Neal S. Gerstein

Should More Patients Continue Aspirin Therapy Perioperatively?: Clinical Impact of Aspirin Withdrawal Syndrome

Objective:To provide an evidence-based focused review of aspirin use in the perioperative period along with an in-depth discussion of the considerations and risks associated with its preoperative withdrawal. Background:For patients with established cardiovascular disease, taking aspirin is considered a critical therapy. The cessation of aspirin can cause a platelet rebound phenomenon and prothrombotic state leading to major adverse cardiovascular events. Despite the risks of aspirin withdrawal, which are exacerbated during the perioperative period, standard practice has been to stop aspirin before elective surgery for fear of excessive bleeding. Mounting evidence suggests that this practice should be abandoned. Methods:We performed a PubMed and Medline literature search using the keywords aspirin, withdrawal, and perioperative. We manually reviewed relevant citations for inclusion. Results/Conclusions:Clinicians should employ a patient-specific strategy for perioperative aspirin management that weighs the risks of stopping aspirin with those associated with its continuation. Most patients, especially those taking aspirin for secondary cardiovascular prevention, should have their aspirin continued throughout the perioperative period. When aspirin is held preoperatively, the aspirin withdrawal syndrome may significantly increase the risk of a major thromboembolic complication. For many operative procedures, the risk of perioperative bleeding while continuing aspirin is minimal, as compared with the concomitant thromboembolic risks associated with aspirin withdrawal. Those cases where aspirin should be stopped include patients undergoing intracranial, middle ear, posterior eye, intramedullary spine, and possibly transurethral prostatectomy surgery.

Ultrasound-guided sciatic nerve block in the popliteal fossa using a lateral approach: onset time comparing separate tibial and common peroneal nerve injections versus injecting proximal to the bifurcation.

BACKGROUND: We hypothesized that blocking the tibial and common peroneal nerves individually using ultrasound distal to sciatic bifurcation would decrease time to complete block compared with a block proximal to the bifurcation. METHODS: Seventy-six patients undergoing foot or ankle surgery received a sciatic nerve block either proximal or distal to the point of bifurcation. A mixture of 28 mL 1.5% mepivacaine with 100 &mgr;g clonidine and 1 mL 8.4% sodium bicarbonate for a total of 30 mL was used. Ultrasound was used to guide needle adjustments to achieve circumferential spread. Block success was defined as a loss of sensation to pinprick in both nerve distributions within 46 minutes. RESULTS: Patients in the tibial-peroneal group had significantly faster time to complete block than the sciatic group (19.2 vs 26.1 minutes; P = 0.006). CONCLUSIONS: Blocking the tibial and common peroneal nerves in the popliteal fossa separately provides for a faster onset than a prebifurcation sciatic block.

Simultaneous Use of Two Defibrillators for the Conversion of Refractory Ventricular Fibrillation

From the *Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico; and †Utah Emergency Physicians, Intermountain Healthcare, Salt Lake City, Utah. Address reprint requests to Neal Stuart Gerstein, MD, University of New Mexico Department of Anesthesiology & Critical Care Medicine, MSC 10 60001, University of New Mexico, Albuquerque, NM 87120. E-mail: ngerstein@gmail.com

Intrathecal baclofen for postoperative analgesia after total knee arthroplasty

STUDY OBJECTIVE To determine whether intrathecal baclofen is an effective adjunctive agent to decrease acute and chronic postoperative pain after total knee arthroplasty. DESIGN Prospective, randomized, double-blind controlled trial. SETTING Operating room and inpatient units of a university hospital. PATIENTS 60 adult, ASA physical status I, II, and III patients presenting for total knee arthroplasty. INTERVENTIONS Anesthesia was provided by spinal injection of 15 mg of 0.75% hyperbaric bupivacaine combined with either 100 mcg baclofen or saline. Sedation was provided with intravenous midazolam and propofol. MEASUREMENTS Data were collected on adverse effects, opioid usage, and verbal pain scale (VPS) from 0 to 10. The study period was divided into six discrete time intervals that included the 1(st) 72-hour postoperative period and a three-month post-discharge follow-up telephone call. MAIN RESULTS The baclofen group used less morphine in the PACU than the control group (5 mg vs. 9.3 mg; P = 0.04). VPS were lower in the baclofen group than the treatment group, but significant differences could be demonstrated only in the time periods 48-72 hours and three months postoperatively. At three months, fewer patients in the baclofen group reported pain than the control group (8/27 vs. 19/29; P = 0.009). Regression analysis showed that the baclofen group was 4.5 times less likely to report pain at three months (95% CI: 1.5-16.6). CONCLUSIONS IT baclofen used as an adjuvant to spinal anesthesia for total knee arthroplasty allows for less postoperative opioid usage and less chronic pain at three months.

Perioperative aspirin management after POISE-2: some answers, but questions remain.

Aspirin constitutes important uninterrupted lifelong therapy for many patients with cardiovascular (CV) disease or significant (CV) risk factors. However, whether aspirin should be continued or withheld in patients undergoing noncardiac surgery is a common clinical conundrum that balances the potential of aspirin for decreasing thrombotic risk with its possibility for increasing perioperative blood loss. In this focused review, we describe the role of aspirin in treating and preventing cardiovascular disease, summarize the most important literature on the perioperative use of aspirin (including the recently published PeriOperative ISchemic Evaluation [POISE]-2 trial), and offer current recommendations for managing aspirin during the perioperative period. POISE-2 suggests that aspirin administration during the perioperative period does not change the risk of a cardiovascular event and may result in increased bleeding. However, these findings are tempered by a number of methodological issues related to the study. On the basis of currently available literature, including POISE-2, aspirin should not be administered to patients undergoing surgery unless there is a definitive guideline-based primary or secondary prevention indication. Aside from closed-space procedures, intramedullary spine surgery, or possibly prostate surgery, moderate-risk patients taking lifelong aspirin for a guideline-based primary or secondary indication may warrant continuation of their aspirin throughout the perioperative period.

A randomized clinical trial comparing the effectiveness of ultrasound guidance versus nerve stimulation for lateral popliteal-sciatic nerve blocks in obese patients.

Ultrasound guidance may decrease the procedural time for many peripheral nerve blocks compared to nerve stimulation, but these studies have generally excluded obese patients. This single‐blinded randomized clinical trial was designed to compare procedural times and related outcomes for ultrasound‐ versus nerve stimulation‐guided lateral popliteal‐sciatic nerve blockade specifically in obese patients.

Arterial to endtidal carbon dioxide gradient during pediatric laparoscopic fundoplication

Background:  Discrepancies between arterial carbon dioxide (PaCO2) and endtidal carbon dioxide (ETCO2) measures have been demonstrated in ventilated children with cyanotic congenital heart disease, infants with respiratory failure and during visceral and urological laparoscopic surgery.

Questions linger over POISE-2 and perioperative aspirin management

Commentary on : Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014;370:1494–503.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Aspirin therapy for secondary prevention in patients with cardiovascular (CV) disease was catalysed by the Antithrombotic Trialists’ Collaboration meta-analysis in which antiplatelet therapy (primarily aspirin) demonstrated a 22% reduction in mortality from any vascular cause.1 Based on this meta-analysis and American Heart Association (AHA) guidelines, high-risk patients (those with coronary artery, cerebrovascular or peripheral vascular disease) should be prescribed aspirin indefinitely.2 For primary prevention, aspirin is equivocal except in patients with diabetes with certain additional risks.3 The recent Perioperative Ischaemic Evaluation-2 (POISE-2) Trial is the largest prospective study to date designed to clarify the issues surrounding perioperative aspirin management. There were two components of POISE-2: perioperative aspirin versus placebo and perioperative clonidine versus placebo. This paper addresses the aspirin component. POISE-2 was a randomised, controlled, multicentre, international … [1]: {openurl}?query=rft.jtitle%253DN%2BEngl%2BJ%2BMed%26rft.volume%253D370%26rft.spage%253D1494%26rft_id%253Dinfo%253Adoi%252F10.1056%252FNEJMoa1401105%26rft_id%253Dinfo%253Apmid%252F24679062%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1056/NEJMoa1401105&link_type=DOI [3]: /lookup/external-ref?access_num=24679062&link_type=MED&atom=%2Febmed%2F19%2F6%2F224.atom [4]: /lookup/external-ref?access_num=000334601600006&link_type=ISI

The Thrombotic and Arrhythmogenic Risks of Perioperative NSAIDs

From the *Department of Anesthesiology, University of New Mexico, Albuquerque, NM; †Department of Internal Medicine, Raymond G. Murphy VA Medical Center, Albuquerque, NM; and ‡Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR. Address reprint requests to Neal Stuart Gerstein, MD, Department of Anesthesiology, MSC 10 6000, 2211 Lomas Blvd N.E. University of New Mexico, Albuquerque, NM 87120. E-mail: ngerstein@gmail.com

Comparison of available gum-elastic bougies

INTRODUCTION The purpose of this study was to compare 4 different gum-elastic bougies (GEBs) for differences in success rate, speed of intubation, and device preference. METHODS This was a randomized study of 4 different GEBs (Sunmed, Portex, Greenfield, and Eschmann) used by emergency medicine (EM) and anesthesiology residents and attending physicians on a simulated difficult airway model. Success, time to intubation, and personal preference were recorded for each participant. Data were compared with analysis of variance, chi(2) and t tests, and 95% confidence intervals (95% CIs) where appropriate. P < .05 was considered significant. RESULTS Twenty-one participants from EM (16 residents, 5 faculty) and 13 from anesthesia (9 residents, 4 faculty) were entered into the study. Overall success rates were 88% for Sunmed, 68% for Portex, 88% for Greenfield, and 79% for Eschmann. Participants were significantly more likely to be successful when using either the Sunmed or the Greenfield GEB compared with the Portex GEB (relative risk [RR] = 1.3, 95% CI = 1.0-15.6). Success rate by specialty was significantly different with 60 (71%) of 84 for EM physicians and 50 (96%) of 52 for anesthesiologists. Speed of intubation was a mean +/- SD of 22.5 +/- 9.7 seconds, with no significant difference by GEB or specialty. Participants were significantly more likely to prefer the Sunmed over the Greenfield (P = .001, RR = 6.9, 95% CI = 1.5-24.8) and the Eschmann over the Greenfield (P = .003, RR = 6.1, 95% CI = 1.6-63.0). CONCLUSION Emergency medicine physicians had better success rates using the Sunmed and Greenfield GEBs but low preference for the Greenfield GEB.