Shared decision-making in peri-operative medicine: a narrative review.

This review on shared decision-making comes at a time when international healthcare policy, domestic law and patient expectation demand a bringing-together of the patient's values and preferences with the physician's expertise to determine the best bespoke care package for the individual. Despite robust guidance in terms of consent, the anaesthetic community have lagged behind in terms of embracing the patient-focused rather than doctor-focused aspects of shared decision-making. For many, confusion has arisen due to a conflation of informed consent, risk assessment, decision aids and shared decision-making. Although they may well be linked, they are discrete entities. The obstacles to delivering shared decision-making are many. Lack of time is the most widely cited barrier from the perspective of physicians across specialties, with little time available to the anaesthetist at the day-of-surgery pre-operative visit. A more natural place to start the process may be the pre-operative assessment clinic, especially for the 'high-risk' patient. Yet shared decision-making is for all, even the 'low-risk' patient. Another barrier is the flow and the focus of the typical anaesthetic consultation; the truncated format presents the danger of a cursory, 'time-efficient' and mechanical process as the anaesthetist assesses risk and determines the safest anaesthetic. As patients have already decided to proceed with therapy or investigation and may be more concerned about the surgery than the anaesthesia, it is often assumed they will accept whatever anaesthetic is offered and defer to the clinician's expertise - without discussion. Furthermore, shared decision-making does not stop at time of anaesthesia for the peri-operative physician. It continues until discharge and requires the anaesthetist to engage in shared decision-making for prescribing and deprescribing peri-operative medicines.

The association between obesity and disability in survivors of joint surgery: analysis of the health and retirement study.

BACKGROUND: Obesity is associated with osteoarthritis and the need for joint surgery. Obese patients who undergo joint surgery may have a higher risk of morbidity compared with normal or overweight patients but less is known about their risk of postoperative disability. The primary objective of our study was to determine the association between obesity and the development of new dependence in activities of daily living within 2 years after joint surgery. METHODS: We obtained data from the Health and Retirement Study, a longitudinal survey of older Americans. We included participants who indicated having joint surgery for arthritis. We defined obesity as a BMI ≥30 kg m-2. Our outcome was a new or increased dependence in one or more activities of daily living after surgery. RESULTS: We analysed data on 2519 respondents who underwent joint surgery for arthritis. Respondents had a median age of 69yr, 65.5% were female, 66.6% had joint replacement surgery and 45.3% were obese. The overall incidence of a new dependence within 2years was 22.1%. Obese respondents had a higher incidence of new dependence compared with non-obese respondents (25.4% vs 19.4%, P<0.001). In adjusted analysis, obese respondents had increased odds of developing dependence [odds ratio 1.35 (95% CI 1.09-1.68), P=0.007]. CONCLUSIONS: Obesity is associated with an increased risk of developing dependence in the 2 years after joint surgery. Our study findings identify a high-risk group that may benefit from targeted interventions and allocation of perioperative resources to optimize recovery and minimize longer-term disability.

Use of failure-to-rescue to identify international variation in postoperative care in low-, middle- and high-income countries: a 7-day cohort study of elective surgery.

BACKGROUND: The incidence and impact of postoperative complications are poorly described. Failure-to-rescue, the rate of death following complications, is an important quality measure for perioperative care but has not been investigated across multiple health care systems. METHODS: We analysed data collected during the International Surgical Outcomes Study, an international 7-day cohort study of adults undergoing elective inpatient surgery. Hospitals were ranked by quintiles according to surgical procedural volume (Q1 lowest to Q5 highest). For each quintile we assessed in-hospital complications rates, mortality, and failure-to-rescue. We repeated this analysis ranking hospitals by risk-adjusted complication rates (Q1 lowest to Q5 highest). RESULTS: A total of 44 814 patients from 474 hospitals in 27 low-, middle-, and high-income countries were available for analysis. Of these, 7508 (17%) developed one or more postoperative complication, with 207 deaths in hospital (0.5%), giving an overall failure-to-rescue rate of 2.8%. When hospitals were ranked in quintiles by procedural volume, we identified a three-fold variation in mortality (Q1: 0.6% vs Q5: 0.2%) and a two-fold variation in failure-to-rescue (Q1: 3.6% vs Q5: 1.7%). Ranking hospitals in quintiles by risk-adjusted complication rate further confirmed the presence of important variations in failure-to-rescue, indicating differences between hospitals in the risk of death among patients after they develop complications. CONCLUSIONS: Comparison of failure-to-rescue rates across health care systems suggests the presence of preventable postoperative deaths. Using such metrics, developing nations could benefit from a data-driven approach to quality improvement, which has proved effective in high-income countries.

Does the use of a volatile anesthetic regimen attenuate the incidence of cardiac events after vascular surgery?

OBJECTIVE: To compare the effects of a volatile anesthetic to a non-volatile anesthetic regimen on the incidence of postoperative cardiac events, including the postoperative elevation of troponin I values after arterial vascular surgery in high risk patients. DESIGN: Retrospective analysis of data of a phase II study that compared the Na+/H+ exchanger type II inhibitor, zoniporide to placebo on the occurrence of cardiac events. SETTING: Multicenter study conducted in 105 sites throughout the United States, South America, Europe and Asia. PARTICIPANTS: 784 subjects scheduled for urgent or elective major arterial vascular surgery and a history of at least 3 of the following: age > or = 65 years, hypertension, documented stroke or transient ischemic attack, previous myocardial infarction, active angina pectoris diabetes mellitus, congestive heart failure, or symptomatic cardiac arrhythmia. INTERVENTIONS: Type of anesthesia was retrospectively retrieved from the database and patients were subdivided in two groups: inhalational (group A) vs non-inhalational anesthetic regimen (group B). Incidence of postoperative cardiac events was compared between the two groups. MEASUREMENTS AND MAIN RESULTS: The incidence of postoperative cardiac events was not different between the two groups. Maximum postoperative troponin I levels was not different between the two groups in the total population and in the patients undergoing peripheral arterial surgery. In patients undergoing aortic surgery the incidence of elevated troponin levels higher than 1.5 and 4 ng x mL(-1) tended to be lower in group A than in group B in the aortic surgery (28% vs 18% and 30% vs 20% respectively) but this difference did not reach statistical significance. CONCLUSION: The results of this hypothesis-generating study suggest that potential beneficial effects on extent of postoperative myocardial damage in high risk patients undergoing arterial surgery will probably be more apparent in abdominal aortic surgery than in peripheral vascular surgery. Further sufficiently powered studies using a standardized protocol should now be performed to definitively address this question.

Coronary artery stenting and non-cardiac surgery--a prospective outcome study.

BACKGROUND: A 45% complication rate and a mortality of 20% were reported previously in patients undergoing non-cardiac surgery after coronary artery stenting. Discontinuation of antiplatelet drugs appeared to be of major influence on outcome. Therefore we undertook a prospective, observational multicentre study with predefined heparin therapy and antiplatelet medication in patients undergoing non-cardiac procedures after coronary artery stenting. METHODS: One hundred and three patients from three medical institutions were enrolled prospectively. Patients received coronary artery stents within 1 yr before non-cardiac surgery (urgent, semi-urgent or elective). Antiplatelet drug therapy was not, or only briefly, interrupted. Heparin was administered to all patients. All patients were on an intensive/intermediate care unit after surgery. Main outcome was the combined (cardiac, bleeding, surgical, sepsis) complication rate. RESULTS: Of 103 patients, 44.7% (95% CI 34.9-54.8) suffered complications after surgery; 4.9% (95% CI 1.6-11.0) of the patients died. All but two (bleeding only) adverse events were of cardiac nature. The majority of complications occurred early after surgery. The risk of suffering an event was 2.11-fold greater in patients with recent stents (<35 days before surgery) as compared with percutaneous cardiac intervention more than 90 days before surgery. CONCLUSIONS: Despite heparin and despite having all patients on intensive/intermediate care units, cardiac events are the major cause for new perioperative morbidity/mortality in patients undergoing non-cardiac surgery after coronary artery stenting. The complication rate exceeds the re-occlusion rate of stents in patients without surgery (usually <1% annually). Patients with coronary artery stenting less than 35 days before surgery are at the greatest risk.

Patient preferences for anaesthesia management during cataract surgery.

BACKGROUND/AIMS: To assess patient preferences for different anaesthesia management strategies during cataract surgery. METHODS: Cross sectional clinic based study of patient preferences for anaesthesia management strategies. Patients rated their preferences using a linear rating scale from 0 to 100. RESULTS: Subjects tended to prefer block to topical anaesthesia and oral to intravenous sedation. On a scale from 0 to 100, subjects preferred oral to intravenous sedation and block to topical anaesthesia by about 8 points. CONCLUSIONS: When given the choice of four different anaesthesia management strategies, 72% of the study subjects preferred block anaesthesia to topical anaesthesia. More patients chose to have oral sedation than intravenous sedation. These findings indicate that patients may prefer anaesthesia management approaches other than the ones they are currently being offered.

Does functional ability in the postoperative period differ between remifentanil- and fentanyl-based anesthesia?

STUDY OBJECTIVES: To compare patients' functional ability in the 24-hour postoperative period following a remifentanil compared to a hypnotic-fentanyl-treated anesthesia regimen using a 24-Hour Functional Ability Questionnaire. DESIGN: Prospective, 1:1 single-blind, randomized, controlled effectiveness study. SETTING: Multicenter study including 156 hospitals and ambulatory surgery facilities. PATIENTS: 2438 patients (1496 outpatients and 942 inpatients) 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness of > or =30 minutes. INTERVENTIONS: Patients were randomized to receive either intravenous remifentanil (0.5 microg/kg/min for induction and intubation; with the infusion rate decreased to 0.25 microg/kg/min after intubation) or fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given in the remifentanil patients and at the discretion of the anesthesiologists in the fentanyl patients. MEASUREMENTS: A validated set of measurements of functional ability, rather than more traditional clinical psychological methods, to compare the recovery of patients from remifentanil- and fentanyl-treated anesthetic regimens up to 24 hours after surgery. MAIN RESULTS: Remifentanil was statistically superior to fentanyl for the four functional assessments evaluated: walking without dizziness, thinking clearly, concentration, and communicating effectively. These differences reflect events occurring within the first 24 hours after anesthesia and surgery. CONCLUSIONS: A remifentanil-treated anesthetic demonstrated earlier return to some functions than a fentanyl-treated technique. Although functional assessment is a field that is still in its infancy, a questionnaire to assess functional ability during the 24 hours after anesthesia may provide more practical information about anesthetic recovery than previously used, traditional psychomotor evaluations.

Hemodynamics and emergence profile of remifentanil versus fentanyl prospectively compared in a large population of surgical patients.

STUDY OBJECTIVE: To compare the responses to, and hemodynamics associated with surgical stress, recovery profiles, and anesthesiologists' satisfaction following balanced general anesthesia using either remifentanil or fentanyl in a large-scale population. DESIGN: Prospective, 1:1 single blind, randomized, controlled effectiveness study in which patients received either remifentanil or fentanyl in combination with a hypnotic-based anesthesia regimen of either isoflurane or propofol. SETTING: Multicenter study including 156 hospitals and ambulatory surgery facilities. PATIENTS: 2,438 patients (1,496 outpatients and 942 inpatients), 18 years of age or older, scheduled for elective surgeries under general endotracheal anesthesia, with an expected duration of unconsciousness > or =30 minutes. INTERVENTIONS: Patients were randomized to receive either intravenous (IV) remifentanil (0.5 microg/kg/min for induction and intubation, with the infusion rate decreased to 0.25 microg/kg/min after intubation) or IV fentanyl (administered according to anesthesiologists' usual practice) as the opioid during surgery. Concomitant hypnotic drugs were either propofol and/or isoflurane (with or without nitrous oxide) titrated according to protocol. Transition analgesia with either morphine or fentanyl was given to the remifentanil patients and, at the anesthesiologists' discretion, in the fentanyl patients. MEASUREMENTS: Vital signs, adverse events, and emergence profiles were assessed and recorded. Recovery profile was assessed by recording time spent in the postanesthesia care unit and step-down recovery unit, number and timing of adverse events, timing and dosage of rescue medications, and time to eligibility for discharge (to home or to hospital room). Anesthesiologists' satisfaction with the anesthetic regimen was assessed at the end of surgery. MAIN RESULTS: Remifentanil-treated patients exhibited lower systolic and diastolic blood pressures (by 10-15 mmHg) and lower heart rates (by 10-15 bpm) intraoperatively compared to the fentanyl-treated patients. This difference promptly disappeared on emergence. Remifentanil-treated patients responded to verbal command, left the operating room, and (for outpatients) were discharged home sooner than fentanyl-treated patients. Anesthesiologists rated the predictability of response to intraoperative titration, assessment of hemodynamic profiles, and the quality of anesthesia higher in the remifentanil-treated patients. CONCLUSIONS: This study confirms previous observations on the hemodynamic properties associated with remifentanil and extends these to a wider context than previously reported. These characteristics provide clinicians with an alternative in opioid-based anesthesia.

Adverse intraoperative medical events and their association with anesthesia management strategies in cataract surgery.

OBJECTIVE: To compare adverse medical events by different anesthesia strategies for cataract surgery. DESIGN: Prospective cohort study. PARTICIPANTS: Patients 50 years of age and older undergoing 19,250 cataract surgeries at nine centers in the United States and Canada between June 1995 and June 1997. INTERVENTION: Local anesthesia applied topically or by injection, with or without oral and intravenous sedatives, opioid analgesia, hypnotics, and diphenhydramine (Benadryl). MAIN OUTCOME MEASURES: Intraoperative and postoperative adverse medical events. RESULTS: Twenty-six percent of surgeries were performed with topical anesthesia and the remainder with injection anesthesia. There was no increase in deaths and hospitalizations associated with any specific anesthesia strategy. No statistically significant difference was observed in the prevalence of intraoperative events between topical and injection anesthesia without intravenous sedatives (0.13% and 0.78%, respectively). The use of intravenous sedatives was associated with a significant increase in adverse events for topical (1.20%) and injection anesthesia (1.18%), relative to topical anesthesia without intravenous sedation. The use of short-acting hypnotic agents with injection anesthesia was also associated with a significant increase in adverse events when used alone (1.40%) or in combination with opiates (1.75%), sedatives (2.65%), and with the combination of opiates and sedatives (4.04%). These differences remained after adjusting for age, gender, duration of surgery, and American Society of Anesthesiologists risk class. CONCLUSIONS: Adjuvant intravenous anesthetic agents used to decrease pain and alleviate anxiety are associated with increases in medical events. However, cataract surgery is a safe procedure with a low absolute risk of medical complications with either topical or injection anesthesia. Clinicians should weigh the risks and benefits of their use for individual patients.

A decision analysis of anesthesia management for cataract surgery.

PURPOSE: To compare the trade-offs in cost and preference of various anesthesia management strategies for cataract surgery. METHODS: Six strategies, differing in sedation, local anesthetic, and monitoring approach, were chosen for comparison. For each strategy, potential complications, and conversions to different anesthesia approaches were modeled. A panel of physicians and anesthetists, well versed in the literature and practice of the anesthesia management of cataract surgery, assigned preference values to the strategies and potential outcomes (0 to 1 scale). Probability estimates were obtained from a study of 19,557 cataract surgeries and from the panel. Cost estimates were derived from several sources. The model was analyzed to determine the strategies associated with the highest expected preference and lowest expected cost. RESULTS: The strategy associated with the highest net preference was intravenous sedation with block anesthesia and an anesthesiologist present throughout the case. The expected net preference for this strategy was 19% greater than the net preference for the next most preferred strategy, oral sedation with block anesthesia and an anesthesiologist on call (0.88 versus 0.74), but the expected anesthesia costs per case were much greater ($324 versus $42). Results were sensitive to plausible variation in the preference values assigned to the six initial management strategies and to the cost of topical versus block anesthesia. CONCLUSION: This analysis emphasizes that cost and preference are important considerations when choosing an anesthesia management strategy for cataract surgery. For some surgeries, substantial cost savings may be available for a small change in preference.

Effect of local anesthetics on patient recovery after transrectal biopsy.

OBJECTIVES: To determine the analgesic efficacy of local anesthetics injected lateral to the seminal vesicles before prostate biopsy, during and immediately after the procedure, because pain is a common side effect of transrectal ultrasound-guided prostate biopsy. METHODS: Patients were randomized to receive 5 mL of either 1% lidocaine or sterile normal saline injected (under ultrasound guidance) lateral to the seminal vesicles bilaterally before performance of the prostate biopsies, with the patient and physician unaware of the treatment group. Five minutes after the injection, a series of 12 prostate biopsies were performed. A visual analog scale (VAS) for pain at rest and with activity was obtained before the biopsy (preprocedure VAS) and immediately (intraprocedure VAS) and 30 minutes (postprocedure VAS) after the biopsy. Surveys examining the patients' expectations for biopsy pain were administered before and immediately after the biopsy. RESULTS: No significant differences were found between the groups with regard to demographic data, VAS pain scores at rest and with activity, and survey results. CONCLUSIONS: Injection of lidocaine lateral to the seminal vesicles before prostate biopsy did not diminish biopsy-associated pain.

Secondary prevention of coronary artery disease in patients undergoing elective surgery for peripheral arterial disease.

The purpose of the study was to assess the implementation of secondary prevention guidelines of coronary artery disease (CAD) in patients undergoing peripheral revascularization surgery. The design was a descriptive study of the prevalence of cardiac risk factors and preventive pharmacological therapy in vascular surgical patients set in an academic medical center between July 1996 and February 1999. A total of 237 patients were recruited, 82 (35%) having carotid surgery and 155 (65%) having lower extremity bypass. Data were collected from an existing database of a study examining perioperative cardiac events in vascular surgery patients. The majority of patients were hypertensive and 58% of patients had a blood pressure >140/90 mmHg. Most patients (81%) reported a history of tobacco use and 23% were active smokers. Of the 41% of patients who were diabetic, 46% had a random glucose >140 mg/dl. Half of the patients took aspirin, 35% a lipid-lowering medication, 30% a beta-blocker. Patients with lower extremity disease were less likely than patients with carotid disease to be on aspirin (45% vs. 62%), a lipid-lowering agent (30% vs. 45%), or a beta-blocker (26% vs. 39%) (all p<0.05). Of patients with heart disease, more men than women were on aspirin (62% vs. 45%) (p<0.05). In conclusion, our findings suggest that patients presenting for vascular surgery have a high prevalence of modifiable CAD risk factors that are not being adequately managed. Preoperative examination of vascular patients is an important opportunity to assess and implement neglected secondary prevention measures.

Synthesis of the literature on the effectiveness of regional anesthesia for cataract surgery.

OBJECTIVE: To synthesize the findings of the randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: The authors performed a systematic search of the literature to identify all articles pertaining to regional anesthesia during cataract surgery on adults. One investigator abstracted the content of each article onto a custom-designed form. A second investigator corroborated the findings. The evidence supporting the anesthesia approaches was graded by consensus as good, fair, poor, or insufficient. MAIN OUTCOME MEASURES: Evidence supporting the effectiveness of different forms of regional anesthesia. RESULTS: There was good evidence that retrobulbar and peribulbar blocks provide equivalent akinesia and pain control during cataract surgery. Additionally, sub-Tenon's blocks were at least as effective as retrobulbar and peribulbar blocks. There was good evidence that retrobulbar block provides better pain control during surgery than topical anesthesia, and there was fair evidence that peribulbar block provides better pain control than topical anesthesia. CONCLUSIONS: This synthesis of the literature demonstrates that currently used approaches to anesthesia management provide adequate pain control for successful cataract surgery, but there is some variation in the effectiveness of the most commonly used techniques. Data are needed on patient preferences to determine the optimal strategies for anesthesia management during cataract surgery.

The methodologic quality of clinical trials on regional anesthesia for cataract surgery.

OBJECTIVE: To assess the methodologic quality of published randomized trials of regional anesthesia management strategies for cataract surgery. DESIGN: Literature review and analysis. METHOD: We performed a systematic search of the literature to identify all articles pertaining to regional anesthesia for cataract surgery on adults. Overall quality scores and scores for individual methodologic domains were based on the evaluations of two investigators experienced in methodologic research who independently reviewed all relevant articles using a quality abstraction form. MAIN OUTCOME MEASURES: Study quality in each of five domains: representativeness, bias and confounding, intervention description, outcomes and follow-up, and statistical quality and interpretation. RESULTS: Eighty-two randomized clinical trials were identified with a mean overall quality score of 44%. The mean domain scores ranged from 37% for representativeness to 58% for outcomes and follow-up. Forty percent or fewer studies received the maximum score for reporting the setting, the population, and the start and end dates; describing the inclusion and exclusion criteria; adequately randomizing subjects; and adequately masking individuals participating in the study. Key outcomes were often inadequately reported, including the distribution of patient-reported pain scores and the mean surgical time. CONCLUSIONS: Greater attention to methodologic quality and detailed reporting of study results will improve the ability of readers to interpret the results of clinical trials assessing regional anesthesia for cataract surgery.

Effectiveness of remifentanil versus traditional fentanyl-based anesthetic in high-risk outpatient surgery.

STUDY OBJECTIVE: To determine if remifentanil would offer a superior hemodynamic and recovery profile compared to the current standard of care, which implements a fentanyl-based technique. DESIGN: Randomized, single-blind study. SETTING: Outpatient center associated with tertiary care center. PATIENTS: 75 outpatients undergoing microsuspension laryngoscopy. INTERVENTIONS: Patients were randomized to either a remifentanil induction (0.5 microg/kg/min) and maintenance (0.25 microg/kg/min) versus fentanyl (maximum of 250 microg) as the only opioid. All patients received propofol as part of the induction and maintenance with or without the use of nitrous oxide. MEASUREMENTS: Assessment of hemodynamics [heart rate (HR) and blood pressure(BP)], presence of perioperative myocardial ischemia on ambulatory electrocardiographic monitoring, and time to discharge. MAIN RESULTS: Significantly fewer patients in the remifentanil group demonstrated episodes of tachycardia (HR > 100 beats per min) compared to the fentanyl group (14% vs. 40%, p<0.05), with significantly fewer episodes of tachycardia and hypertension per patient. Recovery profiles between the two groups did not show clinically significant differences. CONCLUSIONS: Remifentanil, a new short-acting opioid, offers excellent hemodynamic control for brief, intense outpatient procedures performed in high-risk patients; however, its use was not associated with any improvement in recovery profiles.