Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Readmission destination and risk of mortality after major surgery: An observational cohort study. Lancet 2015; 386:884–95.
Hospital readmissions are common after major surgery. Whether patients achieve better outcomes when they are readmitted to the index hospital where their surgical procedure was done is unknown. This observational cohort study examined the association between readmission destination and mortality risk. The authors used a database of 9,440,503 patients among Medicare beneficiaries who underwent 1 of 12 major operations. The number of patients readmitted to the index hospital where the operation was done was high. Readmission to the index hospital was associated with a 26% lower risk of 90-day mortality than was readmission to a nonindex hospital (odds ratio, 0.74; 95% CI, 0.66–0.83). This result was particularly pronounced for readmission after pancreatectomy and aortobifemoral bypass. In the United States, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place.
What is publication bias in a meta-analysis? BMJ 2015; 351:h4419. doi: 10.1136/bmj.h4419.
Meta-analyses of randomized controlled trials are commonly published in anesthesia, pain, and intensive care journals because they may strengthen or invalidate a previous answer to a key question based on one or more individual clinical trial. However, multiple biases can be introduced when meta-analyses are performed. In this paper, the author provides an interactive, educational approach to understand some important biases associated with meta-analyses (reporting bias, and particularly publication bias). It provides a good opportunity for the reader to interpret meta-analyses more critically in the future.
Safety, tolerability, and efficacy of idarucizumab for the reversal of the anticoagulant effect of dabigatran in healthy male volunteers: A randomised, placebo-controlled, double-blind phase 1 trial. Lancet 2015; 386:680–90.
This paper published just 2 months after publication of the first randomized controlled trial on dabigatran reversal by idarucizumab, in the New England Journal of Medicine (see Science, Medicine, and the Anesthesiologist in the October 2015 issue). The first paper examined efficacy, and this follow-up publication examined safety as the primary endpoint. Together, these phase 1 results provide evidence that idarucizumab was associated with immediate, complete, and sustained reversal of anticoagulation induced by the direct thrombin inhibitor dabigatran in healthy men, and was well tolerated with no unexpected or clinically relevant safety concerns, supporting further clinical development.
Predicting decline and survival in severe acute brain injury: The fourth trajectory. BMJ 2015; 351:h3904. doi: 10.1136/bmj.h3904.
Acute brain injury is a devastating injury with clinical management challenges and marked long-term consequences for patients, their families, and our society. These injuries are typically sudden and unexpected and carry an uncertain prognosis, and their long-term outcome relies on early, rapid treatment decisions—decisions that are almost always made with surrogate decision makers. This article analyzes patient trajectories after acute brain injury. The complexity of dealing with unresolved issues in this domain is discussed in detail. The authors provide pragmatic recommendations for optimizing patient care at each stage from injury to death or long-term rehabilitation.
Time to epinephrine and survival after pediatric in-hospital cardiac arrest. JAMA 2015; 314:802–10.
Delay in administration of the first epinephrine dose is associated with decreased survival among adults after in-hospital, nonshockable cardiac arrest. Whether this association is true in the pediatric in-hospital cardiac arrest population remains unknown. One thousand five hundred and fifty-eight pediatric patients (median age, 9 months [interquartile range, 13 days to 5 yr]) with an in-hospital cardiac arrest and an initial nonshockable rhythm who received at least one dose of epinephrine were included in the cohort. The primary outcome was survival to hospital discharge. Among children with in-hospital cardiac arrest with an initial nonshockable rhythm who received epinephrine, delay in administration of epinephrine was associated with decreased chance of survival to hospital discharge, restoration of spontaneous circulation, 24-h survival, and survival to hospital discharge with a favorable neurologic outcome.
Septic shock: Advances in diagnosis and treatment. JAMA 2015; 314:708–17.
Septic shock is a frequent and potentially devastating illness that affects more than 230,000 U.S. patients each year. This article reviewed recent literature obtained from MEDLINE and the Cochrane Database of Systematic Reviews from 2010 to 2015. This review provides a comprehensive update on recent therapeutic strategies, including the strength of evidence in support of current recommendations and the limitations of our knowledge. Use of echocardiography in complicated diagnostic situations (hypovolemia, cardiogenic shock) and prompt administration of intravenous fluids (excluding hydroxyethyl starch) and vasoactive medications aimed at restoring adequate circulation are among key recommendations. The unproven efficacy of early goal-directed protocol-based therapy is discussed in detail.
Different immune cells mediate mechanical pain hypersensitivity in male and female mice. Nat Neurosci 2015; 18:1081–3. Accompanying comment: Sex, drugs and pain control. Nat Neurosci 2015; 18:1059–60.
Women show greater sensitivity to painful experimental stimuli and suffer more frequently from chronic pain, yet the mechanisms underlying these differences have remained elusive. A consortium of investigators now report that immune cell function may be at the root of these sex-related differences. Using models of nerve injury and inflammation, these investigators found that male, but not female, mice showed strong analgesic responses to glial inhibitors such as minocycline. Further experimentation revealed sex-specific differences in microglial P2RX4 expression. The role of the known sexually dimorphic expression of peroxisome proliferator activated receptors types α and γ on T cells was also studied. Activation of the male-predominant α form provided analgesia in male mice while the female-predominant γ form was more closely linked to analgesic responses in females. It is unknown whether similar differences in immune function might explain how men and women experience pain differently.
The impact of rudeness on medical team performance: A randomized trial. Pediatrics 2015; 136:487–95.
Studies suggest that practitioner stressors may heighten iatrogenic events. Rudeness is one such stressor that impairs cognitive processes and team communication. This randomized double-blind simulation trial investigated the effects of rudeness on a neonatal intensive care unit team’s performance. Teams exposed to rudeness demonstrated a significant decline in individual cognitive performance (diagnosis and management skills) and collaborative group performance (information sharing and asking for help). It appears that rudeness caused a decrease in individual practitioner performance and the collaborative team skills that might compensate for these negative individual effects. This article has significant implications for team performance among faculty and trainees. Rudeness may not just be an upsetting annoyance; this study demonstrates that rudeness may impact patient care and outcomes.