Journal Watch - January 2023
Feasibility and outcomes of a real-world regional lung cancer prehabiliation programme in the UK
British Journal of Anaesthesia, 130 (1):e47-e55 (2023)
Prehabilitation describes a process by which a patient can be optimised before treatment. Improved exercise training and tolerance is one aspect of prehabilitation but it can also involve nutritional and psychological wellbeing. Lung cancer is the most common cause of cancer related deaths in the UK. Promotion of earlier detection is underway with increased screening programmes which equates to more patients being suitable for earlier surgical resection as a part of their treatment. A recent meta-analysis of RCT of exercise training in lung cancer surgery published in Thorax 2022 re-iterated the significant reduction in postoperative complications including length of stay and improved exercise tolerance postoperatively. The aim of this study was to introduce a Prehab4Cancer programme for patients in Manchester with a collaborative approach between hospital and community based clinical teams. This study aimed to assess the feasibility, participation and clinical outcomes gained from the delivery of such a prehabilitation programme for lung cancer patients
P4C (Prehab for Cancer) programme combined an enhanced surgery programme plus a community based multi-modal based prehabilitation programme for any lung cancer patient undergoing surgical resection. Significant funding was provided which allowed the establishment of an extensive team of clinical leads, exercise specialists and programme co-ordinators. Patient inclusion criteria were lung cancer MDT-agreed diagnosis of primary lung cancer with a treatment recommendation of surgical resection, aged 18years or over, registered with a primary care services and be able to access the programme independently or with support from family/carer.
Patients were offered a prehabilitation programme tailored to their baseline fitness and they were divided into two groups – ‘universal’ or ‘targeted’ pathway. Targeted pathway exercise prescription included three supervised group gym sessions per week. For the universal pathway patients could exercise independently with weekly monitoring with an exercise specialist. Exercises mainly consisted for high-intensity interval training and prescriptions were escalated as fitness improved. Nutritional status and psychological wellbeing was assessed and monitored. During Covid times this programme was also made available virtually.
During the 11 month period, 377 patients were referred to the Lung P4C services, originating from 11 hospitals across Manchester, median age was 72 years, 52% were female. From time of referral, initial assessment was within 8days. 64.3% of patients who attended a first assessment went on to complete the prehabilitation programme. Median interval from assessment to surgery was 36days. During the exercise delivery period, there was no adverse events during participation reported by the exercise specialists. Overall, statistically significant improvements were observed in the six minute walk test and the incremental shuttle walk tests after prehabilitation, therefore it can be inferred that a similar reduction in the rate of postoperative complications can be inferred. Quality of life assessment demonstrated improvements across multiple assessment scales. 20% of patients opted not to participate at varying stages.
Adequately resource clinical leadership and programme management is key to its success
Manchester and their Cancer Alliance group must be commended for their prioritisation of prehabilitation.
Strong links to community leisure service infrastructure allowing smooth referrals from the NHS
Clinical Led referrals needed encouragement
Patients and family members/carers were fully informed with information leaflets and resources. There is an available programme website also www.prehab4cancer.co.uk
It would have been even better for this study to report LOS postoperatively, pulmonary complications in those that underwent prehabilitation and those who didn’t from previous years data.
Journal Watch December 2022
Tranexamic Acid in Patients Undergoing Non-cardiac Surgery
Devereaux PJ et al. N Engl J Med. 2022;386(21):1986-1997
Perioperative bleeding is common in patients undergoing major noncardiac surgery. This can lead to increased morbidity and mortality. Tranexamic acid (TXA) has increasingly been used to reduce the incidence and severity of bleeding in surgery. Tranexamic acid is an antifibrinolytic drug that acts via inhibition of proteolytic activity of plasmin and displacement of plasminogen from fibrin.
This double-blind randomised controlled trial compared the use of tranexamic acid with placebo in major noncardiac surgery specifically looking at bleeding and composite cardiovascular outcomes (myocardial injury, non-haemorrhagic stroke, peripheral arterial thrombus or proximal venous thromboembolism). This was done in 114 centres in 22 countries from 2018 until 2021. Patients were randomised to receive 1g of tranexamic acid at the beginning and end of surgery or to receive placebo. 9535 patients were recruited with 4757 in the TXA group, and 4778 in the placebo group.
The primary outcome was combination of life-threatening bleeding, major bleeding and bleeding into a critical organ at 30-days. This occurred less in the TXA group (9.1%) compared to the placebo group (11.7%)(Hazard ratio 0.76; 95% CI 0.67-0.87; p<0.001). The outcome pertaining to myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis and proximal venous thromboembolism at 30-days occurred more often in the TXA group (14.2%) compared to the placebo group (13.9%)(Hazard ratio 1.02; 95% CI 0.92 – 1.14; p = 0.04)
The study was stopped early due to the SARS-COV-2 pandemic, however the investigators had reached an appropriate number of patients to perform an accurate analysis. Findings for bleeding was lower in life-threatening bleeding (1.6% vs 1.7%), major bleeding (7.6% vs 10.4%) and bleeding into a critical organ (0.3% vs 0.4%). Outcomes for cardiovascular events between the two groups was small, and the non-inferiority of tranexamic acid was not reached.
Take home points:
Routine administration of TXA, 1g at the beginning and 1g at the end, for non-cardiac surgery resulted in less bleeding compared with placebo. In this study, non-inferiority was not reached for the primary cardiovascular endpoint, and as such, an individualised approach will be needed for each patient when it comes to bleeding and cardiovascular outcome risk
In patients at high risk of bleeding, TXA reduces the risk of bleeding and appears to be safe based on the results of the POISE III study.
Journal Watch: May 2022
Frailty and perioperative patient-reported disability in patients undergoing cardiac surgery:
A pilot study.
This prospective pilot study was conducted in King’s College Hospital London. It looked at the association between pre-op frailty and post-op patient-reported disability-free survival in elective cardiac surgery patients.
Frailty is a clinical syndrome characterised by vulnerability to the development of dependency or mortality; it indicates a lack of physiological reserve and presents clinically as an impaired ability to recover after a destabilising event. Disability is a separate entity, defined by difficulty or dependency in completing activities of daily living and is a potential outcome of frail patients being exposed to a stressor, e.g. cardiac surgery.
Cardiac surgery patients tend to have relatively low pre-op disability scores; this may reflect the selection of patients without disability or that frailty is an important precursor of disability. Traditional cardiac scoring systems, e.g. EuroSCORE II, may miss vital information regarding physiological status that frailty assessment could identify. Adding frailty assessment may help inform surgical decision-making and patient-centred consent.
The hypothesis for this study was that adult patients undergoing elective cardiac surgery with pre-existing frailty would be free of disease and alive at 3-months. Being free of disability and alive have been suggested as relevant key criteria for patient-centred outcome measures after cardiac surgery.
Following ethical approval, any adult patient undergoing elective cardiac surgery was considered for inclusion unless exclusion criteria existed: inability to give informed consent, emergency surgery and severe concurrent CNS disease. The primary outcome was the association of pre-op frailty with post-op disability-free survival (DFS) at 3 months. Secondary outcomes included patient-reported disability scores pre-op and at 1 & 3 months post-op.
Pre-op work-up included routine anaesthetic and surgical assessment, Comprehensive Assessment of Frailty (CAF) scoring by 2 investigators and recording of baseline patient characteristics. The Comprehensive Assessment of Frailty (CAF) scoring system includes baseline biological markers, patient reported levels of exhaustion, physical tests of strength and stability and subjective investigator assessment of frailty using the Canadian Clinical Frailty Scale. The simplified Forecast score was also calculated, as was the EuroSCORE and the 12-question self-reporting disability version of the WHO Disability Assessment Schedule 2.0 (WHODAS-12). Clinicians involved in patient care were blinded to the patient’s frailty score.
Anaesthesia, surgery, cardiopulmonary bypass, and ICU care were conducted according to locally approved protocols. Postoperatively, operative characteristics and outcome data were collected by blinded team members. Telephone interviews were conducted at 1 and 3 months to determine disability-free survival using WHODAS-12 values or mortality data was collected. Deceased patients were assigned a maximal WHODAS-12 disability score of 48 at all post-op time points and were included in the results.
146 patients gave informed consent, 134 completed the 1-month follow up, and 125 completed the 3-month follow up. 32.2% were designated frail by CAF evaluation and 67.8% as non-frail, with no significant difference in age or operative characteristics between the groups. However, mortality was significantly higher in frail patients than in non-frail, both in-hospital and at 3-months.
Frail patients had significantly higher disability scores than non-frail patients pre-op and at 1 and 3 months post-op. Non-frail patients had significantly higher rates of disability-free survival at 1 and 3 months.
Median disability scores in frail patients were non-significantly reduced from baseline to 1 month post-op but significantly reduced from 1 to 3 months. In contrast, non-frail patients had a statistically significant increase in disability scores from baseline to 1 month. However, by 3 months, disability scores had reduced for both groups, with disability reduction being significantly greater in frail patients.
The study also showed that pre-op frailty (CAF) and disability scores (WHODAS-12) were better at predicting disease-free survival at 3 months compared with the EuroSCORE II. They also showed a moderate correlation between pre-op frailty and pre-op WHODAS-12 scores.
Pre-operative frailty is associated with a reduced likelihood of being free of disability and alive when compared with non-frail patients having elective cardiac surgery at all time points. Frail patients also experience a greater degree of disability than their non-frail counterparts. However, frail patients demonstrated a continuous decrease in disability burden postoperatively, while non-frail patients experienced an increase in disability at 1-month post-op, followed by an improvement in disability scores by the 3-month mark. So while frailty is associated with increased mortality, those frail patients who do survive are more likely to see a continuous improvement in their burden of disability after cardiac surgery when compared with their non-frail counterparts.
What does this mean for us?
This study suggests an important interplay between frailty/frailty assessment measures and underlying pathology and existing disability. We should be including these assessments as part of our routine work-up as the traditional cardiac perioperative risk scores in common use are poor predictors of patient-centred outcomes.
Journal Watch: April 2022
Real-Time Ultrasound-Guided Versus Ultrasound-Assisted Spinal Anesthesia in Elderly Patients With Hip Fractures: A Randomized Controlled Trial
Edited by Aoife Lavelle
This prospective, randomised trial compared the performance of spinal anaesthesia on elderly patients with hip fractures undergoing surgical repair using pre-procedural US-assisted (USAS) landmark identification and the more novel real-time ultrasound-guided (USRTG) technique.
Elderly patients with hip fractures needing spinal anaesthesia present a significant clinical challenge due to lumbar degeneration and positioning limitations. Pre-procedural USAS identification of the spinal anatomy has been shown to improve puncture success rate, reduce needle passes and procedural time and increase the procedure's safety.1 While USRTG guidance allows observation of the needle during needle insertion. The authors proposed USRTG spinal anaesthesia as a novel technique to improve the first-attempt success rate of spinal anaesthesia when compared with pre-procedural USAS landmark identification.
This was a prospective randomised trial. 114 patients were recruited over 6 months. All blocks were performed by 1 of 3 consultant anaesthesiologists skilled in US-guided blocks. All patients received an US-guided fascia iliaca compartment block 15 minutes before positioning. No sedatives were administered before or during the puncture procedure. The USAS group received spinal anaesthesia via the paramedian approach at the optimal puncture point as dictated by pre-procedural scanning. In the USRTG group, US was used to identify the midline and the widest intervertebral space. 1 of 3 approaches was used for spinal anaesthesia in this group: paramedian sagittal in-plane, paramedian sagittal out-plane or paramedian transverse in-plane.
The primary outcome was the first-attempt success rate of spinal anaesthesia, defined as successful dural puncture through a single attempt. Secondary outcomes included first-pass success rate (no redirection required during the first attempt), number of attempts & passes, time taken to locate and mark anatomy, time taken to perform spinal anaesthesia, total procedural time, adverse reactions or complications, patient satisfaction and procedural difficulty.
The sample size calculation was based on a pilot study which found USAS and USRTG to have a 76% and 43% first-attempt success rate, respectively. 45 patients were required for each group at the 0.05 significance level and 90% power; this was increased to 57 patients per group to allow for dropout.
The first-attempt success rate was higher in the USAS group than the USRTG group (80.6% vs. 52.6%), while first-pass success rate was 63.2% and 31.6%, respectively. Total number of attempts and passes was significantly lower in the USAS group. While USAS took longer to locate and mark the anatomy than USRTG, USAS took less time to perform spinal anaesthesia and its total time was shorter. Patient satisfaction scores were higher in the USAS group, while procedural difficulty scores were higher in the USRTG group. No significant difference in complications or adverse reactions was noted between the groups. No patients in the USAS group required a switch in technique to acquire CSF, whereas 8 patients in the real-time group did. No patients in either arm of the study required conversion to general anaesthesia.
So what does this mean for our practice?
Even in the hands of skilled sonographers, there does not appear to be an advantage to using real-time US-guidance for spinal anaesthesia. The role of US in spinal anaesthesia appears to be limited to assisting in pre-procedural landmark identification.
iHype – Intraoperative Hypotension in Elderly Patient: an observational study of intraoperative hypotension in patients aged over 65 in UK hospitals.
A. J. Wickham, D. T. Highton, S. Clark, D. Fallaha, D. J. N. Wong and D. S. Martin on behalf of the Research and Audit Federation of Trainees
Edited by Dr Kim Caulfield
iHypes main hypothesis is that the majority of older patients in the UK experience intra-operative hypotension below consensus defined thresholds (MAP <65mmHg, <20% decrease in systolic BP or SBP <100mmHg). The main concern with intra-operative hypotension is its association with myocardial injury, acute kidney injury, stroke and death. Intra-operative hypotension is increasingly implicated in the pathogenesis of perioperative end organ dysfunction most likely secondary to hypoperfusion and ischaemia.
This observation study was designed and carried out by the Research and Audit Federation of Trainees. It was a nationwide collaborative research effort. Ethical approval was sought from the West London and Gene Therapy Advisory Committee Research Ethics Committee. All patients aged >/=65years undergoing general or regional anaesthesia in the UK were enrolled into the study during a 48hour time period during a 4-week period between November and December 2016. Patients who were enrolled were followed for 30 days post-surgery.
Primary Outcome – incidence of intra-operative hypotension: MAP <65mHg, SBP reduction >20% from the preoperative baseline, and SBP <100mmHg. The duration of this event was also recorded. Consequences of hypotension were assessed in the context of AKI, Myocardial infarction and or stroke. Mortality was defined as inpatient mortality within 30days of surgery. Furthermore, a survey of anaesthetists was also distributed concurrently to gain an understanding of intended intra-operative treatments threshold for blood pressure. This survey correlated with the secondary aims of the iHype research initiative.
Data was collected from 4750 patients and 3366 anaesthetists completed the survey in 196 centres across England, Scotland and Wales. Non-invasive and invasive blood pressure readings were recorded. Data was collected from electronic and paper anaesthetic records. The incidence of intra-operative hypotension was 61% with MAP < 65mmHg, 77.5% of patients had a Systolic Blood pressure <100mmHg. More concerning is that 90.5% had a MAP >20% reduction from their normal BP and 91.3% had a reduction of their Systolic BP >20% from their normal. Interestingly, it was noted that the lowest blood pressure recorded was invariably after 30minutes of anaesthesia. Vasopressor use was recorded and interestingly 90.7% of patients blood pressure was treated with bolus of vasopressors rather than continuous infusions. Metaraminol was the most common vasopressor followed by phenylephrine. 7.3% of patients (345patients) had an adverse outcome – be it renal injury, myocardial injury, stroke or death.
As for the survey distributed to anaesthetists it also showed some interesting results. 59.2% of responses was from Consultant Anaesthetists. Anaesthetists most frequently stated that they intended to treat a 20% decrease in SBP or MAP; the most frequent SBP and MAP percentage decreases triggering treatment were 40% reductions.
The main concluding finding from this study suggests that the majority of anaesthetists area applying an absolute target that is below the treatment threshold SBP <90mmHg, MAP<65mmHg. This exposure to hypotension results in end organ dysfunction.
There are several limitations to the study which are highlighted by the research team – they include the reliance on handwritten anaesthetic records whose reliability can be questioned. They comment only on vasopressor use as a treatment for intra-operative hypotension, they don’t account for IV fluid administration, patient position adjustment or dose of anaesthetic adjustment. Furthermore, the use of pre-induction blood pressure as a value for comparison of intra-operative blood pressure may not always be accurate. A single BP in time is not always representative of a patients normal blood pressure. A patients preoperative frailty was not accounted for in terms of their postoperative co-morbidities and outcomes.
In conclusion, this study highlighted that intra-operative hypotension is common in patients >/=65years undergoing surgery in the UK. It also reinforces the need for national wide research. We need to commend the efforts of anaesthetic trainees and RAFT. It highlights our need as anaesthetists to increase our vigilance at targeting intra-operative blood pressure thresholds. It raises the question for the need for electronic records to enhance documentation of intra-operative blood pressure and more well designed clinical trials to define the best treatment strategies for intra-operative hypotension.
Journal Watch: January 2022
Evidence based strategies to reduce the incidence of post-operative delirium: a narrative review
C.J Swarbrick and J.S.L. Partridge. Anaesthesia 2022, 77 (Suppl. 1), 92–101. doi:10.1111/anae.15607
Edited by Siobhán Clarke
This review article focusses on delirium, one the most common postoperative complications affecting up to 40% of adult patients having surgery. Associated with increased postoperative mortality, morbidity, psychological sequelae and healthcare costs, delirium is preventable in up to 40% of cases.
At risk patients should be identified early in the pre-operative setting and while several delirium risk tools exist none of these have been validated in all elective and emergency surgical specialities. Most of the published evidence supports the use of non-pharmacological approaches in the prevention of delirium including multi-component intervention and comprehensive geriatric assessment. This narrative summary eloquently and concisely condenses this discussion.
Avoidance of certain medications e.g benzodiazepines is supported by strong evidence and multimodal analgesia including regional anaesthesia is recommended. There is conflicting evidence surrounding the use of steroids, dexamedetomidine and melatonin for the prevention of postoperative delirium. Burgeoning research suggests a correlation between depth of anaesthesia and post- operative delirium (1).
The age-old question of regional anaesthesia vs general anaesthesia rages on with a recent study in hip fracture patients concluding that mode of anaesthesia did not influence the incidence of postoperative delirium or survival (2). Finally, this narrative review addresses the challenges involved in multi-component interventions such as those needed in delirium prevention.