Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Does brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners. Pain 2017; 158:278–88.
In the United States and other developed countries the prescription of opioids for chronic noncancer pain remains at levels far higher than those observed a decade or more ago. Unfortunately, there have been significant problems including a high rate of prescription opioid-related deaths that have paralleled the increased prescribing of opioids. Educational efforts designed to curb opioid prescribing have been introduced, although the effectiveness of such programs in real-world settings is unclear. Using a previously described three-part intervention, Holliday et al. conducted a controlled trial in which Australian general practice registrars were educated on optimal opioid prescribing practices. From 2010 to 2015 prescribing data from clinical encounters totaling more than 168,000 patient problems were analyzed. Opioid analgesics were prescribed for about 2.5% of patient problems and were not reduced by opioid prescribing training (P = 0.186). From this study it appears that educational encounters alone are ineffective at modifying opioid prescribing behaviors in physicians.
Take home message: Modifying opioid prescribing behaviors requires more than changing knowledge through brief educational efforts.
Association between tracheal intubation during adult in-hospital cardiac arrest and survival. JAMA 2017; 317:494–506.
In-hospital cardiac arrest is a cause of significant mortality. Little is known about the effect of tracheal intubation during in-hospital cardiac arrest and long-term patient outcomes. The study by Andersen et al. retrospectively analyzed data on 108,079 patients from 668 hospitals that had in-hospital cardiac arrests between 2000 to 2014 and compared those receiving tracheal intubation during the resuscitation to those who did not receive tracheal intubation. The primary outcome measure was survival to hospital discharge. Only 22.4% of the patients survived to hospital discharge. Interestingly, patients intubated within the first 15 min of a cardiac arrest had lower survival rates (16.3%) when compared to those who were not intubated (19.4%, risk ratio = 0.84; 95% CI, 0.81 to 0.87; P < 0.001). Functional outcomes were also lower among intubated patients (10.6%) when compared to patients who were not intubated (13.6%, risk ratio = 0.78; 95%CI, 0.75 to 0.81; P < 0.001). Tracheal intubation during adult in-hospital cardiac arrest in this retrospective study was associated with worse outcomes.
Take home message: Tracheal intubation during in-hospital cardiac arrest may be associated with higher mortality.
The effect of endotracheal tubes versus laryngeal mask airways on perioperative respiratory adverse events in infants: A randomised controlled trial. Lancet 2017; 389:701–8.
Perioperative respiratory events are common in the setting of pediatric anesthesia with the highest risk group being infants under 1 yr of age. Prior studies have demonstrated that the use of a laryngeal mask airway when compared to an endotracheal tube reduced the risk of adverse respiratory events in children over 1 yr of age. Unresolved is whether the use of a laryngeal mask airway reduces the risk of adverse perioperative respiratory events in children under 1 yr of age. To address this question Drake-Brockman et al. randomized 180 patients less than or equal to 12 months of age scheduled for a minor elective surgical procedure with general anesthesia to airway management with either a laryngeal mask airway or an endotracheal tube and assessed the incidence of adverse respiratory events. Similar to the findings in older children, infants in the endotracheal tube group had a higher incidence of respiratory events (53%) when compared to infants treated with a laryngeal mask airway (185, risk ratio = 2.94; 95% CI, 1.79 to 4.83; P < 0.0001). These data suggest that in young infants undergoing a minor surgical procedure the use of a laryngeal mask airway is associated with a lower incidence of respiratory events.
Take home message: The use of a laryngeal mask airway for minor surgical procedures in infants is associated with a lower incidence of adverse perioperative respiratory events.
Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and noninvasive positive pressure ventilation? A systematic review and meta-analysis. Chest 2017 Jan 13. [Epub ahead of print].
Questions remain regarding the efficacy of high flow nasal cannula oxygenation in patients with acute respiratory failure when compared to noninvasive positive pressure ventilation and conventional oxygen therapy to prevent endotracheal intubation and mortality. The study by Ni et al. describes a systematic review and meta-analysis of the studies published to date to address this question. They included 18 studies with 3,881 pooled patients. High flow nasal cannula oxygenation was associated with fewer endotracheal intubations when compared to conventional oxygen therapy (P = 0.01) but not noninvasive positive pressure ventilation (P = 0.16). There were no differences in intensive care unit mortality between high flow nasal cannula oxygenation and conventional oxygen therapy (P = 0.13) or noninvasive positive pressure ventilation (P = 0.15), although the analysis may have been under powered to detect the latter.
Take home message: High flow nasal cannula oxygenation is as effective at preventing endotracheal intubation in patients with acute respiratory failure as noninvasive positive pressure ventilation but this did not lead to improved intensive care unit survival.
A case suspended in time: The educational value of case reports. Acad Med 2017; 92:152–6.
Questions have been raised about the value of case reports in the medical literature. This article by Packer et al. reminds us of the value that students can accrue from Case Reports. They report on a 7-yr experience requiring third-year medical students to craft a “mini-thesis” in the form of a case report that “…puts the case in context, offers a hypothesis to explain the clinical events, and makes a teaching point.” They identified five educational benefits from case reports including observation and pattern recognition skills, hypothesis-generating skills, understanding of patient-centered care and writing skills. They also noted a number of limitations to case reports including patient confidentiality, over interpretation and emphasis on rare events, and low publication rates. This manuscript demonstrates that written case reporting can have substantial educational benefits for students.
Take home message: Case reports can have important educational benefits for students.
Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Crit Care Med 2017; 45:486–552. Management of sepsis and septic shock. JAMA 2017; 317:847–8.
Sepsis is one of the most challenging conditions intensivists encounter in their practice. To standardize diagnosis and treatment of sepsis, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine jointly released the most recent international sepsis guidelines. Sepsis patients can be readily identified by the quick sepsis related organ failure assessment criteria (qSOFA): respiratory rate greater than or equal to 22/min; altered mentation and systolic blood pressure less than or equal to 100 mmHg. Early goal-directed therapy was strongly advocated in the 2012 guidelines, but has been found not to be superior to nonprotocolized therapy. In this latest set of guidelines sepsis-induced hypoperfusion should be treated with at least 30 ml/kg of IV crystalloid given in 3 or fewer hours. The guidelines reiterate the central importance of aggressive infection control, initial broad-spectrum coverage with subsequent targeted antimicrobial therapy. Norepinephrine is considered as the first-choice vasopressor and packed red blood cell transfusions are only recommended when the hemoglobin is less than 7.0 g/dL except under extenuating circumstances (e.g., myocardial ischemia, significant hemorrhage). For sepsis-induced acute respiratory distress syndrome, high positive end-expiratory pressure with tidal volume of 6 ml/kg predicted body weight and maximum plateau pressures less than 30cm H2O are recommended ventilator targets. Tolerated upper blood glucose levels are now less than or equal to180 mg/dL rather than less than or equal to 110 mg/dL as described in previous guidelines.
Take home message: Recent sepsis guidelines have been published and suggest changes in the management of septic patients from the previous guidelines.
Video laryngoscopy vs. direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: A randomized clinical trial. JAMA 2017; 317:483–93.
With the introduction of video laryngoscopy into clinical practice questions have arisen as to whether video laryngoscopy increases intubation of the trachea on the first attempt. This multicenter randomized controlled trial aimed to address this question by comparing intubations using a McGrath MAC video laryngoscope to standard direct laryngoscopy in intensive care unit (ICU) patients requiring tracheal intubation. The trial openly randomized 371 patients from seven ICUs in France. Primary outcome was the proportion of patients with successful first-pass orotracheal intubation. The underlying hypothesis was that video laryngoscopy would increase the success of first-pass orotracheal intubation to 80% compared with direct laryngoscopy (65% expected success rate). Overall, the results of the trial were negative and did not show a difference between the two methods. First-pass intubation success was 68% for video laryngoscopy versus 70% for direct laryngoscopy (absolute difference: −2.5% [95% CI, −11.9 to 6.9%]; P = 0.60). Severe life-threatening complications were more common in the video laryngoscopy group (9.5%) versus in the direct laryngoscopy group (2.8%) (absolute difference, 6.7% [95% CI, 1.8 to 11.6%]; P = 0.01). The authors concluded that video laryngoscopy was not superior to direct laryngoscopy in ICU patients and appeared to be associated with a higher incidence of life-threatening adverse events.
Take home message: In the ICU setting the use of video laryngoscopes may lead to more life-threatening complications without enhancing first pass intubation.
Efficacy of liposomal bupivacaine infiltration on the management of total knee arthroplasty. JAMA Surg 2017; 152:90–5.
It is unclear whether the benefits of periarticular infiltration with liposomal bupivacaine is superior to patients undergoing total knee arthroplasty. This study presents a single-center retrospective cohort study among U.S. veterans undergoing primary total knee arthroplasty in an attempt to answer this question. The primary endpoint was the use of opioids after discharge from the postanesthesia care unit (PACU). The study compared two phases, one before (n = 101) and one after implementation of periarticular infiltration with liposomal bupivacaine (n = 98). In this before-and-after comparison, patients who received periarticular infiltration with liposomal bupivacaine required less opioids (12.5 vs. 22.5 IV morphine equivalents, P = 0.001), fewer uses of patient-controlled analgesia (49 vs. 91, P < 0.001), and required fewer antiemetics (13 vs. 34, P < 0.001). Pain scores among patients receiving periarticular infiltration with liposomal bupivacaine were lower in the PACU but higher 48, 72, and 96 h after surgery. The authors estimated the institutional cost savings at $27,000/yr. Although the authors conclude that the results of this study support the use of periarticular infiltration with liposomal bupivacaine in patients undergoing total knee arthroplasty, substantial limitations including the retrospective study design and the lack of standardized postoperative pain management and assessment warrant caution in extrapolating these findings into clinical practice.
Take home message: Periarticular liposomal bupivacaine infiltration for total knee arthroplasty may decrease pain and opioid use in the PACU but may be associated with higher subsequent pain scores.