Post on 20-Mar-2017
WAS February 27, 2016
Best Papers of 2015 Alana M. Flexman, MD FRCPC Clinical Assistant Professor Department of Anesthesiology and Perioperative Care Vancouver General Hospital University of British Columbia
Whistler Anesthesiology Summit February 27, 2016
WAS February 27, 2016
Disclosures • Research grants:
² Canadian Anesthesiologists’ Society ² Hospira, Inc ² Masimo, Inc
• Honoraria ² Hospira, Inc
WAS February 27, 2016
Paper selecGon
• Clinical Focus • General Appeal • Past 12 months • 5 papers selected
Objec&ve: To review influen&al publica&ons from the past year
WAS February 27, 2016
Survey says… Premedication with lorazepam results in which of the following:
A. Improved patient satisfaction B. Similar time to extubation C. Reduced intraoperative hypotension D. Slower recovery of early cognition
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
To assess the efficacy of preoperative sedation in influencing a patient’s perioperative experience
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
N=1062 randomized Elective surgery, GA
N=354 Lorazepam
2.5 mg
N=354 No Premed
N=354 Placebo
Primary Outcome: Patient Satisfaction (EVAN-G) Secondary Outcomes: PQRS, cooperation, anxiety, pain, well-being, quality of sleep & recover, time to extubation
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
Lorazepam No premed
Placebo P-Value
Overall satisfaction
72 73 71 0.38
Time to extubation
17 min 12 min 13 min <0.001
Amnesia 24% 6% 6% <0.001 Anxiety in OR (VAS)
35 38 44 0.001*
Pain satisfaction
68 66 53 0.01
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
• Sedation with lorazepam did NOT improve self-reported patient experience the day of surgery • But reduced anxiety on arrival to OR
• Sedation was associated with 4 min prolongation of extubation time and lower rate of early cognitive recovery
WAS February 27, 2016
Szamburski et al
Szamburski et al, JAMA 2015; 313: 916-‐925.
Rou&ne premedica&on with lorazepam
WAS February 27, 2016
Survey says… In the management of acute STEMI, providing supplemental oxygen to normoxic patients results in:
A. Worse patient outcomes B. No effect on patient outcomes C. Improved patient outcomes
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
• AMA: : no clear recommendation • 90% receive supplemental oxygen Beasley et al, J R Soc Med 2007;100:130-‐133.
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
Compare supplemental oxygen therapy with no oxygen therapy in normoxic patients with STEMI to determine its effect on myocardial infarct size
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
Primary Outcome: Myocardial injury (peak cTnI & CK) Secondary Outcomes: ST-‐segment resoluGon, mortality, major adverse cardiac events, infarct size at 6 months
N=470 enrolled, 441 completed STEMI, SpO2 >94%
Supplemental O2 8 L/min N=218
No O2 unless SpO2 <94% N=223
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
• 7% of No Oxygen group required O2
• SpO2 higher in Supplemental O2 group • Baseline characteristics, hemodynamics and procedures similar
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
Outcome Oxygen No Oxygen P-value
Mean peak TnI 57.4 48.0 0.18 Mean peak CK 1948 1543 0.01 Mean infarct size 14.6 10.2 0.06 ST resolution 62% 70% 0.10 Recurrent MI 5.5% 0.9% 0.006 Death 1.8% 4.5% 0.11 Major arrhythmias 40% 31% 0.05
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
• Routine oxygen therapy not associated with reduction in symptoms or infarct size
• Routine high-flow oxygen may be accompanied by harm
WAS February 27, 2016
Stub et al
Stub et al, CirculaGon 2015;131:2143-‐2150.
Supplemental O2 in normoxia for STEMI?
(cardiac ischemia?)
WAS February 27, 2016
Survey says…
Jorgenson et al, JAMA 2014;312(3):269-‐277.
Which of the following is most effective in reducing intravascular catheter-associated infections?
A. Chlorhexidine-alcohol B. Iodine C. Iodine-alcohol D. Skin scrubbing before insertion
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
1) To compare the efficacy of chlorhexidine-alcohol vs providone iodine-alcohol to prevent short-term catheter-related infections
2) To determine the effect of skin scrubbing with antiseptic detergent on catheter colonisation
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
N=2349 enrolled ICU requiring CVL or arterial line >48h
Iodine-alcohol & scrubbing N=1286
catheters
Iodine-alcohol & no
scrubbing N=1326
catheters
Chlorhex-alcohol & scrubbing N=1270 catheters
Chlorhex- alcohol & no
scrubbing N=1277
catheters
Primary Outcome: Incidence of catheter-‐related infecGons Secondary Outcomes: Incidence of catheter colonisaGon
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
• Groups similar with respect to: • Demographics • History of immune deficiency/disease • Metastatic cancer • Indication for admission • Type of line inserted • Operator experience
WAS February 27, 2016 Mimoz et al, Lancet 2015;386:2069-‐2077.
WAS February 27, 2016 Mimoz et al, Lancet 2015;386:2069-‐2077.
NNT 78 catheters in place for a mean of 8 days to prevent 1
infection
WAS February 27, 2016 Mimoz et al, Lancet 2015;386:2069-‐2077.
Less catheter-related blood infections with chlorhexidine
WAS February 27, 2016 Mimoz et al, Lancet 2015;386:2069-‐2077.
No benefit to scrubbing
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
• No difference in ICU length of stay or mortality between the preps
• No difference in incidence of colonisation with scrubbing
• Higher rate of severe skin reactions with chlorhexidine-alcohol (3% vs 1%, p=0.0017)
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
1 infection=€19583 ($39346.89)
Chlorhexidine for 78 catheters=€227 ($456.14)
WAS February 27, 2016
Mimoz et al
Mimoz et al, Lancet 2015;386:2069-‐2077.
• Chlorhexidine-alcohol combination should now be standard of skin preparation before major intravascular catheter insertion
• Scrubbing of the skin with detergent should not be standard
WAS February 27, 2016
Pollack et al
Pollack et al, NEJM 2015; 373: 511-‐20.
Chlorhexidine-‐alcohol ✔
WAS February 27, 2016
Survey says… Which of the following is NOT associated with increased perioperative mortality:
A. Age > 65 years B. Case start after 4:00pm C. ASA physical status > 3 D. Male gender E. Age <1 year
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
• Predictors of postoperative mortality across broad surgical populations unclear
• National Anesthesia Clinical Outcomes Registry (NACOR)
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
To identify factors associated with perioperative mortality using the NACOR dataset
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
Entire NACOR Dataset 18 487 093
Outcome eligible 2 948 842 cases
Missing data 17383 cases
Obstetric 65318 cases
Final Dataset 2 866 141
cases
No outcome 15 538 251 cases
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
Predictor variables: PracGce/facility type
PaGent factors (age, sex, ASA) Emergency/elecGve
Procedure factors (type) Anesthesia factors (type)
Case start Gme and duraGon
Primary Outcome: Death within 48 hours of inducGon
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
Predictor variables: PracGce/facility type
PaGent factors (age, sex, ASA) Emergency/elecGve
Procedure factors (type) Anesthesia factors (type)
Case start Gme and duraGon
Primary Outcome: Death within 48 hours of inducGon
Multivariate regression
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
Predictor variables: PracGce/facility type
PaGent factors (age, sex, ASA) Emergency/elecGve
Procedure factors (type) Anesthesia factors (type)
Case start Gme and duraGon
Primary Outcome: Death within 48 hours of inducGon
Sensitivity analyses Multivariate regression
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
Variables independently associated with mortality
Increasing ASA
Emergency case
Age < 1 year
Age > 65 years
Cases beginning between 4:00pm and 6:59am
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
WAS February 27, 2016
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
• Confirmed association with known predictors of outcome (e.g. ASA class, age)
• Increased mortality in cases starting after 4pm • Potentially modifiable risk factor
NEW
WAS February 27, 2016
Minimize surgery aIer 4:00pm?
✔
Whitlock et al
Whitlock et al, Anesthesiology 2015;123:1312-‐1321.
WAS February 27, 2016
Survey says… In patients with atrial fibrillation, bridging warfarin with LMW heparin around surgery:
A. Reduces the risk of stroke B. Increases the risk of bleeding C. Reduces the risk of DVT/PE D. Reduces the risk of death
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
N=1884 randomized Afib on Warfarin
Bridging (Dalteparin)
No bridging (Placebo)
Primary Efficacy Outcome: Arterial thromboembolism Primary Safety Outcome: Major bleeding
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
Patients: • Mean CHADS2 score: 2.3 • 34% on ASA • 3.7% on Clopidogrel • 31% CHF or LV dysfunction
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
Outcome No Bridging Bridging P-‐value
Arterial thromboembolism 0.4% 0.3% 0.73 (0.01 Non-‐Inf)
Major Bleeding 1.3% 3.2% 0.005
Death 0.5% 0.4% 0.88
Myocardial Infarc&on 0.8% 1.6% 0.10
DVT/PE 0% 0.1% 0.25
Minor Bleeding 12% 20.9% <0.001
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
• Discontinuing warfarin without bridging was non-inferior to bridging in preventing arterial thromboembolism
• Bridging led to increased major and minor bleeding
• No difference in MI, VTE, death • Net benefit in avoiding bridging
WAS February 27, 2016
DoukeGs et al
DoukeGs et al, NEJM 2015;373:823-‐33.
Rou&ne bridging for atrial fibrilla&on
WAS February 27, 2016
References 1. Maurice-Szamburski A, Auquier P, Viarre-Oreal V, Cuvillon P, Carles M, Ripart
J, et al. Effect of sedative premedication on patient experience after general anesthesia: a randomized clinical trial. JAMA. 2015 Mar 3;313(9):916-25.
2. Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, et al. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015 Jun 16;131(24):2143-50.
3. Mimoz O, Lucet JC, Kerforne T, Pascal J, Souweine B, Goudet V, et al. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet. 2015 Nov 21;386(10008):2069-77.
4. Whitlock EL, Feiner JR, Chen LL. Perioperative Mortality, 2010 to 2014: A Retrospective Cohort Study Using the National Anesthesia Clinical Outcomes Registry. Anesthesiology. 2015 Dec;123(6):1312-21.
5. Douketis JD, Spyropoulos AC, Kaatz S, Becker RC, Caprini JA, Dunn AS, et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015 Aug 27;373(9):823-33.