Peri-operative Replacement of Exogenous Steroids (PREdS): a national audit of current peri-operative prescribing for patients taking therapeutic steroids.

INTRODUCTION: Approximately 1% of the UK population take oral corticosteroids for ≥ 28 days each year, for broadly two reasons: deficiency in corticosteroid requiring replacement; or therapeutic corticosteroid for inflammatory conditions. Acute deficiency can occur at times of physiological stress (e.g. surgery), potentially leading to major complications. The Association of Anaesthetists' 2020 consensus guideline provides detailed advice for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. This national audit aimed to assess compliance with this guideline. METHODS: Data were collected from 59 Trusts over 14 consecutive days for all eligible patients undergoing procedures under the care of an anaesthetist. Patients who were prescribed ≥ 5 mg oral prednisolone equivalents pre-operatively, in whom supplementary corticosteroid would be indicated, were compared with those prescribed < 5 mg oral prednisolone equivalents. RESULTS: Operations for 21,731 patients were audited: 277 (1.3%) patients were taking therapeutic corticosteroids. Detailed peri-operative data were collected for all patients receiving therapeutic corticosteroids: 201/277 (73%) were ASA physical status ≥ 3; 184/277 (66%) underwent elective procedures; and 252/277 (91%) were prescribed prednisolone pre-operatively, of whom 219/277 (79%) were prescribed ≥ 5 mg oral prednisolone equivalents. In the patients who were prescribed ≥ 5 mg oral prednisolone equivalents, 186/219 (85%) received pre-operative glucocorticoid supplementation and 97/219 (42%) received it postoperatively; however, only 67/219 (31%) and 43/219 (20%) respectively received glucocorticoid supplementation according to the guidelines. Overall, peri-operative prescribing was compliant in 19/219 (9%) patients. A similar proportion, 30/219 (14%), received no supplementation. In the patients taking < 5 mg oral prednisolone equivalents pre-operatively, 28/58 (48%) received inappropriate supplementation. CONCLUSIONS: Despite 125/277 (45%) of anaesthetists reporting Association of Anaesthetists' guidelines use, compliance remained low, with adherence in only 27/125 (22%) patients. Further research is required to identify the correct peri-operative strategy for patients taking therapeutic corticosteroids.

Non-aneurysmal subarachnoid haemorrhage in COVID-19.

Coronavirus disease of 2019 (COVID-19) is associated with hypercoagulopathy, but haemorrhage, including spontaneous intracerebral parenchymal haemorrhage and diffuse petechial cerebral haemorrhage, has also been reported. We present two cases of nonaneurysmal subarachnoid haemorrhage (SAH) in patients with severe COVID-19. Careful review of neuroimaging for haemorrhagic complications of COVID-19 should be undertaken, particularly for those patients receiving enhanced prophylaxis for venous thromboembolism. Although likely to be a marker of severe disease, non-aneurysmal SAH can be associated with favourable outcome.

An Unusual Case of Acute Muscle Weakness.

A previously healthy 35-year old man presented to hospital with acute leg weakness following an alcohol binge. On assessment, tachycardia, urinary retention and bilateral upper and lower limb proximal weakness with preserved peripheral power were noted. Biochemistry revealed marked hypokalaemia, which responded to intravenous replacement, and biochemical thyrotoxicosis, leading to the diagnosis of Thyrotoxic Periodic Paralysis (TPP). Anti-thyroid therapy and beta-blockers were commenced and his neurological symptomatology resolved as he became progressively euthyroid. TPP is a rare acquired subtype of hypokalaemic periodic paralysis, typically causing proximal muscle weakness associated with thyrotoxicosis. It is most common in young Asian males. Acute treatment requires cautious oral potassium supplementation, beta-blockade, and anti-thyroid therapy. TPP is prevented by maintaining euthyroidism; otherwise recurrence is likely.

Protocol for a systematic review and meta-analysis of tobacco-cessation interventions delivered perioperatively.

INTRODUCTION: Tobacco smoking is associated with a substantially increased risk of perioperative complications. The perioperative period is an opportunity to introduce tobacco-cessation strategies. A previous systematic review provided evidence that perioperative interventions increase short-term abstinence and may reduce postoperative complications. The evidence base has since expanded, with the subsequent publication of numerous randomised studies. This protocol outlines a systematic review examining the impact of perioperative tobacco-cessation interventions on successful abstinence from tobacco smoking, and on the incidence of perioperative complications. METHODS AND ANALYSIS: A systematic search of the literature will be run across EMBASE (Ovid), MEDLINE (Ovid), CINAHL (Ebsco) and PsycInfo (ProQuest), from inception to present, using text words and subject headings. Randomised controlled trials published in English, examining adults in the perioperative period and reporting the outcomes from tobacco-cessation interventions will be included.Abstract screening and data extraction will be performed by five reviewers. Each abstract will be screened by two blinded reviewers, with discrepancies resolved by group consensus. The primary outcome will be point prevalence abstinence from tobacco-use at the time of surgery. Secondary outcomes are prolonged abstinence from tobacco use at 6 months and 12 months, and postoperative complications. Any other reported outcomes will be documented in the descriptive analysis. The review will also describe details of the investigated perioperative tobacco-cessation interventions. If sufficient studies report relevant data, meta-analysis of the primary and secondary outcomes will be undertaken. Results will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement. ETHICS AND DISSEMINATION: No ethical approval is required. Results will be disseminated by open-access, peer-reviewed journal publication and conference presentations. Results will underpin future work to modify perioperative tobacco-cessation interventions to enhance engagement and accessibility, and to develop trials aiming to facilitate abstinence from tobacco-use in patients presenting for surgery.

Seven-year follow-up of persistent postsurgical pain in cardiac surgery patients: A prospective observational study of prevalence and risk factors.

BACKGROUND: Our aim was to describe the long-term prevalence, risk factors and impact on quality of life of persistent postsurgical pain (PPP) following cardiac surgery. METHODS: All patients undergoing sternotomy in a single centre over 6 months were prospectively interviewed by telephone at six months and seven years following surgery. RESULTS: We analysed data from 174 patients at six months and 146 patients at seven years following surgery, revealing a PPP prevalence of 39.7% (n = 69) and 9.6% (n = 14) respectively. At six post-operative months, younger age, higher acute pain score, intraoperative remifentanil infusion and more prolonged surgery were associated with sternotomy-site PPP. These variables, in combination, predict PPP in this study group with area under the receiver operating curve of 0.91 (95% CI 0.86-0.94) at 6 months and 0.74 (95% CI 0.57-0.86) at 7 years. Quality of life scores were significantly lower with PPP (median change in EQ-5D score = -0.23 [-0.57, -0.09] compared to 0.00 [0-0.24] without PPP at 7 years, p < 0.001). At7 years, younger age, prolonged surgery and intraoperative remifentanil infusion were associated with sternotomy-site PPP. CONCLUSIONS: To the best of our knowledge, this is the longest follow-up of PPP across all surgical specialities and certainly within cardiac surgery. Prevalence of PPP and impact on QOL after cardiac surgery are high and associated with young age, high acute pain score, use of remifentanil and long operative time. We present a predictive score to highlight patients at risk of developing PPP. SIGNIFICANCE: Seven years after cardiac surgery, almost 10% of patients in this cohort described persistent pain in and around the incision. While higher than previous reports in the literature (limited to up to five post-operative years), this assessment was made following three maximal coughs and therefore is movement or function evoked. High incident of persistent postsurgical pain may adversely affect long-term quality of life which is measured using a validated tool.

A retrospective analysis of inpatient cardiac arrests over one year at a tertiary heart attack and cardiothoracic centre identifying potential candidates for an inpatient extracorporeal cardiopulmonary resuscitation service.

INTRODUCTION: Extracorporeal cardiopulmonary resuscitation (ECPR) is an internationally recognised treatment for refractory cardiac arrest, with evidence of improved outcomes in selected patient groups from cohort studies and case series. In order to establish the clinical need for an in-hospital extracorporeal cardiopulmonary resuscitation service at a tertiary cardiac centre, we analysed the inpatient cardiac arrest database for the previous 12 months. METHODS: Evidence-based inclusion criteria were used to retrospectively identify the number of patients potentially eligible for extracorporeal cardiopulmonary resuscitation over a 12-month period. RESULTS: A total of 261 inpatient cardiac arrests were analysed with 21 potential extracorporeal cardiopulmonary resuscitation candidates meeting the inclusion criteria (1.75 patients per month, or 8% of inpatient cardiac arrests (21/261)). The majority (71%) of these cardiac arrests occurred outside of normal working hours. Survival-to-discharge within this sub-group with conventional cardiopulmonary resuscitation was 19% (4/21). CONCLUSION: Sufficient numbers of refractory inpatient cardiac arrests occur to justify an extracorporeal cardiopulmonary resuscitation service, but a 24-h on-site extracorporeal membrane oxygenation team presents a significant financial and logistical challenge.

Presentation of papillary fibroelastoma of the aortic valve with atypical symptoms.

Papillary fibroelastomas are rare benign tumours arising from the cardiac endothelium. The rationale behind the treatment of fibroelastomas is to eliminate the risk of embolic events and the associated morbidity and mortality. These tumours present predominantly in males during the seventh decade of life and most commonly affect the aortic valve. We report a case of aortic valve papillary fibroelastoma with an atypical clinical presentation, treated with valve-sparing surgical excision. Our case highlights the management of this rare but serious condition and emphasises the need to develop clear guidelines regarding the treatment of asymptomatic patients with a papillary fibroelastoma.

Quantification of the Range of Motion of Kidney and Ureteral Stones During Shockwave Lithotripsy in Conscious Patients.

Effective shockwave lithotripsy requires accurate targeting of the stone throughout the course of treatment. Stone movement secondary to respiratory movement can make this more difficult. In vitro work has shown that stone motion outside the focal region reduces the efficacy of stone fragmentation; however, there are few clinical data on the degree of stone movement in patients during treatment. To investigate this, X-ray fluoroscopic images of the kidney and ureteral stones at the upper and lower limits of the normal respiratory cycle were acquired during shock wave lithotripsy of 58 conscious patients, and stone excursion was calculated from these images. In addition, the respiration rate and patient perceived pain were recorded during the course of the treatment. It was found that stone motion secondary to respiration was 7.7 ± 2.9 mm for kidney stones and 3.6 ± 2.1 mm for ureteral stones-less than has been reported in studies with anesthetized patients. There was no significant change of motion over the course of treatment although pain was found to increase. These data suggest that stone motion in conscious patients is less than in anesthetized patients. Furthermore, it suggests that lithotripters with focal regions of 8 mm or greater should not suffer from a marked drop in fragmentation efficiency due to stone motion.