An observational study of perioperative risk associated with aortic stenosis in non-cardiac surgery.

This prospective multicentre observational study investigated the risk of non-cardiac surgery in patients with moderate or severe aortic stenosis (AS). Patients with AS undergoing non-cardiac surgery in five New Zealand hospitals between August 2011 and September 2015 were studied. Preoperative variables were analysed for a significant association with postoperative major adverse cardiac events (MACE) and 30-day mortality. Of the 147 patients recruited, 13 (9%) died within 30 days and 33 (22%) had a MACE. Using univariate analysis, patients with severe AS had four times higher 30-day mortality than patients with moderate AS (16% versus 4%, P=0.007). Other factors associated with increased 30-day mortality included having a smaller aortic valve area, smaller dimensionless severity index, concomitant mitral regurgitation, and higher overall surgical risk. Patients with symptoms attributable to AS had a higher incidence of MACE compared to patients without symptoms (36% versus 16%, P=0.011). Variables significantly associated with both 30-day mortality and MACE were age, American Society of Anesthesiologists physical status, emergency surgery, New York Heart Association classification, preoperative albumin level, frailty, and history of congestive heart failure. Using multivariate analysis, emergency surgery, symptoms attributable to AS, preoperative albumin level, and AVA remained significantly associated with adverse outcome. While these findings should be interpreted with caution due to the observational nature of the study, limited power and multiple simultaneous comparisons, they suggest that patients with severe AS have a higher risk of adverse outcome after non-cardiac surgery than patients with moderate AS.

A retrospective observational study of patients with dilated cardiomyopathy undergoing non-cardiac surgery.

The perioperative risks and factors associated with adverse cardiac outcomes in patients with dilated cardiomyopathy undergoing non-cardiac surgery are unknown. Interrogation of the Nelson Hospital transthoracic echocardiogram database identified 127 patients with dilated cardiomyopathy who satisfied the study criteria and underwent non-cardiac surgery between June 1999 and July 2013. Demographic and clinical data along with postoperative death within 30 days or a major adverse cardiac event were retrieved and analysed. The mean age was 75.9 years. Seventy-one percent of the patients had severe impairment of left ventricular function and 35% had a severely dilated left ventricle. A major adverse cardiac event occurred in 18.1% of patients and 5.5% of patients died within 30 days of surgery. Increased surgical risk and absence of cerebrovascular disease were associated with adverse outcome (P <0.001, P <0.05, respectively). Forty-three and a half percent (43.5%) of patients undergoing high-risk surgery had an adverse outcome compared to 36.1% and 5.9% for moderate and low-risk surgery, respectively. A major adverse cardiac event was observed in 26.7% of patients with cardiovascular disease compared to 9.8% of patients without cardiovascular disease. We were unable to exclude an influence of other potential risk factors due to the retrospective observational nature of the study. These findings highlight a potential increase in complications with moderate or high surgical risk, whilst are reassuring in demonstrating the relative safety of low-risk surgery in this group of high-risk patients.

Home blood pressure monitoring in an anaesthetic pre-admission clinic.

We suspected that many high blood pressure measurements taken in our anaesthetic pre-assessment clinic and immediately prior to induction of anaesthesia were unusually elevated due to a 'white coat' effect. These high blood pressure measurements were causing late cancellations of surgery, even though white coat measurements may not be representative of the patient's usual blood pressure or of their risk of end-organ damage due to hypertension. In this audit, patients with high blood pressure in our pre-admission clinic were provided with training and a home blood pressure monitor to use prior to surgery. These were compared to the pre-admission clinic measurements to determine the incidence of white coat hypertension. We also compared home to general practice blood pressure monitoring where possible. Fifty-two patients were provided with monitors. Fifty-one of these took at least five measurements at home. Thirty-four (66%) patients had average measurements at home at least 20 mmHg lower than pre-admission clinic measurements. A total of 33% of general practice clinic measurements were also ≥ 20 mmHg higher than average home measurements. White coat hypertension was common in our audit population. Relying on average home blood pressure measurements rather than 'one off' in-hospital measurements may have helped to prevent the postponement or cancellation of surgery for 13 patients who had recorded blood pressure ≥ 180/110 mmHg in our pre-admission clinic.

Oral transmucosal fentanyl citrate versus placebo for painful dressing changes: a crossover trial.

OBJECTIVE: Fentanyl is a potent opioid that is well absorbed via the oral mucosa. It can be given as an oral lozenge. The onset of analgesia is rapid and matches the pain profile observed at dressing changes. METHOD: Patients experiencing pain during daily dressing changes were given entonox plus either placebo or oral transmucosal fentanyl citrate (OTFC) for two consecutive dressing changes in a randomised double-blind placebo-controlled crossover trial. RESULTS: Nine patients were recruited. The mean worst pain score during dressing changes was 7/10 with placebo and 4/10 with OTFC; the reduction in pain achieved with OTFC was significant. The mean number of breaths of entonox taken during the dressing change was 27.67 with placebo and 4.67 with OTFC; the reduction in the number of entonox breaths with OTFC was significant. One patient in the OTFC group suffered nausea. CONCLUSION: Compared with placebo, OTFC improved analgesia during painful dressing changes without an increase in side-effects.

Delivery of local anaesthetic via a sternal catheter to reduce the pain caused by sternal fractures: first case series using the new technique.

Sternal fractures cause considerable pain, and a proportion of patients require admission for analgesia. Local anaesthetic techniques have been used to reduce the pain from chest wall injuries and may reduce complications from these injuries. The use of a local anaesthetic delivered via a sternal catheter over a fractured sternum has been described in a patient whose pain was inadequately controlled with opiates. This technique was recently offered to patients in the emergency department at the Royal Devon and Exeter Hospital, Exeter, UK, and the experiences of patients and doctors are reported. Findings from this first case series suggest that the technique seems to be effective, well tolerated and acceptable to patients.

Epidural analgesia after spinal surgery via intervertebral foramen.

Patients undergoing major spinal surgery may experience significant postoperative pain. Epidural analgesia has previously been shown to be safe and effective and may confer some advantages over opioid-based postoperative analgesia. We discuss the case of a 47-yr-old female patient undergoing the prolonged anterior component of a lower thoracic/upper lumbar spine correction involving the stripping of the diaphragm from the lower thoracic spine and retraction of the left lower lobe of the lung. Despite initially planning opioid-based postoperative analgesia, a joint anaesthetic and surgical decision was made to use epidural analgesia in an attempt to avoid potential postoperative respiratory complications. Because of the surgical anatomy of the correction, the catheter was inserted via the T11 intervertebral foramen. A bolus of bupivacaine 0.25% intraoperatively with a postoperative infusion of bupivacaine 0.167% with diamorphine 0.1 mg ml(-1) provided excellent analgesia. The technique was associated with no postoperative complications.

Pain on medical wards in a district general hospital.

BACKGROUND: Little attention has been paid to pain on medical wards, with publications limited to the management of surgical patients. We wanted to establish the prevalence and severity of pain in the general medical setting, and how this compared with other clinical specialties. METHODS: All consenting adult in-patients were assessed daily for 5 days. Patients recorded the occurrence and severity of pain, and whether their pain was bearable. The pain team reviewed patients with unbearable pain. RESULTS: 1594 questionnaires were completed, representing 54% of the target population. 887 patients reported pain, 17% with pain scores over 6, and 10% with unbearable pain. The distribution of pain was similar for all ward types with 52% of patients on medical wards reporting pain. Of these, 20% reported severe pain and 12% unbearable pain. When patients with pain scores over 6 were analysed by consultant specialty, elderly care, general medicine, and general surgery scored highest. In each specialty 20-25% of patients with pain reported a pain score over 6. In patients reviewed by the pain team, reasons for poor analgesia included inadequate information, pain assessment, analgesic prescribing, and administration and patient reporting. CONCLUSION: Patients in all hospital specialities experience pain. Until the issue of pain management in medical patients is fully addressed the situation will not improve.

Preliminary experience with the Doppler ultrasound guided vascular access needle in paediatric patients.

Percutaneous cannulation of the internal jugular vein (IJV) in infants and children may be technically difficult and can lead to complications. Various techniques exist to achieve successful cannulation and to reduce the rate of complications. We report the use of the Doppler ultrasound guided vascular access needle (the SMART needle) for IJV cannulation in 10 infants and young children (mean age 3.7 months) weighing less than 10 kg (mean weight 5.5 kg) who were to undergo cardiac surgery at Great Ormond Street Hospital for Children. Successful cannulation was achieved in six out of 10 patients with haematoma complicating the procedure in two patients. We believe this is the first reported use of this device for cannulation of the IJV in this patient group.

Cervical spine movements during laryngoscopy. Comparison of the Macintosh and McCoy laryngoscope blades.

We studied cervical spine movement in 10 patients scheduled for elective surgery under general anaesthesia. Each patient was fitted with a rigid cervical collar before undergoing direct laryngoscopy for orotracheal intubation. Laryngoscopy was performed using the McCoy laryngoscope in the activated position and the standard Macintosh blade. Displacement of the cervical spine at laryngeal exposure was measured using lateral cervical spine X-rays. Flexion and extension movements of the cervical spine during the use of the two laryngoscope blades were compared. For each blade, the greatest degree of extension occurred at the joint between the first and second cervical vertebrae. There was no significant difference in cervical spine movement when the two blades were compared.

Sevoflurane for predicted difficult tracheal intubation.

Ten patients, predicted to pose a difficult intubation of the trachea, underwent inhalational induction of anaesthesia using sevoflurane. In all 10 cases the airway was secured successfully and the patient proceeded to have the planned operation. In six of the cases the anaesthetist experienced a problem during the induction but in no case did this present any real difficulties or lead to a critical incident. We feel that sevoflurane has a place for inhalational induction in this challenging group of patients.

A lesson in investigation of the airway.

Tracheobronchography is not a new radiological investigation but is seldom used in ventilator dependent infants. It is a simple, safe and accurate investigation of the airways. Its potential in this group of patients is demonstrated in the case described.