Richard Halliwell

Thoracic epidural anesthesia for cardiac surgery: the effects on tracheal intubation time and length of hospital stay.

UNLABELLED Improvements in analgesia after major surgery may allow a more rapid recovery and shorter hospital stay. We performed a prospective randomized trial to study the effects of epidural analgesia on the length of hospital stay after coronary artery surgery. The anesthetic technique and postoperative mobilization were altered to facilitate early intensive care discharge and hospital discharge. Fifty patients received high (T1 to T4) thoracic epidural anesthesia (TEA) with ropivacaine 1% (4-mL bolus, 3-5 mL/h infusion), with fentanyl (100-microg bolus, 15-25 microg/h infusion) and a propofol infusion (6 mg x kg(-1) x h(-1)). Another 50 patients (the General Anesthesia group) received fentanyl 15 microg/kg and propofol (5 mg x kg(-1) x h(-1)), followed by IV morphine patient-controlled analgesia. The TEA group had lower visual analog scores with coughing postextubation (median, 0 vs 26 mm; P < 0.0001) and were extubated earlier (median hours [interquartile range], 3.2 [2.1-4.6] vs 6.7 [3.3-13.2]; P < 0.0001). More than half of all patients were discharged home on Postoperative Day 4 (24%) or 5 (33%), but there was no difference in the length of stay between the TEA group (median [interquartile range], Day 5 [5-6]) and the General Anesthesia group (median [interquartile range], Day 5 [4-7]). There were no differences in postoperative spirometry or chest radiograph changes or in markers for postoperative myocardial ischemia or infarction. No significant TEA-related complications occurred. In summary, TEA provided better analgesia and allowed earlier tracheal extubation but did not reduce the length of hospital stay after coronary artery surgery. IMPLICATIONS We found that epidural analgesia was more effective than IV morphine for cardiac surgery. Epidural anesthesia also allowed earlier weaning from mechanical ventilation, but it did not affect hospital discharge time.

A Comparison of Epidural Ropivacaine Infusion Alone and in Combination with 1, 2, and 4 [micro sign]g/mL Fentanyl for Seventy-Two Hours of Postoperative Analgesia After Major Abdominal Surgery

UNLABELLED Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl. IMPLICATIONS Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.

Acute pain management: Scientific evidence, fourth edition, 2015

This guideline summary describes the fourth edition of Acute pain management: scientific evidence, which was published by the Australian and New Zealand College of Anaesthetists (ANZCA) and its Faculty of Pain Medicine (FPMANZCA) in December 2015. The fourth edition summarises the best available evidence on acute pain management, following methods established over the preceding three editions. It provides additional information by scoring the quality of and reporting further details on randomised controlled trials and meta‐analyses. The information is condensed into key messages that provide: ➢concise statements on each topic, showing the highest level of evidence; and ➢clinical practice points based on clinical experience or expert opinion.

Postoperative vascular complications in unrecognised Obstructive Sleep apnoea (POSA) study protocol: an observational cohort study in moderate-to-high risk patients undergoing non-cardiac surgery

Introduction Emerging epidemiological data suggest that obstructive sleep apnoea (OSA) is common in the general surgical population. Unfortunately, the majority of these patients are unrecognised and untreated at the time of surgery. There is substantial biological rationale to indicate that patients with unrecognised OSA are at a higher risk of postoperative vascular events. However, the extent of this morbidity is currently unknown. We have initated the postoperative vascular complications in the unrecognised obstructive sleep apnoea (POSA) study to determine the associations between OSA, nocturnal hypoxia and major postoperative vascular events in 1200 moderate-to-high risk patients undergoing major non-cardiac surgery. Methods and analysis The POSA study is an international prospective observational cohort study. Using a type 3 portable sleep monitoring device and ambulatory oximetry, we will quantify the severity of OSA. The primary outcome is a composite of vascular death, myocardial infarction; non-fatal cardiac arrest; stroke; pulmonary embolism; congestive heart failure and new arrhythmia within 30 days of surgery. As of November 2013, we have recruited over 700 patients from nine centres in six countries. The mean age is 68 years, the mean body mass index is 27 kg/m2 and 55% of patients are men. 27.9% of patients have known coronary artery disease, over 76% have diabetes. The majority of patients underwent orthopaedic surgery (28%) and colorectal resection (18.5%). Ethics and dissemination The POSA study has received ethics approval from all study sites before patient recruitment. Informed consent will be obtained from all patients. The POSA study will determine the risk of unrecognised OSA in major non-cardiac surgery. We will publish these findings in peer-reviewed journals. Trial Registration: ClinicalTrials.gov Identifier: NCT01494181

Cardiac assessment prior to non-cardiac surgery.

Increasingly, patients undergoing non‐cardiac surgery are older and have more comorbidities yet preoperative cardiac assessment appears haphazard and unsystematic. We hypothesised that patients at high cardiac risk were not receiving adequate cardiac assessment, and patients with low‐cardiac risk were being over‐investigated.

332 CARDIAC RISK FACTORS AS PREDICTORS OF MYOCARDIAL INJURY AFTER NON CARDIAC SURGERY

Background: We compared cardiac risk factors and the revised cardiac risk index (RCRI) as predictors of post-operative myocardial injury after non-cardiac surgery. Methods: Consecutive patients ≥45 years undergoing non-cardiac surgery were recruited. Patients had cardiac troponin T (cTnT, 4th or 5th generation Roche assay) measured on days 0, 1, 2 and 3 post-operatively. Results: Three hundred and eighty-nine patients were recruited. The mean age was 65, 50% were female, 17% had a history of coronary artery disease, 3.6% a history of heart failure, 20% diabetes, 58% hypertension, 41% on cholesterol-lowering statin therapy and 78% had current or previous tobacco exposure. Post-operatively 10.3% (n=40) had cTnT elevation (>99th percentile) and 3.6% (n=14) a clinical MI (elevated cTnT plus symptoms and/or ECG changes). Increasing age, a RCRI ≥2 and higher creatinine levels were independent predictors of myocardial injury. Smoking and hypertension may also play a role (table). Conclusions: Cardiac risk factors are prevalent in the non-cardiac surgical population and have potential as predictors of risk in addition to the RCRI score. Further work is required to better identify those at risk and develop strategies to reduce its occurrence.