

Methods
Delineation of methods was clear and exhaustive. The presentation of supplemental digital content aids in a more comprehensive understanding of the data. The major shortcoming is the explicit exclusion of non-English literature.

Major findings
A strong recommendation (moderate evidence) is made for healthy adults to drink carbohydrate-containing (CHO-containing) clear liquids until 2 h before elective procedures requiring general anaesthesia. When comparing CHO-containing and clear fluids:
• Patients reported less sensations of hunger
• There were no differences in nausea, regurgitation, aspiration or patient satisfaction
• There was no difference in residual gastric volume
• There is insufficient evidence to recommend protein-containing clear liquids preferentially over other clear liquids
• All protein-containing fluids studied also contained carbohydrates. Comparison studies between protein and carbohydrates containing fluids were insufficient to make a recommendation for one over the other
• Chewing gum should not delay surgery. Data was low strength; there was no increase in gastric volume, change in gastric pH or increase in aspiration risk
• Supports clear liquids in children at low risk of aspiration to 2 h before procedures. Data showed no difference between outcomes for 1 hr vs 2 hr fasting (very low strength of evidence)
• No differences in patient-reported hunger or thirst, incidence of aspiration or regurgitation, and gastric pH or residual gastric volume.
• They noted that recent European and Canadian guidelines have recommended reducing clear liquid fasting to 1h in children.

Perioperative fasting protocols revolve around optimisation of patient outcomes (i.e. less post op nausea, better patient satisfaction, contribution to ERAS pathways; and patient safety i.e. should this patient be cancelled due to their fasting status). These guidelines provide reassurance for continuing to minimise preoperative fasting in otherwise well adults and children. The continuing difficulty is delineating which patients are at a higher risk of aspiration, the degree of that risk and the risk of poor outcomes if aspiration occurs.

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Pediatric Anesthesia

Submitted January 2023 by Dr Susan Hale

Read by 253 Journal Watch subscribers

Aim
To evaluate the impact of the Women’s Empowerment and Leadership Initiative (WELI) on career development over time.

Method
This is an anonymous voluntary email survey study of proteges and mentors who participated in the WELI program which was launched in 2018. Surveys were sent in May 2021 and January 2022; additionally, an initial baseline survey was emailed in November 2020 with findings published in 2021. The survey consisted of 2 parts:

Firstly, 5-point Likert-type questions assessing how program components influenced career development areas such as project completion, goal setting, self-rated mentorship abilities, career advancement opportunities and wellbeing.

The second part of the survey consisted of open-ended questions asking for descriptions about how WELI impacted career development, networking, sense of purpose or wellbeing, the value of specific features of the WELI program and suggestions to improve WELI. This was qualitatively analysed to identify themes and identify quotes used as examples.

Responses rates were between 51-52% with 161 and 185 members answering the 6 and 14 month surveys respectively, approximately half being mentors and half proteges.

Findings
1. Value of program components – the advisor-protégé pairing, workshops and nomination to WELI were seen as being very valuable whereas the virtual networking sessions were less valuable.
2. Contribution to career opportunities
a. Assistance with projects: mixed results with improvements at the 6-month survey for proteges for starting a new project which returned to baseline at 14 months. There was consistent contribution to improving and completing projects and finding new collaborators for both proteges and mentors.
b. Support for career advancement: proteges described WELI as contributing somewhat to invited speaker opportunities, applying for promotions. There was improvement at the 6-month survey in applying for and receiving leadership positions, but this returned to baseline at 14 months.
c. Contribution to wellbeing and ability to mentor others: mentoring skills and professional optimism improved for all and helped proteges improve clarity of priorities, and personal sense of achievement and meaning in their work.
3. From the quantitative analysis the following themes were identified.
a. Facilitation of meaningful networking; more so for proteges than advisors
b. Fostering of new career opportunities, skills and projects important for career advancement and promotion
c. Builds confidence to try new things
d. Helped improve personal-professional life balance
e. Helped improve mentorship skills
f. Effects of the covid 19 pandemic resulting in a desire for in person rather than virtual meetings

Commentary
The WELI program has demonstrated its value in contributing positively to the career development of women paediatric anaesthesiologists with benefits seen for advisors as well as protégés. The context of this study taking place during the Covid 19 pandemic is significant with likely effects on factors from response rate to outcomes such as the perceived value of virtual meetings in an environment where virtual meetings were the main mode of professional group interaction. Limitations include the lack of a true baseline survey, the potential for survey bias and response bias and the lack of demographic data such as age, ethnicity and colour.

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Anaesthesia & Intensive Care Medicine

Submitted January 2023 by Dr Susan Hale

Read by 264 Journal Watch subscribers

The Critical Care, Resuscitation, Airway Skills: Helping you return to work course (CRASH) course is a bi-national (Australia and New Zealand) collaboration between anaesthetists, intensivists and emergency physicians. The course consists of tailored sessions using simulation and case-based discussions to practice skills and clinical decision-making together with access to resources to aid return to work (RTW). Since 2014, 197 participants have attended the course, either virtually or in-person.

This article describes the background, course development and evolution, adaptation during the COVID-19 pandemic, demographic data of the course participants and future plans for the CRASH course. The background includes an interesting description of the literature around inactivity and RTW.

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Pediatric Anesthesia

Submitted January 2023 by Dr Susan Hale

Read by 243 Journal Watch subscribers

This editorial, written by authors from the Department of Anaesthesia and Pain Management at Perth Children’s Hospital, describes various initiatives such as the Woman’s Empowerment and Leadership Initiative (WELI) and ANZCA’s Panel Pledge. It reflects on the failure to achieve gender equity in academic medicine despite these efforts. A possible rationale for this failure is offered which argues that change may require not only empowering women but also challenging the current paradigms of leadership to provide more attractive leadership options. Examples of how this might work include changing the traditional pyramidical vertical leadership model to collective or shared leadership models which would be more appropriate for not just for women but all, in an environment where there is demand for better work life balance together with the ability to commit to other responsibilities such as childcare.

Another example is separating academic and clinical leadership roles within a department. Spreading leadership to more than one individual has advantages in enabling better continuity and retention of corporate knowledge while allowing for improved diversity and the ability to allow more junior members of a department to participate in leadership roles while having support from more experienced colleagues.

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