Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Publication and reporting of clinical trial results: Cross sectional analysis across academic medical centers. BMJ 2016; 352:i637.
Between 25% and 50% of clinical trials remain unpublished, sometimes years after completion. The role of academic centers in promoting regular and high quality publications of clinical trials is critical. The objective of this study was to determine rates of publication and reporting of results within 2 yr for all completed clinical trials registered in ClinicalTrials.gov across leading academic medical centers in the United States. Among the 4,347 interventional clinical trials across 51 academic medical centers identified between October 2007 and September 2010, only 1,005 (23%) enrolled more than 100 patients, and 1,216 (28%) were double blind. The proportion of clinical trials published within 24 months of study completion ranged from 10.8% (4/37) to 40.3% (31/77), which is a modest and heterogeneous performance for medical U.S. academic centers.
Stopping vs. continuing aspirin before coronary artery surgery. N Engl J Med 2016; 374:728–37.
The PeriOperative ISchemic Evaluation-2 (POISE-2) trial (Devereaux et al.: Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370:1494–503) on 10,000 noncardiac surgical patients at vascular risk found no difference in a composite outcome of death and nonfatal myocardial infarction between patients continuing versus stopping aspirin preoperatively, yet aspirin increased bleeding. Stopping aspirin preoperatively if necessary should thus not to be considered systematically as a catastrophic event. The present paper reports the “aspirin” part of an Australia/New Zealand trial testing aspirin versus placebo and tranexamic acid versus placebo in a similar patient population. Two thousand one hundred patients were randomly assigned to receive 100 mg of aspirin or matched placebo preoperatively. The primary outcome was a composite of death at day 30 and thrombotic complications. Aspirin resulted in neither a lower risk of death or thrombotic complications nor a higher risk of bleeding than that with placebo.
A randomized trial comparing skin antiseptic agents at cesarean delivery. N Engl J Med 2016; 374:647–55.
Preoperative skin antisepsis has the potential to decrease the risk of surgical-site infection. However, there is limited evidence to guide the choice of antiseptic agent for cesarean delivery, the most common major surgical procedure among women in the United States. In this single-center, randomized, controlled trial enrolling 1,147 patients, patients undergoing cesarean delivery were allocated to skin preparation with either chlorhexidine–alcohol or iodine–alcohol. The primary outcome was superficial or deep surgical-site infection within 30 days after cesarean delivery. It was found that the use of chlorhexidine–alcohol for preoperative skin antisepsis resulted in a significantly lower risk of surgical-site infection after cesarean delivery than did the use of iodine–alcohol (relative risk, 0.55; 95% CI, 0.34 to 0.90; P = 0.02).
High-dose perioperative atorvastatin and acute kidney injury following cardiac surgery: A randomized clinical trial. JAMA 2016; 315:877–88.
The beneficial role of statins in the perioperative context of cardiac surgical patients remains uncertain. In this prospective randomized controlled trial, the authors tested the hypothesis that statin therapy (either continued in patients receiving statin therapy prior to surgery [n = 416] or introduced preoperatively in patients naive to statins [n = 199]) would reduce acute kidney injury (AKI) after cardiac surgery. The primary outcome measure was AKI defined as an increase of 0.3 mg/dl in serum creatinine concentration within 48 h of surgery. Among patients undergoing cardiac surgery, high-dose perioperative atorvastatin treatment compared with placebo did not reduce the risk of AKI overall among patients naive to treatment with statins or in patients already taking a statin. These results do not support the initiation of statin therapy to prevent AKI after cardiac surgery.
Developing a new definition and assessing new clinical criteria for septic shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315:775–87.
A task force of the Society of Critical Care Medicine and the European Society of Intensive Care Medicine developed a new definition and clinical criteria for identifying septic shock in adults. The main outcome and measures were evidence for and agreement on criteria for defining septic shock. Forty-four studies reporting outcomes of critically ill patients with septic shock were identified (166,469 patients retrieved from systematic reviews, surveys, and cohort studies). The septic shock–associated crude mortality was 46.5% (95% CI, 42.7% to 50.3%). The new definition of septic shock is a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than sepsis alone. Adult patients with septic shock can be identified using the clinical criteria of hypotension requiring vasopressor therapy to maintain mean blood pressure 65 mmHg or greater and having a serum lactate level greater than 2 mM after adequate fluid resuscitation.
Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016; 315:788–800.
The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) study aimed to evaluate intensive care unit (ICU) incidence and outcome of acute respiratory distress syndrome (ARDS) and to assess clinician recognition, ventilation management, and use of adjuncts—for example, prone positioning—in routine clinical practice for patients fulfilling the ARDS Berlin Definition. This was a large multicenter prospective international cohort study of patients undergoing invasive or noninvasive ventilation, conducted during four consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across five continents. The outcomes reported included incidence of ARDS (primary outcome), assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS. Of the 29,144 eligible patients, 3,022 (10.4%) fulfilled ARDS criteria. Less than two thirds of patients with ARDS received a tidal volume of 8 ml/kg or less of predicted body weight. Clinician recognition of ARDS was associated with higher positive end-expiratory pressure, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was high: 34.9% (95% CI, 31.4% to 38.5%). These findings indicate potential for improvement in the recognition and management of ARDS in ICU patients.
Prescription trajectories and effect of total hip arthroplasty on the use of analgesics, hypnotics, antidepressants, and anxiolytics: Results from a population of total hip arthroplasty patients. Pain 2016; 157:643–51.
Multiple lines of evidence have converged to demonstrate important relationships between pain and psychologic conditions including depression, anxiety, and insomnia. By treating the sources of discomfort, we would hope to both reduce pain and improve psychologic functioning. In their recently published analysis, the authors utilized a set of interlinked Norwegian surgical and prescription pharmaceutical databases including 39,688 patients to determine whether hip joint arthroplasty did in fact achieve these goals. In this analysis they compared prescription drug use in the year before to the year after hip surgery. The data showed the escalation of analgesic (nonsteroidal antiinflammatory drug and opioid) as psychotropic (hypnotic, anxiolytic, and antidepressant) drug use during the year leading up to surgery. Use of analgesics spiked after surgery as might be expected, but then declined to levels below those observed presurgically. Overall, this unique study provides strong evidence from a large data set that hip replacement reduces pain, improves sleep, and reduces anxiety.
Unprofessional behaviors among tomorrow’s physicians: Review of the literature with a focus on risk factors, temporal trends, and future directions. Acad Med 2016 Feb 23 [Epub ahead of print].
Professionalism is one of the six Accreditation Council for Graduate Medical Education competencies that is expected of medical trainees. This 30-yr review of the literature proposes to describe various unprofessional behaviors as well as to identify the incidence of these behaviors among medical students and residents. Overall, unprofessional behavior including cheating, misrepresentation of publications, and plagiarism was fairly common. On average, 5% to 15% of medical students and residents reported to have engaged in these behaviors. Up to 20% of applicants to some residency programs and 40% to some fellowship programs misrepresented their publications. Other behaviors like fabricating duty hours were even more common at 40% to 60%. It appears there are risk factors for some of these behaviors. Foreign (non-U.S.) medical graduates seemed more likely to be dishonest regarding plagiarism and misrepresentation of publications. Residents in surgical training programs were more likely to falsify duty hours. More importantly, professional stress and burnout were risk factors for unprofessional behavior in medical students. This review of the literature appears to demonstrate that unprofessional behavior is common in medical students and residents. Defining this behavior is the first step to understand what motivates this behavior and how to mitigate it.