Abstract
These abstracts are published as supplied and have not been subject to editorial review or correction.
Pre-operative activity levels and outcome following major abdominal surgery
1Christchurch Hospital, University of Otago
2Christchurch Hospital
3University of Otago
Multiple methods and indices exist for assessing patient risk prior to planned surgical intervention. As the surgical demographic changes to reflect the ageing population in the community, the concept of frailty is seen as an increasingly important part of risk assessment.1 Frailty is often characterised as hard to define, but easy to identify; it is a state of decreased physiological reserve seen with increasing frequency in older persons and is independent of any organ specific diagnosis. In this prospective cohort study we examined pre-operative activity levels based on measured step count in comparison with more conventional frailty assessments in 100 older patients presenting for elective abdominal surgery. Multi day step data may provide a more accurate picture of functional status compared to snap shot clinic assessment, and also provide a low cost tool to guide prehabilitation in the future.
Methods
Patients aged 65 years and over, meeting study criteria and presenting for major elective abdominal surgery were approached to take part. Consent was obtained in pre-operative clinics, and the average lead time was 12 days prior to surgery.
In addition to routine pre-operative preparation, participants were assessed with administration of the Edmonton Frail Scale (EFS), additional blood work and finally were fitted with a Garmin Vívofit® 3 wearable activity tracker. Participants were instructed to wear the device continually and proceed with their normal daily activities.
The primary study end point was hospital length of stay. A variety of other post-operative data was collected including standardised surgical complication scores.
Results
100 patients were recruited to the study, and 85 complete data sets were obtained for analysis. Average age was 76 +/− 6.2 years with an equal M:F ratio. Of the 85 patients, 73 were assessed as not frail by EFS, and 12 identified as frail.
Median pre-operative step count was 4569 steps/day (IQR 2727–6830). Patients with a median pre-operative step count of <2500 were defined as low activity for older adults.2 There were 17 low step count (LSC) patients identified, and of these 9 were identified as frail by EFS.
Median length of stay in the LSC group was more than double that of those with a normal step count at 14 days (IQR 9–17) vs 6 days (IQR 4.8–8), P < 0.01.
Pre-operative LSC was predictive of adverse post-operative outcomes including; ICU admission (IRR 3.14, 95% CI 1.64–6.05), post-operative complications (OR 3.25, 95% CI 1.1–12.1), and discharge to another health care facility (OR 14.2, 95% CI 3.74–63.2).
Discussion
Objective pre-operative low physical activity levels, as assessed by step count, has been shown to be highly predictive of an increased risk of adverse outcome in abdominal surgery patients. The most commonly used frailty assessment tool, EFS, only identified half of these at risk individuals. Accurate preoperative identification may allow for treatment modification and tailored perioperative care. The possibility of a wearable activity tracker as a simple but powerful pre-habilitation tool is raised as an obvious avenue for future study.
References
Efficiency and acceptability of an automated electronic system (DayCOR) compared with a telephone call system, for follow-up of day surgery patients: a parallel-group observational study
1Epworth Healthcare, University Of Melbourne
2Newcastle
In Australia, 2.34 million anaesthetics were performed for day surgery procedures in 2016–17.1 Post-discharge telephone call systems (TCS) are widely used for assessing recovery of day surgery patients, however they capture incomplete information from a small patient sample. Any alternative method of follow-up should have well-defined efficiency and acceptability benefits. The Day Care Anaesthesia Outcomes Registry (DayCOR) is an automated web-based system which collects, alerts, manages and analyses patient-reported data. Patients may opt-in to respond to a 15-question survey via a link sent by text message or email 24 hours after discharge. This study’s primary objectives were to compare the quality of data collected by each system, and to undertake a basic cost comparison study of the two systems. Our secondary objective was to assess the user acceptability of each system.
Methods
In February 2018 DayCOR was introduced to the study hospital, 1 of 7 acute care hospitals of a non-profit private healthcare organisation in Victoria, Australia. 35 anaesthetists gave consent for their patients to be followed-up using DayCOR. The remaining patients at the study hospital, and other 6 hospitals, were followed up with the usual TCS. We calculated the reported patient response rate using DayCOR, and the proportion of patients called and successfully contacted using the TCS. Both systems collected data on clinical, process and experience outcomes; we compared the proportion of patients who provided an answer to each item of data collected by each system. We measured the time required for a nurse to enter a patient’s demographic details, and act on patient responses in the DayCOR database. DayCOR’s fixed per patient fee was $0.52. We measured the time required for nurse-initiated phone calls. The cost of nursing time was AUD$41.00/hour. We did not calculate costs of hospital phone calls or internet access, or those incurred by patients or anaesthetists. We considered nurses who used both systems and anaesthetists who had >20 patient responses in DayCOR to be ‘users’ of the systems. We asked which system they preferred, which provided the most valuable patient feedback, and whether their clinical practice had changed.
Results
During the six-month study period 30637 patients underwent day surgery at all 7 hospitals. Due to operational differences of the two systems of follow-up, and limitations of the hospital’s administrative data management system, a direct comparison of outcomes was not possible. 1152 (77.5%) patients submitted surveys via DayCOR, compared with 7274 (66.0%) patients who were called and successfully contacted using the TCS. Completeness of data collection was 100% with DayCOR compared with a range of 51–61.4% with the TCS. The estimated annual cost of following up 60000 day surgery patients per year was $88,590 with DayCOR compared with $192,600 for the TCS. 17 (78%) nurses and 15 (94%) anaesthetists preferred DayCOR to the TCS. 16 (100%) anaesthetists stated that DayCOR provided more valuable feedback; 3 (19%) had changed their clinical practice as a result.
Discussion
DayCOR had a higher patient response rate, a higher completion rate of similar patient-reported outcomes, lower cost and higher user-acceptability, compared with the TCS.
References
Anaesthetists’ attitudes to random alcohol and drug testing in the anaesthesia workplace
Royal Perth Hospital and University of Western Australia
The use of alcohol and other drugs exists in healthcare workers in Australia and elsewhere. Use of drugs in the workplace poses a threat to the safety of workers, their colleagues and patients. Random drug testing (RDT) is established in aviation, mining and defence industries.1 It is also common practice in many countries to test drivers for the presence of alcohol and illicit drugs. Health Departments and hospital administrators have attempted to limit illicit use of drugs, and their diversion, in the healthcare settings by education and strict regulation of their storage and dispensation. There are no data on the attitudes and knowledge regarding RDT of healthcare workers. This study surveyed attitudes to RDT in the anaesthesia workplace. Random testing for alcohol and drugs can include breath-testing, saliva testing, urine sampling and blood sampling.2 This survey did not seek opinions on the accuracy of various screening and laboratory methods. Also, views about drug use and impairment and workplace injury were not sought.
Methods
With institutional and heads of departments’ approval, an email invitation was sent to consultants and trainees in Western Australia. The email contained a link to an on-line survey questionnaire containing 18 questions and one box for written comments.
Results
At the time of abstract submission, 156 responses (16% trainees, 71% male) were received. Most respondents (62%) thought that RDT did not infringe on employees’ rights and 85% felt that healthcare organisations have the right to require such testing when an employee is suspected of using alcohol or drugs before commencing work. Fifty-two percent felt that RDT would improve patient safety but only 44% thought that it would improve staff safety. Most (90%) respondents thought that RDT would not influence their personal use of alcohol and drugs. Sixty-three percent supported RDT of anaesthetists and there were similar levels of support for RDT of surgeons (62%), anaesthesia assistants (66%), PACU staff (65%), operating theatre nurses (64%) and hospital pharmacists (66%). If RDT was introduced, respondents differed in their preferred frequency of testing (26% twice a year, 27% unsure, 9% monthly). RDT of road users by police was supported by 96% of respondents and there were widely differing views on the current system of drug security, distribution or disposal being a deterrent or reducing drug diversion. Several respondents would support a pilot program of RDT so long as all workers in the anaesthesia workplace were included and others suggested a targeted program of RDT for those workers who had been observed to have a decline in their performance.
Discussion
The introduction of RDT into the anaesthesia workplace has been discussed elsewhere.3 Our survey found majority support for such programs in our hospitals as long as the testing extended to others who work alongside us. There was disagreement whether RDT would enhance patient or staff safety; and the preferred frequency of testing staff if it was to be introduced. There was high support for police testing of road users and uncertainty about the current systems for drug security.
References
Comparison of bed-up-head-elevated intubation position with Glidescope-assisted tracheal intubation: a randomised, controlled, non-inferiority trial
University Malaya Medical Centre, University Of Malaya
Proper positioning during intubation is critical in order to increase the likelihood of success. The bed-up-head-elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications and prolong safe apneic time during intubation. Concurrently in the last decade, there has been an exponential increase in the use of video laryngoscopy (VL) devices, especially for difficult airway patients, as it has been shown to improve laryngeal exposure. The use of VL will increase, and may replace traditional laryngoscopy one day. In this study, we sought to determine if the BUHE intubation position is non-inferior to Glidescope-assisted intubation with regards to laryngeal exposure. In addition, we aimed to determine the differences in time required for intubation (TRI) in the two groups.
Methods
A total of 138 ASA 1 to 3 adults planned for elective surgeries were recruited into the study. Patients with Body Mass Index more than 35 kgm-3 were excluded, as were patients who required rapid sequence intubation or awake fibreoptic intubation. Randomisation was performed in blocks of six using computer generated sequences, equally allocating patients into two groups using sealed envelopes. Group A patients (n = 69) were intubated in the BUHE position (end point being the horizontal alignment of the external auditory meatus to the sternal angle), while Group B patients (n = 69) were intubated using Glidescope laryngoscopy. In both groups, baseline laryngoscopy was first performed in the sniffing position using Macintosh laryngoscope. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score, and non-inferiority will be declared if the mean POGO scores in both groups do not differ by −15% for a one sided 97.5% confidence interval. The TRI was measured from beginning of laryngoscopy to the first detected end tidal carbon dioxide and assessed for superiority, as were the secondary outcomes (Number of intubation attempts, use of airway adjuncts, effort during laryngoscopy and complications during intubation).
Results
Mean POGO score in Group A was 80.14 +/− 22.03%, while in Group B it was 86.45 +/− 18.83% (p = 0.073), with a mean difference of −6.3% (95% confidence interval −13.2%, 0.6%). In both groups, there was a significant improvement in mean POGO scores (Group A 25.8 +/− 4.7%, Group B 30.7 +/− 6.8%) when compared to baseline laryngoscopy in the sniffing position (p < 0.0001). The mean TRI was 36.23 +/− 14.41s in Group A while Group B had a mean TRI of 44.33 +/− 11.53s (p < 0.0001). There were no differences in both groups with regards to secondary outcomes. A post-hoc analysis in patients with baseline Cormack-Lehane 3 grading found a trend for improved laryngeal exposure in Group B (70.5 +/− 29.7%) compared to Group A (49.2 +/− 19.6%) (p = 0.054).
Conclusion
In the normal population, BUHE intubation position provides a non-inferior laryngeal view to Glidescope intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In addition, there is a shorter time to intubation in the BUHE position compared to Glidescope intubation. In view of the many advantages of the BUHE position for intubation, the lack of adverse effects, the simplicity and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the normal population.
Hypercoagulability detected by thromboelastography in patients undergoing elective total hip arthroplasty
1Department Of Anaesthesia, Austin Health, Melbourne, Australia
2Department Of Intensive Care, Austin Health, Melbourne, Australia
3Department Of Orthopaedic Surgery, Austin Health, Melbourne, Australia
Hypercoagulability has been identified as a risk factor for venous thromboembolic disease in patients undergoing total hip arthroplasty. Whilst low molecular weight heparin (LMWH) is administered as routine postoperative chemo-thromboprophylaxis in this group, monitoring the effects of LMWH on global coagulation remains relatively unexplored. Thromboelastography (TEG) is a viscoelastic test that provides a global assessment of coagulation. We used TEG to explore the coagulation state of total hip arthroplasty patients receiving standard chemo-thromboprophylaxis. We hypothesised that a hypercoagulable state would be present in this patient group and performed a prospective observational study to test our hypothesis.
Methods
After Human Research Ethic Committee approval and informed patient consent, we performed this study in a University teaching hospital. We included adult patients undergoing primary elective total hip arthroplasty under general or spinal anaesthesia. We excluded patients on any anticoagulation or antiplatelet therapy and patients with any renal or hepatic impairment. The primary objective was to assess hypercoagulability as measured by TEG by examining changes in the maximum amplitude from baseline values to values on postoperative days 1, 3 and 5. Secondary outcomes included i). evaluating perioperative changes in other TEG parameters (R-time, K-time, and alpha angle) ii). comparing perioperative changes in TEG parameters in patients receiving general anaesthesia (GA group) and spinal anaesthesia (Spinal group), and finally iii). to assess perioperative changes in conventional coagulation tests, namely INR, activated partial thromboplastin time and fibrinogen. TEG parameters of whole blood were assessed immediately prior to skin incision, midpoint intraoperatively, prior to skin closure, and for 5 days postoperatively. Conventional coagulation tests were sampled preoperatively and on postoperative day 5.
Results
Fifty-two patients were enrolled. 20 participants underwent total hip arthroplasty under general anaesthesia and 32 patients underwent spinal anaesthesia. All patients received postoperative 40 mg enoxaparin SC daily. For the primary end point the median (IQR) MA increased from baseline values of 62 mm (56:68) and 61 mm (54:65) in the GA and Spinal groups respectively to 77 mm (74:81) and 78 mm (72:82) (p = 0.01) on postoperative Day 5. Compared to baseline values the reaction and coagulation times decreased and the α angle increased in the middle and at the end of surgery. There were no significant changes in the postoperative conventional coagulation tests from baseline values. No patients developed postoperative venous thromboembolism.
Discussion
Chemo-thromboprophylaxis with LMWH in patients following elective total hip arthroplasty failed to prevent a postoperative hypercoagulable state when assessed by TEG. Conversely, the same chemo-thromboprophylaxis did not demonstrate hypercoagulability when assessed by conventional laboratory coagulation tests. Study implications: first our findings suggest that TEG may assist in the detection of perioperative hypercoagulability in patients undergoing elective total hip arthroplasty; second, additional strategies such as the early use of antiplatelet drugs and/or increased doses of fractionated or unfractionated heparin may be needed in select patients to improve the therapeutic benefit of chemo-thromboprophylaxis after total hip arthroplasty.
Assessing tracheostomy tube colonisation and infection within a large multidisciplinary tracheostomy team
Westmead Hospital
A long-term tracheostomy tube is a significant cause of morbidity and mortality in hospitalised and community patients. Biofilm formation and colonisation in particular has been linked with in-dwelling devices and have contributed to associated infections including sepsis.1
Tracheostomy tubes are changed routinely for a number of reasons including the prevention of stoma granulation, prevention of tube blocking and to facilitate weaning or speech by changing tube size and type. Currently tubes are reviewed and changed at variable time frames usually 6 weeks post insertion and then every 3 months. However, these time frames have considerable variability between institutions and in practice. Further no current evidence based guidelines exists to guide the timeframe of tube changes. The last relatable published guidelines, was published over 15years ago by the American Thoracic Society and limited to a paediatric population.2
The Westmead Hospital tracheostomy service is one of the largest multi-disciplinary tracheostomy teams in Australia. This study aims to assess the rates of colonisation and infection of tracheostomy tubes within this service.
Methods
Data was prospectively collected over a one year time period from adult patients who are currently part of the Westmead Hospital, Department of ENTs multidisciplinary tracheostomy service. A total of 34 patients have currently been collected on an ongoing basis over the last eight months from both inpatients and the services outpatient clinic.
During routine changes stomas were assessed and a microbiology swab taken from the cuff and tip/inner-cannula and sent for routine MCS. A true colonised sample was interpreted as a positive culture of similar microorganisms from both swabs for cuffed tubes or the tip/inner-cannula alone for un-cuffed tubes. Descriptive statistics and chi-square tests (p < 0.05) were performed to compare culture results with other tracheostomy tube endpoints.
Results
A total of 34 patients were included in the study. Chi squared analysis showed a significant difference in colonisation with cuffed vs un-cuffed tubes (74%v27%, p = 0.010). There was also a significant difference in colonisation with inpatients vs outpatients (73% v 33%, p = 0.026).
There was no statistically significant result when comparing timing of tube changes, indication for insertion or fenestration.
Conclusion
This study supports our initial hypothesis that the timing of tracheostomy tube changes may not effect colonisation and infection rates among tracheostomised patients.
A significant difference in inpatients vs outpatients strengthens the argument that a dedicated multidisciplinary tracheostomy service with outpatient reach can reduce colonisation/infection rates and possibly the need for frequent tube changes. This may pave the way towards earlier education, training and discharge of patients and carers on routine tracheostomy care in the outpatient setting.
Further, a significant difference in positive culture rates among patients with cuffed tubes, indicates that they may hinder certain innate immune responses such as mucocilliary clearance in the prevention of infection.
References
Development of a feedback tool to compare individual pain scores to a department average
1The Wollongong Hospital, Wollongong, Australia. University of Wollongong Graduate Medicine, Wollongong, Australia. University of Sydney, Sydney, Australia
2Department of Anaesthesia, The Wollongong Hospital, Wollongong, Australia, University of Wollongong Graduate Medicine, Wollongong, Australia. Charles Sturt University, Albury, Australia
3Department of Anaesthesia, The Wollongong Hospital, Wollongong, Australia. University of Wollongong Graduate Medicine, Wollongong, Australia. University Of Nottingham Medical School, Nottingham, England
Acute post-operative pain remains a major problem, resulting in many undesirable outcomes if inadequately controlled.1 The numerical rating scale (NRS) is used to assess pain intensity in our post anaesthesia care unit(PACU) and has been shown to be valid and reliable while generating auditable data.2 In 2013, ANZCA revised its CPD standards placing a much greater emphasis on practice evaluation than knowledge and skills acquisition. One valued aspect of practice evaluation is the comparison of your own results with other anaesthetists.3 In this study we aim to improve post-operative pain outcomes at a departmental level by facilitating reflective practice through a confidential feedback tool that enables anaesthetists to compare their own post-operative pain scores with their peers.
Method
We collaborated with various departments within our hospital and the South Eastern Sydney Local Health Network (SESLHN) to modify a pre-existing data extraction code (SN015) to enable the automatic extraction of NRS pain scores assessed and recorded in PACU. We were then able to run the code to extract all PACU pain scores for a specific surgery within a specific time period. We ran a pilot study looking at all emergency laparoscopic cholecystectomies performed at The Wollongong Hospital during 2016. Once the pain score data for the pilot study was extracted, it was de-identified and stratified before being applied to statistical analysis software (SAS) to generate a departmental average pain score represented as a normal distribution bell curve.
This same curve was emailed to every anaesthetist with an addition of three superimposed vertical lines representing their individual average pain score and both the average minimum and the average maximum pain scores for all their cases. Raw pain scores were also displayed as a table for transparency of the data leading to their results. Individual surgical dates and patient MRNs can also be added to enable anaesthetists to look up each procedure for further reflection on their scores. The information was sent using manual encryption to maintain confidentiality.
Results
Pain scores were available for 66 anaesthetists. 23 had > five cases, 17 had two to four cases and 26 had one case. The departmental average of average, average of minim and average of maximum NRS pain scores were: 1.5072 (SD: 2.241), 0.806 and 2.188 respectively. 58% of all cases captured by the SN015 extraction code had NRS pain scores completed. There was heterogeneity in the number of pain scores entered per case.
Discussion
We developed an efficient and confidential feedback tool that enables anaesthetists to compare their post-operative pain scores but also refer to the specific cases leading to their relative scores. This tool encourages reflective practice and we anticipate that over time, with its recurrent use, both the departmental average and the departmental spread of pain scores will decrease.
References
Methadone provides a preventive analgesic effect in patients undergoing cardiac surgery
Northshore
Preventive analgesic medications are those in which the analgesic benefits persist beyond the clinical duration of action (defined as more than 5.5 half-lives of the agent).1 Methadone is an opioid with the longest elimination half-life of the clinically-used opioids. Clinical studies have reported that patients administered methadone had lower pain scores and analgesic requirements during the first 72 postoperative hours, compared to subjects given conventional opioids.2 The intensity of acute postoperative pain is one of the strongest predictors for the development of chronic postsurgical pain.1 In addition, methadone is a potent N-methyl-D-aspartate (NMDA) receptor antagonist and has been reported to decrease the requirements for opioid medications (and possible resultant opioid-induced tolerance and hyperalgesia). The aim of the present investigation was to determine whether the analgesic benefits of methadone persisted beyond the hospital discharge date (1, 3, 6, and 12 months postoperatively). We hypothesized that patients administered methadone would have a lower incidence of persistent pain, defined as fewer episodes of pain per month.
Methods
The NorthShore Institutional Review Board approved this follow-up clinical investigations, and all patients gave their written consent to participate. 156 patients undergoing cardiac surgery were enrolled in a double-blinded clinical trial comparing pain scores and analgesic requirements in subjects randomized to be administered either a single intravenous dose of methadone (0.3 mg/kg) or fentanyl (12 mcg/kg) prior to cardiopulmonary bypass.1 In this initial study, pain scores and analgesic requirements were reduced for the first 72 postoperative hours. Patients were sent a brief questionnaire 1, 3, 6, and 12 months after their surgery. Patients were asked to record levels of pain (chest, back and leg pain at rest, coughing, and movement) that were present at the time the surveys were completed using an 11-point visual analog scale (VAS) (0 = no pain, 10 =worst pain imaginable). The weekly frequency of pain was recorded (primary endpoint), as well as need for analgesic medications and pain interference with sleep and daily activities.
Results
Chest pain scores at rest, with coughing, and with movement were significantly lower in the respondents in the methadone cohort at 1-month (all P < 0.0001). Similarly, leg pain scores were significantly less at 3-months at rest in the methadone group (P = 0.004). The frequency of postsurgical pain was less in the methadone group (0 (less than once a week) compared to the fentanyl group (2 (twice per week), P = 0.004)) at 1-month, but low thereafter (0 to 0.5) in both cohorts and not significantly different. Although fewer patients in the methadone group required postoperative opioid analgesics, the overall number of patients by 3 months was small and no differences between respondent groups was observed at any time.
Discussion
Cardiac surgical patient administered intraoperative methadone reported significantly less postoperative pain 1-month after surgery, compared to subjects given fentanyl. These findings support the use of methadone as a preventive analgesic agent.
References
The feasibility of a fast-track cardiac anaesthesia protocol in a single centre Australian teaching hospital
1Department of Anaesthesia, Austin Health
2Department of Cardiac Surgery, Austin Health
3Monash University Medical School
4Department of Intensive Care, Austin Health
Introduction
Fast-track cardiac anaesthesia (FTCA) (tracheal extubation <4hours postoperatively and discharge to HDU bed on the day of surgery) may be an acceptable model of cardiac surgical care. Advantages include shorter ventilation and ICU times, and cost-effective utilisation and allocation of ICU beds. Risks include delays in ICU readmission for timely management of post-surgical complications, need to escalate vasoactive and inotrope therapy, and duplication of ICU resources within a well-established hospital setting. In 2016, Austin Health received institutional support for 16 patients go undergo a FTCA programme. Primary aim: to test whether a dedicated FTCA programme was feasible. We assessed programme compliance, reasons for fast-track failure, and logistical feasibility i.e. availability of a post ICU discharge bed. Secondary objectives: evaluate the impact on postoperative ventilation hours, length of ICU and hospital stay, and postoperative complications. We compared the secondary outcome to a cohort of patients undergoing usual care (UC group).
Methods
With ethics approval, a FTCA programme was developed by a multidisciplinary team of cardiac surgeons, anaesthetists, and intensivists. We included adult patients (age >18years), undergoing primary CABG or valve surgery requiring cardiopulmonary bypass. We excluded emergency and redo-surgery, aortic surgery, patients with abnormal preoperative ventricular function, pulmonary hypertension, and respiratory disease. The FTCA protocol included a pre-specified FTCA technique (no premedications, short acting opioids, reversal of all neuromuscular blockade with sugammadex, multimodal analgesia) and the requirements for a-priori metrics for postoperative bleeding, haemodynamic stability, vasoactive medications, gas exchange, and neurological and sedations scores.
Results
16 patients were included in the FTCA protocol. There were no violations in the protocol. Compared to the UC group, patients in the FTCA group were younger (median IQR) age 56 years (40:66) vs. 65.6 years (58:73) (p = 0.008), with lower Euroscores 1.5 % (0.9:2.2) vs. 4% (2:6). All other baseline characteristics including preoperative ventricular function, and cardiopulmonary bypass and aortic clamp times were similar. Of the 16 FTCA patients, 5 (31%) were extubated on the operating table, 9 (56%) within 4 postoperative hours in the ICU, and 2 (12%) within 18 hours postoperative hours in the ICU. Median (IQR) ventilation hours was 2.1 hours (0:6.5) in the FTCA group and 8 hours (5:11.5) in the UC group (p = 0.004). 4 (25%) patients were transferred out of ICU on the same postoperative day. Reasons for failure to transfer out of ICU included no HDU bed available (4 patients), inadequate analgesia (2 patients), postoperative bleeding (2 patients), poor postoperative gas exchange (3 patients), and return to theatre for bleeding (1 patient). Median length of ICU stay was 22 hours (12.2:40.5) in the FTCA group and 37 hours (20.5:67) in the UC group; p = 0.03. There no were no differences in complications between the FTCA and UC groups. Total hospital stay was 6 days (5.2:8.5) in the FTCA group and 7 days (6:12.5) in the UC group; p = 0.11.
Conclusions
The FTCA protocol was feasible with no violations in our proposed protocol. There was no association harm. The FTCA protocol translated into shorter ventilation and ICU times, but no significant differences in complications and length of hospital stay. Our findings support this FTCA programme being validated in a randomised pilot trial.
Donepezil and neuromuscular blockers: an important drug interaction
Wellington Hospital
Summary
A patient did not respond to rocuronium. This was attributed to the presence of donepezil.
Preoperatively she had good power throughout all her limbs. All blood tests were within normal limits.
Anaesthesia was induced and maintained via TIVA. Following induction 0.6 mg/kg rocuronium was administered and tracheal intubation was achieved. A peripheral nerve stimulator (PNS) demonstrated no reduction in adductor pollicis brevis train of four (TO4) stimulation. Further doses were given totalling 2.3 mg/kg. Again, no reduction in TO4 was seen. The operation was completed, and after reversal with 3.3 mg/kg sugammadex, the patient was extubated awake and had an uncomplicated stay in PACU.
Discussion
Donepezil is a reversible inhibitor of acetylcholinesterase (AChE), a central neurotransmitter reduced in patients with Alzheimer’s disease. Donepezil improves cognitive function and activities of daily living in patients with Alzheimer’s disease. It is not a treatment for Alzheimer’s disease; but is used to slow disease progression. We are likely to encounter more patients on this drug as the population ages.
The literature on the interactions between AChE inhibitors and NMBs is scarce. However there have been similar case reports1,2. In addition, unpredictably delayed recovery of neuromuscular function in a patient who received suxamethonium has been described3.
Patients on donepezil in whom muscle relaxation is essential should have it ceased at least two weeks in advance if possible, or plans made for alternative methods such as remifentanil or increased depth of anaesthesia. If a non-depolarizing NMB is indicated, a supra-therapeutic dose of rocuronium is likely to be required. A PNS should be utilized intraoperatively, as should always be standard practice. There have been no studies on the utility of sugammadex in this situation, but it would not be unreasonable to use it as the reversal agent of choice in this situation. Suxamethonium should be avoided altogether due to the risk of a prolonged block.
Donepezil has a terminal half-life of 70 hours, necessitating withdrawal of this drug at least two weeks prior to anticipated surgery. Other AChE inhibitors such as galantamine and rivastigmine, have half-lives of 5 hours and 1.4–1.7 hours respectively. and can therefore be stopped one day prior to anaesthesia. The long-term cognitive effects of temporarily ceasing AChE inhibitors are unclear so we suggest that the decision to withhold these drugs be done in consultation with the original prescriber.
This case also highlights the importance of routine use of a PNS during every anaesthetic involving the use of a NMB.
References
Seven years of Transtracheal Jet Ventilation: Lessons Learnt
Monash Health
Background
Management of the difficult airway in ENT surgery can be challenging, particularly because conventional difficult airway algorithms often are not applicable. Awake tracheostomies are now less frequently performed by surgeons, and in some cases may not be feasible due to the location and spread of pathology. Transtracheal jet ventilation (TTJV) offers a safe, feasible alternative that can be performed with minimal discomfort on the awake patient, yet is rarely practiced in Australian healthcare centers due to lack of familiarity.1 To our knowledge, no audit has been performed on TTJV in Australia on this scale for ENT surgery.
Methods
We report a retrospective audit of the use of TTJV in a tertiary healthcare centre in Melbourne, Victoria, over the past 7 years, with a total of 50 patients with severe airway compromise undergoing pharynolaryngeal surgery.
Results
TTJV was successful in 98% of patients. Only one patient required further postoperative attention for possible airway compromise, but recovered uneventfully. Minor complications occurred in 12% of patients, which is a substantial improvement compared to other cases in the literature. Rates of complications and ease of insertion(measured by number of needle passes) demonstrated improvement.
Conclusions
TTJV should always be performed using a high-frequency jet ventilator (HFJV). Imaging prior to TTJV is highly recommended. Cannulation of the trachea below the cricothyroid membrane is feasible but more challenging to the inexperienced anaesthetist. Apnoeic oxygenation through the TTJV cannula is delays desaturation in the well-preoxygenated patient.
References
Clinical audit of perioperative use of intravenous lignocaine infusions in non-obstetric patients undergoing intra-abdominal surgery at the Royal Brisbane and Women’s Hospital
Royal Brisbane and Women’s Hospital, University of Queensland
The use of perioperative intravenous lignocaine infusions (ILI) have been gaining traction in recent years, namely for its role in improving perioperative analgesia and consequently reducing perioperative opioid use.1 Optimal dosing and timing of ILI regimens are not known. In a recent Cochrane meta-analyses,2,3 regimens varied with a bolus of 0–3 mg/kg, and the infusions from 1.5–4 mg/kg/hr. Additionally, there is a lack of evidence regarding the individual weight metric to use, particularly in the obese population. At present there are no consensus statements nationally or internationally to guide the use of perioperative ILI, the consequences of which may result in impaired efficacy, extending to significant toxicity. This also leads to significant heterogeneity amongst published studies, hampering efforts to draw credible conclusions from datasets. This audit aimed to identify the current practice of perioperative ILI use for non-obstetric intra-abdominal surgery by anaesthetists within the Department of Anaesthesia at the Royal Brisbane and Women’s Hospital (RBWH) during a 3-month period, and to identify potential areas that may contribute to patient harm.
Methods
Retrospective chart review of all non-obstetric patients at the RBWH who have undergone open or laparoscopic abdominal surgery between 1st March – 31th May 2018. Patient demographics, medical history, intraoperative lignocaine use, surgical type and adverse events requiring intralipid were audited. Bolus dose and infusion data was calculated for the total body weight (TBW), lean body weight (LBW), ideal body weight (IBW) and adjusted body weight (ABW). Ref No: HREC/18/QRBW/286
Results
750 surgeries were identified of which 149 (19.9%) used ILI, and 144 were included in the audit. Mean ± standard deviation for Total bolus dose (87.7 ± 36 mg), adjusted for TBW (1.0 ± 0.4 mg/kg), IBW (1.4 ± 0.5 mg/kg). Infusion Rate (101.4 ± 47 mg/hr), adjusted for TBW (1.2 ± 0.4 mg/kg/hr), IBW (1.6 ± 0.7 mg/kg/hr). Sub-analysis for obesity class 1 or greater – bolus dose (102.2 ± 37.8 mg), adjusted for TBW (0.9 ± 0.4 mg/kg), IBW (1.6 ± 0.6 mg/kg). Infusion rate (122.8 ± 56.5 mg/hr) adjusted for TBW (1.1 ± 0.5 mg/kg/hr) and IBW (1.9 ± 0.8 mg/kg/hr). Surgical case type – 48% general surgery, 27% gynaecology, 17% bariatric, Urology 7%, Trauma 1%
Relative contraindications – 6.3% had renal dysfunction, 5.6% had hepatic dysfunction, nil had cardiac dysfunction, 2.1% had history of arrhythmia. Nil adverse events occurred requiring intralipid use.
Discussion
ILI’s are used frequently in the non-obstetric intra-abdominal surgery at the RBWH, however there is a reasonable amount of heterogeneity across the doses used for bolus and infusion rates in this population. This leads to further heterogeneity when calculating for different weight metrics, which may have effects on efficacy and toxicity. This could be improved by having a standardized protocol at the RBWH for ILI use.
References
Audit of perioperative nursing knowledge of emergency “can’t intubate can’t oxygenate” (CICO) equipment preparation and protocols
Royal Eye and Ear hospital Melbourne
Background
The management of an unanticipated difficult airway has traditionally been the domain of the attending anaesthetist. More recently, national guidelines have stressed the importance of a team based approached to difficult airway management with cognitive cues from recognised difficult airway algorithms .
The Royal Victorian Eye and Ear Hospital (RVEEH) is a specialised ophthalmic and ENT institution which serves as a state-wide referral service. Operations are performed over two distinct campuses with variable equipment and nursing resources. The majority of operating lists are run by sole anaesthetists with limited additional consultant/trainee anaesthetic support.
As the sole anaesthetist involved in a “Can’t Intubate Can’t Oxygenate” (CICO) emergency will likely be focused on the evolving airway crisis, it is imperative that perioperative nursing staff are familiar with various CICO techniques and necessary equipment required to progress down a CICO algorithm. At our institution, we have sought to create a high-fidelity simulation-based nursing education program, which would provide a training experience that has similar efficacy to those reported internationally.
Aim
The primary aim of this study is to determine the preparedness of perioperative nursing staff for CICO emergencies in our institution. The secondary aim of this study is to determine the value of crisis simulation in continuing nurse education.
Methods
Ethics approval was granted by the RVEEH ethics committee prior to commencing this study (Approval number 18/1382HS).
In this audit, anonymous surveys were conducted relating to nursing knowledge of CICO equipment and preparation both before and after emergency airway education.
The aims of the survey questions were to:
a) identify the role of the perioperative staff member;
b) determine the level of experience of the perioperative staff member;
c) identify their knowledge of the three main CICO intervention techniques;
d) assess the level of confidence and supervision required to setup CICO equipment; and
e) determine the amount of time each staff member believes they will require to prepare CICO equipment for a CICO intervention.
Results
A total of 43 surveys were collected, representing the majority of the regular perioperative staff at our institution. Significant improvement was demonstrated after emergency airway education in all areas surveyed, including the location of CICO equipment (86% to 96%), awareness of different CICO techniques (52% to 100%), confidence in CICO equipment setup, and a decrease in expected CICO equipment setup time (from >5 minutes to <3 minutes).
Conclusion
The preparedness of perioperative nursing staff for CICO emergencies in our institution was below expectation. However, preliminary surveys performed after emergency airway education involving simulation demonstrated significant improvement in knowledge and confidence for CICO equipment setup. Further study would be useful to evaluate degradation of CICO knowledge over time and whether additional resources need to be invested into continuing nurse education for crisis simulation.
Flinders Medical Centre regional anaesthesia audit 2018: evaluating current processes and future directions
Flinders Medical Centre, Adelaide
Flinders Medical Centre (FMC) is a tertiary teaching hospital providing regional anaesthesia for patients undergoing a large range of surgical procedures. Presently, regional anaesthesia is provided by each anaesthetist on their own operating list. That anaesthetist is responsible for the consent, performance, and testing of the block.
The aim of this project was to establish baseline data on the current regional anaesthesia practice at FMC to confirm if this is consistent with international standards and determine the non-operative cost of performing peripheral nerve blocks at FMC.
Methods
A prospective audit was conducted from June to December 2018 at FMC including patients ≥18 years old receiving a peripheral nerve block (upper limb, lower limb, thoracic, truncal, and abdominal), excluding neuraxial, ophthalmic, and blocks performed by surgeons.
Data was collected on the type of block performed, surgical procedure, anaesthesia provided for the block, anaesthesia provided for the surgery, location block performed, training level of person performing block, level of supervision, time to complete and test the block, maximum pain score in recovery, and patient satisfaction. For patients who had a block without an audit form completed, the Operating Room Management Information System (ORMIS) and medical records were used to retrospectively capture block information as outlined by our audit form.
Ethics approval was sought but not required after consultation with Southern Adelaide Local Health Network’s Human Research Ethics Committee.
Results
In total, 573 blocks were performed approximating an average of 3 blocks per day with an audit response rate of 59%. 56% of blocks performed were lower limb blocks followed by 29% upper limb and 93% of blocks were single shot. 91% of blocks were performed in the operating theatre and 62% were performed under GA with only 11% of blocks formally tested. Most blocks were performed by senior anaesthetic trainees and consultants. A block took on average 10 minutes to perform and 30 minutes to test.
Discussion
Regional anaesthesia is widely performed at FMC for numerous surgical specialties. Most blocks are untested and performed under GA including brachial plexus blocks despite current ASRA guidelines advising that brachial plexus blocks be performed on awake patients to reduce the risk of neuropraxia.1
Based on the estimated time to perform and test blocks from this data and using established figures for operating theatre costs,2 the non-operative cost of performing blocks at FMC is calculated to be over $1.3 million a year.
In order to align our practices with current standards, improve teaching opportunities for junior trainees and reduce the non-operative costs of performing blocks in theatre, we plan to trial an area outside the operating theatre dedicated to performing RA in a parallel streaming process called a block room and reaudit our process.
References
Simulating crisis management in paediatric anaesthesia
Queensland Childrens Hospital
Introduction
Paediatric anaesthesia requires a high level of supervision to ensure patient safety.1 Exposure to paediatric anaesthesia in Queensland is variable, and may be limited to a single three-month term. The ANZCA curriculum dictates core competencies in paediatric anaesthesia including management of exceedingly rare events.2 It is unlikely that trainees will receive sufficient real-life exposure to these events to be deemed proficient.1
Simulation is an effective educational modality for adult learners. It allows safe application of knowledge and skills, with facilitated discussion promoting analysis of decision making and evaluation of performance. ANZCA promote the use of simulation courses in crisis management, and these courses have become a mandatory component of the training curriculum.2
The Managing Emergencies in Paediatric Anaesthesia (MEPA) course was designed in Bristol in 2006 and aims to improve training in paediatric anaesthesia using simulated crisis management scenarios and didactic lectures.1 The content is evidence-based, peer-reviewed and adjusted for variations in local practice.1
Methods
The MEPA course was introduced to Queensland Children’s Hospital (QCH) in 2015. We have delivered 30 courses and captured all trainees rotated through QCH from 2015 to 2018. For each course, after an introduction to the course objectives and simulation environment, we deliver six simulated clinical scenarios from the MEPA database. All trainees have an opportunity to act as a first and second responder. After each scenario we provide a structured debrief by two specialist paediatric anaesthetists followed by a peer-reviewed, evidence-based presentation adapted to reflect Australasian practice and ANZCA guidelines.
Results
Confidentiality agreements and consent were obtained from all participants. Trainees completed a questionnaire including self-reported experience and confidence measured on a Leichardt scale pre and post course completion, as well as qualitative feedback of each scenario.
The overall course rating was 6.18 out of a possible 7. Experience ratings for the scenarios (on a scale of 1 to 8) ranged from an average of 2.06 to 5.26, and confidence levels prior to the course ranged from 3.29 to 5.02. This was compared to confidence levels after to the course, which ranged from 6.37 to 7.36, with an average overall increase in confidence ratings of 34.7% (range 25–42% for individual scenarios).
Discussion
MEPA has been well-received among trainees with a very high overall course rating and universally positive qualitative feedback. There was a significant increase in self-rated confidence levels for each scenario. The MEPA course has proven utility and benefit for anaesthetic trainees in Queensland, and as the course is adopted in other tertiary paediatric centres it may be a very useful tool in addressing a deficiency in trainee education throughout Australia and New Zealand.
References
A randomized crossover study comparing the success rates, speed of insertion and safety of the intraosseous access devices Bone Injection Gun and the EZ-IO in trainees within the department of anaesthesia in a tertiary institution
1Box Hill Hospital, University Of Queensland
2Box Hill Hospital
The intraosseous route (IO) is the preferred route of drug administration in adult cardiac arrest when intravenous access is not available.1
Within our institution, two IO devices, the Bone Injection Gun (BIG) and EZ-IO are available. The majority of the literature reviewed suggested that the EZ-IO was associated with higher success rates and decreased procedural time as compared to the BIG.2,3
We compare these two devices, to evaluate the success rate, time of insertion and safety of intraosseous access during simulated resuscitation performed by trainees in the department of anaesthesia.
Methods
We obtained prospective approval from the institution’s Office of Research and Ethics.
A randomized crossover study was conducted in our department with 24 trainees participating. They were timed from start of procedure to successful insertion and assessed on their safety in handling the BIG and the EZ-IO. Safety is scored according to the 5-level Likert scale, in response to statement “I observed that the participant was able to insert and IO in a safe manner, and the risk of bodily harm to self or others is unlikely”; a score of 5 is defined as strongly agree (details of this scale available on request).
Results
Success rate for first intraosseous insertion attempts for the 100% (24/24) for the EZ-IO vs BIG 25% (6/24). Mean procedure time for successful insertion was 53 ± 21 seconds for EZ-IO vs 119 ± 52 seconds for BIG. The safety score (1-5) for the BIG was 2.7 ± 1.1, compared to EZ-IO 4.8 ± 0.3. The paired safety and procedure time outcomes were analysed, with p < 0.001 (sign test).
Discussion
The use of the EZ-IO, as compared to the BIG is associated with higher success rates and appears faster and safer to use. This study suggests that there is merit in standardizing our intraosseous devices within our institution, and highlights the need for a formal training workshop to facilitate safe and expeditious intraosseous device use, especially if the BIG is to remain in clinical use.
References
A pharmacokinetic model for optimal prophylactic cefazolin dosing in elective bariatric surgery patients
1Department Of Anaesthesia, Sunshine Coast University Hospital, Birtinya, Australia; Department Of Anaesthesia, Royal Brisbane And Women’S Hospital, Brisbane, Australia; Faculty Of Medicine, The University Of Queensland, Brisbane, Australia
2Department Of Anaesthesia, Royal Brisbane And Women’S Hospital, Brisbane, Australia; Faculty Of Medicine, The University Of Queensland, Brisbane, Queensland, Australia
3Department Of Surgery, Royal Brisbane And Women’S Hospital, Brisbane, Australia
4Centre For Clinical Research, Faculty Of Medicine, The University Of Queensland, Brisbane, Australia
5Department Of Anaesthesia, Royal Brisbane And Women’S Hospital, Brisbane, Australia; Centre For Clinical Research, Faculty Of Medicine, The University Of Queensland, Brisbane, Australia
6Department Of Intensive Care Medicine, Royal Brisbane And Women’S Hospital, Brisbane, Australia; Centre For Clinical Research, Faculty Of Medicine, The University Of Queensland, Brisbane, Australia
Obesity is a risk factor for surgical site infection. Surgical prophylactic antibiotic dosing aims to achieve therapeutic drug concentrations in blood and interstitial fluid (ISF). Australian guidelines recommend cefazolin 2 g is administered to patients undergoing bariatric surgery, regardless of body size.1 American guidelines recommend 3 g for patients with a total body weight (TBW) > 120 kg.2 Evidence to guide optimal dosing is limited.
This study aimed to develop a pharmacokinetic (PK) model describing the plasma and ISF cefazolin concentrations in patients undergoing bariatric surgery and to develop guidelines for optimal dosing in these patients.
Methods
Cefazolin 2 g was given to patients undergoing bariatric surgery. Microdialysis catheters, inserted into the abdominal subcutaneous tissue, measured ISF concentrations. Microdialysate and blood samples were collected at specific time points. Total and unbound concentrations were measured using liquid chromatography and mass spectrometry. Population PK analyses was conducted using PMetrics software.
The target ISF concentration was the minimum inhibitory concentration 90 (MIC90) of cefazolin for Staphylococcus aureus, 2 mg/L.3
Monte Carlo dosing simulations (n = 1000) using various cefazolin dosing regimens were performed using the final covariate model to determine the fractional target attainment (FTA). The FTA identifies the likely success of treatment by comparing the pharmacodynamic exposure against a MIC distribution. The FTA was calculated using various cefazolin doses to achieve a priori target of 90% unbound concentrations > 2 mg/L throughout 4 h of surgery using five levels of pre-operative weight (100, 120, 145, 180 and 200 kg). Ethics approval was obtained (HREC/15/QRBW/551).
Results
Fourteen patients were included, with a mean (SD) bodyweight of 148 (35) Kg. Thirteen patients received cefazolin 2 g and one patient received a 2 g dose followed by a 1 g dose at 3 h.
A four-compartment PK model best described the concentration–time data. TBW and age were supported for inclusion as covariates on central volume and clearance respectively.
The FTA was between 76 and 84% for all five levels of pre-operative weight following a simulated cefazolin 2 g dose 30 minutes prior to skin incision. Cefazolin 4 g at the time of skin incision was required to achieve an FTA > 90% in all pre-operative weight levels. A 4 g bolus 30 mins prior to skin incision improved the FTA to >95 %.
Discussion
Cefazolin penetration into the ISF was low and variable using standard dosing. Our study demonstrates that the optimal prophylactic cefazolin dose in bariatric surgery patients weighing >100 kg is 4 g, 0–30 mins prior to skin incision.
References
Postoperative opioid requirement in elective unilateral knee replacement surgery at Alfred Health: a retrospective cohort study
1The Alfred Hospital
2The Alfred Hospital, Monash University
Background
In 2018 ANZCA and the FPM released a position statement that slow-release (SR) opioids are not recommended for use in the management of patients with acute pain. At Alfred Health, current ERAS protocols specify the routine use of SR opioids after hip and knee replacement surgery. A retrospective cohort study was conducted to provide data on SR opioid use after elective unilateral total knee replacement (TKR) to inform a possible change of practice in this area.
Methods
From September 2017 to August 2018, 204 TKR surgeries were performed at Alfred Health. We reviewed the first 100 consecutive TKR patient records from 1 January 2018 (limited to the first 10 inpatient days). Primary outcomes were the proportion of patients given postoperative SR opioids, duration of SR opioid use, number of doses given, total daily opioid requirement (OME), and lowest and highest daily pain scores, reported on a scale from 0 to 10 and categorised as mild (0–4), moderate (5–7) or severe (8–10). Secondary outcomes were safety indicators including lowest RR, worst sedation score, MET calls (↓ RR, sedation or narcosis), and naloxone use.
Results
Results for the first 50 patients are presented. Median (IQR) age was 71.5 ( 64–76) years, 66% were female, and all were ASA-PS 1 (4%), 2 (52%) or 3 (44%). 58% (29/50) received a neuraxial anaesthetic with 96% receiving local-anaesthetic wound infiltration. No patient received a peripheral nerve block or catheter. PCA was prescribed for 3 (6%) patients. 100% received postoperative SR opioids in accordance with the ERAS protocol.
72% (36/50) were opioid naïve, receiving SR opioids for a median of (IQR) 6.0 (4.25–9.75) days, and a median (IQR) of 12.5 (7.25–19.5) doses. Median total opioid dose (OME) on the first three postoperative days was 89, 64 and 49 mg respectively. The worst pain score was mild or moderate in 72% on day 1, 85% on day 2 and 97% on day 3.
28% (14/50) were opioid tolerant, with a baseline median (IQR) daily opioid requirement (OME) of 50 ( 20–80) mg. This group received SR opioids for a median of 5.5 (4.75–9.50) days, with a median (IQR) of 14.0 (8.0–23.0) doses. Median total opioid dose (OME) on the first three postoperative days was 112, 93 and 75 mg. The worst pain score was mild or moderate in 54% on day 1, 85% on day 2 and 77% on day 3.
The daily dose of SR opioid was not tapered during admission. In many patients with extended length of stay, SR opioid was continued beyond day 10.86% (31/36) of previously opioid naïve patients were discharged with a prescription for SR opioids. We found no instance of respiratory depression (RR < 7) and naloxone was not given to any patient. Lowest sedation score (AVPU) was P in 1 opioid tolerant patient on day 1.
Conclusion
Our data demonstrate the daily opioid requirements after TKR at our institution. As anticipated in this small sample size, we found no evidence of acute harm relating to opioid administration.
Key additional findings:
1. SR opioids were not routinely down-titrated as daily pain scores reduce
2. Many patients remained on SR opioids until discharge, except where the anaesthetist had limited the prescription duration on the medication chart
3. Most patients (86%) were discharged on SR opioids
References
Pre-operative frailty score of elective joint replacement patients and the associated post-operative complications and length of stay
1Blacktown And Mount Duitt Hospitals
2Blacktown And Mount Duitt Hospitals, Fanzca
Frailty is often described as a syndrome of susceptibility to the stressors of surgery and hospitalisation.1 Goals were to determine 1) if we could accurately assess pre-operative frailty at our institutions and 2) if frailty was a risk factor for increased length of stay (LOS) and post-operative complications. We used the modified frailty index (mFI), an “accumulation of deficits” scoring system, validated by the American College of Surgeons National Surgical Quality Improvement Program.2
Methods
We reviewed the electronic medical records of 404 patients who underwent elective unilateral total knee or hip replacement surgery between 01/02/2017–31/12/2017 at Blacktown and Mount Druitt Hospitals. 388 patients met inclusion criteria. Using the mFI, we allocated patients to frailty groups based on accumulated deficits: 0–1 deficits indicating low frailty, 2–3 deficits signifying moderate frailty, 4 or more deficits representing high frailty. Frailty groups were compared to their post-operative complications, acute orthopaedic LOS, and total LOS (including rehabilitation admission). Primary outcomes included acute kidney injury (AKI), infection, 30-day readmission, unplanned ICU admission, blood transfusion and rehabilitation admission. Following statistical analysis of patient groups, contingency tables were constructed for all complications and significance tested with Chi-squared or Fisher Exact Tests. Between group differences in LOS were tested with Kruskal-Wallis, ANOVA and Linear Regression testing for significant relationships between age, frailty, and LOS.
Results
5% of the population was highly frail and 35% were moderately frail. The highest frailty score was 6, the average score was 1.4. The average age was 68. One-way ANOVA modelling showed acute orthopaedic admission LOS and total LOS, were significantly different (p < 0.05) between frailty groups. Mean Total LOS [SD] was 14.1 [13.2] and 5.7 [5.1] days for the high and low frailty groups, respectively. The highly frail had statistically significant higher relative risk of complication compared to the whole group and significantly (p < 0.05) more AKIs, infections, unplanned ICU admissions and blood transfusions compared to low and moderately frail groups. High frailty patients had a 3.58 relative risk of requiring post-operative rehab admissions compared to low or moderate frailty patients (RR 0.60 and 1.26 respectively).
Discussion
Using the mFI, we identified frail elective surgical patients. There was a statistically significant association between increasing frailty scores and longer LOS as well as poorer post-operative outcomes. Increased LOS, in the highly frail, was likely due to increased incidence of in-hospital complications and requirement for post-operative rehabilitation admission. An obvious limitation to this study was the lack of consistent information on EMR and poor patient recall. This likely resulted in lower frailty scores as some patients’ past medical history is forgotten, lost, or undocumented. 90% of the highly frail patients had elective hip replacements. Since we can identify frail patients, further research is required to delineate ways to optimize their pre-operative care to reduce complications and LOS.
References
A prospective single centre study on the efficacy and safety of erector spinae plane blocks for the management of rib fractures
Wollongong Hospital
Rib fractures are present in 10% of all trauma patients. They typically cause severe pain that can lead to an increased risk of atelectasis, pneumonia and ultimately respiratory failure requiring mechanical ventilation. Despite regular oral and intravenous analgesics, rib fracture pain is often poorly controlled and high doses of opioids can lead to adverse effects such as sedation and respiratory depression in addition to nausea, reduced bowel mobility and bowel obstruction.
The erector spinae plane (ESP) block is an ultrasound guided interfascial plane block first described in 2016.1 It provides rapid onset analgesia as well as ongoing pain relief via a catheter infusion. Currently there is limited published efficacy and safety data however our study supports this simple and safe technique for thoracic analgesia in the management of rib fractures.
Methods
From August 2018 to January 2019, the pain team assessed patients who presented to Wollongong Hospital with rib fractures prospectively and an erector spinae block was offered if pain control was inadequate. A total of 20 patients were recruited over a period of 6 months.
Pain scores on deep inspiration (NRS-11) were recorded prior to and 30 minutes after the block. Total oral morphine equivalent daily dose (oMEDD) were calculated and compared between 24 hours before and 24 hours after block insertion. A reduction >20 mg of oMEDD was considered a clinically significant improvement in pain control.
Results
The median age of patients in the study was 72 years old (ranging from 44 to 94 years old). All 20 patients had multiple rib fractures.
There was a 75% reduction in the median pain score (pre block 8 out of 10, post block 2 out of 10). Every patient had a reduction in pain score of more than 30%, which is considered a clinically significant improvement.2 Sixteen (80%) patients had a substantial reduction in pain of more than 50%. Improvements in pain scores occurred within 30 minutes after block placement in all patients.
Ten patients (50%) had a decrease of >20 mg of oMEDD 24 hours post block placement (clinically significant). Eight patients showed no significant change in oMEDD.
No complications (pneumothorax, lung injury, bleeding, infection, or nerve injury) occurred during or after the block.
Discussion
This study demonstrated good efficacy and safety of the ESP block in patients with multiple rib fractures.
We identified several plausible reasons for no significant change in oMEDD for 8 patients. A reluctance of some patients to use systemic opioids prior to block placement for fear of adverse effects possibly reduced the 24 hour prior oMEDD, and a reduction in rib fracture pain after block insertion may have increased awareness of pain from other injuries resulting in an increased 24 hour post block oMEDD. We also believe that the absence of a known standardised local anaesthetic regimen led to some patients receiving inadequate dosing therefore further contributing to an increased 24 hour post oMEDD. A notable limitation of the study was the small sample size.
Overall, the results of this audit support the existing evidence that ESP block is a safe and effective regional technique for analgesic management of ribs fractures and could be considered as first line intervention for patients with multiple rib fractures.