Adult perioperative cardiac arrest: An overview of 684 cases reported to webAIRS.

There were 684 perioperative cardiac arrests reported to webAIRS between September 2009 and March 2022. The majority involved patients older than 60 years, classified as American Society of Anesthesiologists Physical Status 3 to 5, undergoing an emergency or major procedure. The most common precipitants included airway events, cardiovascular events, massive blood loss. medication issues, and sepsis. The highest mortality rate was 54% of the 46 cases in the miscellaneous category (this included 34 cases of severe sepsis, which had a mortality of 65%). This was followed by cardiovascular precipitants (n = 424) in which there were 147 deaths (35% mortality): these precipitants included blood loss (53%), embolism (61%) and myocardial infarction (70%). Airway and breathing events accounted for 25% and anaphylaxis 8%. A specialist anaesthetist attended the majority of these cardiac arrests. As webAIRS is a voluntary database, it is not possible to determine the incidence of perioperative cardiac arrest and only descriptive information on factors associated with cardiac arrest can be obtained. Nevertheless, the large number of reports includes a wide range of cases, precipitants, demographics and outcomes, providing ample opportunity to learn from these events. The data also provide rich scope for further research into further initiatives to prevent cardiac arrest in the perioperative period, and to improve outcomes, should a cardiac arrest occur.

Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments.

BACKGROUND: Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia, haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of hypoxaemia, morbidity and mortality. OBJECTIVES: To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive care unit and operating theatre environments compared to no apnoeic oxygenation during intubation. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO2), 5. intensive care unit (ICU) stay, 6. first pass success rate, 7. adverse events and 8. MORTALITY: We used GRADE to assess certainty of evidence. MAIN RESULTS: We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024 participants). We considered two studies to be at low risk of bias across all domains. None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no difference in the incidence of severe hypoxaemia (SpO2 less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, I² = 0%; 15 studies, 1802 participants; low-certainty evidence). There was insufficient evidence of any effect on the incidence of hypoxaemia (SpO2 less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, I² = 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, I² = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean difference (MD) ‒1.13 days, 95% CI ‒1.51 to ‒0.74; P < 0.0001, I² = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no difference in first pass success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, I² = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little to no difference in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest when apnoeic oxygenation is used. There was insufficient evidence about any effect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06, I² = 0%; 6 studies, 1015 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation. However, the differences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable effect on the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear as there was little to no difference in first pass success or adverse event rates.

Erector spinae plane block: the ultimate 'plan A' block?

The erector spinae plane block (ESPB) is one of seven 'Plan A' blocks proposed by Regional Anaesthesia UK, covering the key areas of commonly encountered surgeries and acute pain. Unlike the other six blocks, the ESPB can be performed at all levels of the spine and provides analgesia to most regions of the body, leading to the argument that the ESPB is the ultimate Plan A block. Current studies show a high level of evidence supporting use in thoracoabdominal surgery but a lack of benefit in upper and lower limb surgery compared with local infiltration and other Plan A blocks. Thus, there is insufficient evidence to support the claim that the erector spinae plane block is the ultimate Plan A block.

Management of surgical patients on opioid replacement therapy: An audit of current practice.

Patients on opioid replacement therapy hospitalised with acute pain represent a clinical challenge and have poorer perioperative outcomes. There is limited evidence relating to acute pain management of this complex cohort. The primary objectives of this retrospective audit was to establish the number of patients who are admitted on opioid replacement therapy with an acute pain condition under surgical services and evaluate the management of these patients to determine consistency of pain management practices. Secondarily, we aimed to evaluate the documentation of opioid replacement therapy in clinical notes to determine adherence to operational protocols and record clinically relevant outcomes including infection or postoperative complication rates. Forty-four episodes of care for buprenorphine patients and 19 episodes of care for methadone patients were included. There was significant variability in inpatient opioid prescribing, including practice of dose modification, and there was high utilisation of additional opioids, although agent choice varied. Multimodal analgesia was utilised, especially following acute pain service review. There was an 11% readmission rate for complications of the initial presentation. Documentation at transitions of care was poor. There is a need for further clinical studies into specific acute pain management strategies, and their effect on clinically relevant outcomes, to guide consistent management practices.

Perioperative corneal abrasions: A report of 42 cases from the webAIRS database.

Corneal abrasions are an uncommon complication of anaesthesia. The aim of this study was to identify potential risk factors, treatment and outcomes associated with corneal abrasions reported to the web-based anaesthesia incident reporting system (webAIRS), a voluntary de-identified anaesthesia incident reporting system in Australia and New Zealand, from 2009 to 2021. There were 43 such cases of corneal abrasions reported to webAIRS over this period. The most common postoperative finding was a painful eye. Common features included older patients, individuals with pre-existing eye conditions, general anaesthesia and procedures longer than 60 minutes. Most cases were treated with a combination of lubricating eye drops or aqueous antibiotic eye drops. The findings indicate that patients who sustain a perioperative corneal abrasion can be reassured that in many cases it will heal within 48 hours, but they should seek earlier review if symptoms persist or deteriorate. None of the cases in this series resulted in permanent harm. Well established eye protective measures are important to utilise throughout the perioperative period, including the time until the patient has recovered in the post-anaesthesia care unit.

The association between erector spinae plane block timing and reduced rib fracture related respiratory complications: A cohort study.

STUDY OBJECTIVE: Is erector spinae plane (ESP) catheter insertion within 24 h of hospital admission for rib fractures associated with a lower incidence of respiratory complications compared to those having an ESP within 48 h or after 48 h of admission. DESIGN: Retrospective cohort study. SETTING: Hospital. PATIENTS: 199 patients admitted for rib fractures, who received an ESP catheter. INTERVENTIONS: Timing of ESP performance was assessed by dividing the study cohort into three subgroups: prompt block within 24 h, early block within 48 h and late block after 48 h of admission. MEASUREMENTS: The primary outcome of interest was the development of respiratory complications. This included pneumonia, pulmonary embolism and respiratory failure. Secondary outcomes included intensive care unit (ICU) length of stay and hospital length of stay. MAIN RESULTS: A prompt ESP within 24 h was performed in 14.5% (n = 29) of patients, 47% (n = 95) received an early block within 48 h and 37% (n = 75) of patients received a late block after 48 h from admission. There was a significantly higher rate of respiratory complications (p = 0.005) with late block. A late block was associated with a significantly longer ICU length of stay (7.82 ± 5.2 days) compared to patients who received an early block (5.84 ± 2.8 days; p = 0.044). There was no significant association with hospital length of stay (p = 0.06). There were no differences between the prompt (within 24 h) and early (within 48 h) block groups for any outcome. CONCLUSIONS: The performance of an ESP block after 48 h of admission was associated with an increased incidence of respiratory complications and ICU length of stay. There appears to be no added benefit associated with the provision of a prompt ESP within 24 h.

Alzheimer's Disease: Epidemiology and Clinical Progression.

Alzheimer's disease (AD) is prevalent throughout the world and is the leading cause of dementia in older individuals (aged ≥ 65 years). To gain a deeper understanding of the recent literature on the epidemiology of AD and its progression, we conducted a review of the PubMed-indexed literature (2014-2021) in North America, Europe, and Asia. The worldwide toll of AD is evidenced by rising prevalence, incidence, and mortality due to AD-estimates which are low because of underdiagnosis of AD. Mild cognitive impairment (MCI) due to AD can ultimately progress to AD dementia; estimates of AD dementia etiology among patients with MCI range from 40% to 75% depending on the populations studied and whether the MCI diagnosis was made clinically or in combination with biomarkers. The risk of AD dementia increases with progression from normal cognition with no amyloid-beta (Aß) accumulation to early neurodegeneration and subsequently to MCI. For patients with Aß accumulation and neurodegeneration, lifetime risk of AD dementia has been estimated to be 41.9% among women and 33.6% among men. Data on progression from preclinical AD to MCI are sparse, but an analysis of progression across the three preclinical National Institute on Aging and Alzheimer's Association (NIA-AA) stages suggests that NIA-AA stage 3 (subtle cognitive decline with AD biomarker positivity) could be useful in combination with other tools for treatment decision-making. Factors shown to increase risk include lower Mini-Mental State Examination (MMSE) score, higher Alzheimer's Disease Assessment Scale (ADAS-cog) score, positive APOE4 status, white matter hyperintensities volume, entorhinal cortex atrophy, cerebrospinal fluid (CSF) total tau, CSF neurogranin levels, dependency in instrumental activities of daily living (IADL), and being female. Results suggest that use of biomarkers alongside neurocognitive tests will become an important part of clinical practice as new disease-modifying therapies are introduced.

The Humanistic and Economic Burden of Alzheimer's Disease.

Alzheimer's disease (AD) is the leading cause of cognitive impairment and dementia in older individuals (aged ≥ 65 years) throughout the world. As a result of these progressive deficits in cognitive, emotional, and physical function, AD dementia can cause functional disability and loss of independence. To gain a deeper understanding of the recent literature on the burden of AD, including that of mild cognitive impairment (MCI) due to AD, we conducted a comprehensive targeted review of the PubMed-indexed literature (2014 to 2021) to examine the humanistic and economic burden of AD (including MCI) in North America, Europe, and Asia. Our literature review identified a range of factors associated with quality of life (QoL): some factors were positively associated with QoL, including caregiver relationship, religiosity, social engagement, and ability to engage in activities of daily living (ADL), whereas other factors such as neuropsychiatric symptoms were associated with poorer QoL. While patient- and proxy-rated QoL are highly correlated in patients with early AD dementia, proxy-rated QoL declines more substantially as severity worsens. The maintenance of self-reported QoL in patients with more severe AD dementia may be due to lack of awareness or to adaptation to circumstances. Compared to persons with normal cognition, MCI is associated with a greater cost burden, and individuals with MCI exhibit worse QoL. Key drivers of the societal economic burden of AD include disease severity, dependence level, institutionalization, and comorbidity burden. Evaluation of the impact of a hypothetical disease-modifying treatment delaying the progression from MCI to AD has suggested that such a treatment may result in cost savings.

Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials.

This systematic review aimed to compare the analgesic effectiveness and complications rates for anterior suprascapular nerve blocks (ASSB) compared to interscalene brachial plexus blocks (ISB) for arthroscopic and outpatient shoulder surgery. Only randomized controlled trials (RCTs) comparing the ASSB versus ISB in the context of arthroscopic shoulder surgery were eligible for inclusion. The primary outcomes included pain scores (Numeric Rating Scale of 0 to 10) up to 24 h postoperatively and analgesic consumption. Secondary outcomes included block complications. Meta-analysis was performed using random-effects modeling and result certainty was determined using the GRADEpro tool. Six RCTs (709 patients) were included for analysis. ISB displayed a statistically significant reduction in pain scores by 0.40 (95%CI = 0.36 to 0.45; p < 0.00001) but not morphine equivalent consumption (mean difference = 0.74 mg; 95%CI = - 0.18 to 1.66 mg; I2 = 60%; p = 0.11; moderate certainty) immediately in the postoperative care unit. Opioid consumption and pain scores at 6 to 24 h were not significantly different. There was no difference in respiratory events postblock. ASSB demonstrated a significantly lower incidence of Horner's syndrome (relative risk (RR) = 0.17; 95%CI = 0.08 to 0.39; p < 0.00001; high certainty), voice hoarseness (RR = 0.24; 95%CI = 0.10 to 0.57; p < 0.00001; high certainty) and impaired respiratory function (p < 0.00001). The ASSB could be considered an appropriate analgesic option for arthroscopic shoulder surgery with potentially fewer complications than the ISB.

Comparison of Supraglottic Airway Devices With Endotracheal Intubation in Low-Risk Patients for Cesarean Delivery: Systematic Review and Meta-analysis.

BACKGROUND: The safety and adverse event rate of supraglottic airway (SGA) devices for cesarean delivery (CD) is poorly characterized. The primary aims of this review were to determine whether the first-pass success was higher and time to insertion for SGA was faster than endotracheal intubation for elective CD. The secondary aim was to determine the airway-related adverse event rate associated with SGA use compared to endotracheal intubation in elective CD under general anesthesia (GA). METHODS: Six databases were systematically searched until September 2019. Included studies reported on the use of SGA in comparison to endotracheal tube intubation. A comparative meta-analysis between SGA and endotracheal intubation was performed using RevMan 5.3 software. Dichotomous outcomes were reported using an odds ratio (OR) with 95% confidence interval (CI). The results for continuous outcomes were reported using a weighted mean difference (WMD) with 95% CI. RESULTS: Fourteen studies with 2236 patients compared SGA and endotracheal intubation. Overall, there was no statistically significant difference in first-attempt success rate (OR = 1.92; 95% CI, 0.85-4.32; I = 0%; P = .44). There was no clinically significant difference in time to insertion (WMD = -15.80 seconds; 95% CI, -25.30 to -6.31 seconds; I= 100%; P = .001). Similarly, there was no difference in any adverse event rate except sore throat which was reduced with the use of an SGA (OR = 0.16; 95% CI, 0.08-0.32; I= 53%; P < .001). CONCLUSIONS: Despite the reasonable insertion success rate and safety profile of SGAs demonstrated in this meta-analysis, the analysis remains underpowered and therefore inconclusive. At present, further studies are required before the use of an SGA as the first-line airway for an elective CD can be recommended.