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A big PONV meta-analysis

Interesting Cochrane meta-analysis looking at PONV prophylaxis from German (Weibel et al. 2021) that included almost 100,000 study participants across 585 trials. Interesting not so much because it confirms much of what we already new (or assumed, based on our common PONV prophylaxis drug choices), but because it reassures us that side-effects from commonly used PONV drugs are low to non-existent.

PONV Takeaway:

Granisetron is probably the best single-agent or in combination with other agents because of it's efficacy (better than ondansetron), low-cost, long duration, and absent side-effects.

A cognitive aid to better manage perioperative bleeding

Although the benefits of cognitive aids to many areas of anaesthesia are well established, our resistance to using decision support tools persists. Whether due to misplaced perceptions of losing autonomy or Dunning Kruger-adjacent inflated belief in our ability to perform under pressure, is unclear.

In Anaesthesia, Kataife et al. (2021) describe a cognitive aid for better managing perioperative haemorrhage, the Haemostasis Traffic Light algorithm. Using a simulation-based RCT across two centres (University Hospital Zurich & The Italian Hospital of Buenos Aires, N=84), they showed that using the HTL improved case solutions (OR 7.23, 3.82-13.68), quickened therapeutic decisions, (HR 1.97, 1.18-3.29), improved therapeutic confidence, (OR 4.31, 1.67-11.11) and reduced workload perception.

The aim of the HTL is to improve both situational awareness and decision making, by integrating clinical judgement and point-of-care testing (ROTEM) within an accessible, structured algorithm.

Haemostasis Traffic Light takeaway:

Kataife's study again shows the benefit of cognitive aids, particularly in critical, time-sensitive situations. The anaesthesia and critical care community's historical resistance to decision-support tools requires challenge.

Read on for timing of surgery after COVID infection...

Three papers from the first BJA of the new decade highlight the importance of non-inferiority: protective ventilation strategies, dexamethasone for prolonging interscalene blocks, and high inspired oxygen and surgical site infections.

Although none investigated new questions, they all represent studies into areas of ongoing uncertainty. They are each a useful reminder that most perioperative interventions do not significantly improve outcomes, although the majority of these probably do not ever make it to publication.

Lung-protection and atelectasis

Généreux et al. investigated the atelectasis-preventing benefit of a common protective ventilation strategy (PEEP and regular recruitment manoeuvres). Notable not just because there was no difference in atelectasis after extubation, but because the use of ultrasound to measure atelectasis helped to better track the intraoperative and post-extubation changes between the intervention and control groups. [→ article summary]

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Three interesting articles that appeared in the past few months, all following a common theme of ‘protection with small changes’. Although only one is itself practice changing, together they challenge us to continue to look to how small practice changes may have significant protective and preventative effects in the lives of our patients.

Antihypertensives evening dosing

Hermida et al. (2019) published impressive results from the massive, 10-year Hygia Project, which randomised almost 20,000 patients to take anti-hypertensive medications at bedtime or awakening.

Not only did patients who took antihypertensives (of any class) in the evenings have better blood pressure control, they also received a 45% reduction in major cardiovascular outcomes, including CVD death, infarct, coronary revascularisation, heart failure and stroke!

Given that many critical care doctors briefly touch on the medications their patients are taking, a simple “you should ask your primary physician about when its best to take your blood pressure tablets” could have a disproportionately large impact on patient health.

Read on for protection with intravenous lidocaine and ischaemic conditioning...

Recently I needed to refer a patient preoperatively to a cardiologist for review. This is not an uncommon situation – one which happens thousands of times every week throughout the world. And yet it is a referral that anesthesiologists and anesthetists often do very poorly.

Avoid hypoxia, avoid hypotension?

We sometimes roll our eyes at recommendations made by physician colleagues: either providing unhelpful physiological parameters that we normally aim to maintain anyway (“avoid hypoxia?”), or stepping outside their expertise and boxing the anesthetist in by suggesting specific anesthetic techniques (“okay for a spinal”).

It is easy to be annoyed at both the lack of value this adds to our perioperative planning, as well as to the nonchalant ignorance of intraoperative medicine that it betrays. At the end of the day though, it’s our fault.

As Dr Andrew Silvers, a Melbourne cardiac and neuro-anesthetist recently opined, if your cardiologist replies with “avoid hypoxia and avoid hypotension” then YOU the anesthetist or anesthesiologist are at fault for not asking your cardiology colleague specific questions that will materially effect your perioperative planning.

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Metoclopramide had long been written off by many anesthetists and anesthesiologists, aware of trials and meta-analyses that show no or limited effect in treating or preventing nausea and vomiting – in particular limited ability to prevent post-operative nausea and vomiting (PONV). Most recently Henzi, Walder and Tramèr (1999) were able to show only very limited benefit for metoclopramide 10 mg in preventing vomiting and no significant effect in preventing nausea in adults.^1,2,3

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