Key Papers from the Most Recent Literature Relevant to Anesthesiologists
Early oral feeding as compared with traditional timing of oral feeding after upper gastrointestinal surgery: A systematic review and meta-analysis. Ann Surg 2016; 264:54–63.
While early postoperative oral feeding is becoming more common, particularly as part of multimodal or fast-track protocols, concerns remain about the safety of early oral feeding after upper gastrointestinal surgery. This systematic review and meta-analysis compared the effects of early oral feeding to traditional (or late) timing of oral feeding after upper gastrointestinal surgery on clinical outcomes. Fifteen studies comprising 2,112 adult patients met inclusion criteria. Mean hospital stay was significantly shorter in the early-fed group than in the late-fed group (weighted mean difference, –1.72 days; 95% CI, –1.25 to –2.20; P < 0.01). Postoperative length of stay was also significantly shorter (weighted mean difference, –1.44 days; 95% CI, –0.68 to –2.20; P < 0.01). There was no significant difference in risk of anastomotic leak, pneumonia, nasogastric tube reinsertion, reoperation, readmission, or mortality in randomized controlled trials.
Take home message: Early postoperative oral feeding when compared with traditional feeding is associated with shorter hospital length of stay and is not associated with an increase in clinically relevant complications.
Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. JAMA 2016; 315:2312–20.
There is an ongoing debate about the link between exposure to anesthesia and surgery during infancy and delayed impaired cognitive development. This trial aimed to examine if a single anesthesia exposure in otherwise healthy young children was associated with impaired neurocognitive development and abnormal behavior in later childhood. A sibling-matched cohort study was conducted between May 2009 and April 2015 at four university-based U.S. pediatric tertiary care hospitals. The study cohort included sibling pairs within 36 months in age and currently 8 to 15 yr old. The exposed siblings were healthy at surgery/anesthesia. The exposure was a single exposure to general anesthesia during inguinal hernia surgery in the exposed sibling and no anesthesia exposure in the unexposed sibling, before age 36 months. The primary outcome was global cognitive function (intelligence quotient). In the 105 sibling pairs included, there were no statistically significant differences in global cognitive function (intelligence quotient) scores in later childhood between exposed and nonexposed children, which is consistent with most of the recent trials in this area.
Take home message: Among healthy children with a single anesthesia exposure before age 36 months, compared with healthy siblings with no anesthesia exposure, there were no statistically significant differences in global cognitive function scores in later childhood.
Prescription of long-acting opioids and mortality in patients with chronic noncancer pain. JAMA 2016; 315:2415–23.
Long-acting opioids increase the risk of unintentional overdose deaths and may also increase mortality from cardiorespiratory and other causes. The aim of this retrospective cohort study was to compare all-cause mortality for patients with chronic noncancer pain who were prescribed either long-acting opioids or alternative medications for moderate to severe chronic pain using propensity matching. The primary outcome was total and cause-specific mortality as determined from death certificates. The Hazard Ratio for total mortality was 1.64 (95% CI, 1.26 to 2.12) with a risk difference of 68.5 excess deaths (95% CI, 28.2 to 120.7) per 10,000 person-years in the intervention group versus control medications.
Take home message: Prescription of long-acting opioids for chronic noncancer pain, compared with anticonvulsants or cyclic antidepressants, was associated with a significantly increased risk of all-cause mortality, including deaths from causes other than overdose.
Caesarean section surgical techniques: 3 year follow-up of the CORONIS fractional, factorial, unmasked, randomised controlled trial. Lancet 2016; 388:62–72.
This is a 3-yr outcome update of the CORONIS trial, which reported differences in short-term maternal morbidity when comparing five pairs of alternative surgical techniques for cesarean delivery. The CORONIS trial was a pragmatic international randomized controlled trial done at 19 sites in Argentina, Chile, Ghana, India, Kenya, Pakistan, and Sudan. Pregnant women were eligible if they were to undergo their first or second cesarean delivery through a planned transverse abdominal incision. Women were randomly assigned to one intervention from each of the three assigned pairs of surgical techniques. Outcomes included pelvic pain; deep dyspareunia; hysterectomy and outcomes of subsequent pregnancies. Overall, severe adverse outcomes were uncommon in these settings. Although the study was not powered to detect modest differences in rare but serious events, there was no evidence to favor one surgical technique over another.
Take home message: Follow-up of patients enrolled in the CORONIS trial for cesarean delivery found no differences between surgical techniques at long-term follow-up, which suggests that other aspects of the operation are likely to account for any observed differences in outcome.
Effect of aspirin on development of ARDS in at-risk patients presenting to the emergency department: The LIPS-A randomized clinical trial. JAMA 2016; 315:2406–14.
Observational studies have suggested a potential preventive role for antiplatelet therapy in patients at high risk for acute respiratory distress syndrome (ARDS). The aim of this multicenter, double-blind, randomized clinical trial was to evaluate the efficacy and safety of early aspirin administration for the prevention of ARDS in patients admitted to the emergency department. Patients at risk for ARDS received aspirin, 325 mg followed by 81 mg/day (n = 195) or placebo (n = 195) within 24 h of emergency department presentation and continued to hospital day 7, discharge, or death. The primary outcome was the development of ARDS by study day 7. Among at-risk patients presenting to the emergency department, the use of aspirin compared with placebo did not reduce the risk of ARDS at 7 days.
Take home message: Early aspirin administration should not be recommended for prevention of ARDS in at-risk patients entering the emergency department.
Effect of a primary care management intervention on mental health–related quality of life among survivors of sepsis: A randomized clinical trial. JAMA 2016; 315:2703–11.
Survivors of sepsis face long-term sequelae that diminish health-related quality of life and result in increased care needs in the primary care setting, including medication, physiotherapy, or mental health care. This randomized controlled trial examined if a primary care–based intervention improves mental health–related quality of life after intensive care unit (ICU) stay. Participants were randomized to usual care (n = 143) or to a 12-month intervention (n = 148). Usual care was provided by their primary care physician and included periodic contacts, referrals to specialists, and prescription of medication, other treatment, or both. The primary outcome was change in mental health–related quality of life between ICU discharge and 6 months after ICU discharge using the Mental Component Summary of the 36-Item Short-Form Health Survey. Overall mortality was 13.7% at 6 months and 18.2% at 12 months. There was no significant difference in change of mean Mental Component Summary scores at 6 months between the control and intervention groups.
Take home message: Among survivors of sepsis and septic shock, the use of a primary care–focused team-based intervention, compared with usual care, did not improve mental health–related quality of life 6 months after ICU discharge.
Combination of pregabalin with duloxetine for fibromyalgia: A randomized controlled trial. Pain 2016; 157:1532–40.
Fibromyalgia is an enigmatic condition involving widespread pain, mood disorders, and sleep disturbance. Although neuromodulators such as pregabalin and antidepressants are approved for the treatment of fibromyalgia, response rates are very poor for these drugs when used individually. Combination treatment is often recommended, but little data are available to help guide this approach to treatment. In this study, a four-treatment blinded crossover trial involving 6-week placebo, pregabalin, duloxetine, and combination treatment periods (N = 41) was utilized. The research team observed that combination treatment was statistically superior to placebo or pregabalin alone in reducing pain. Several secondary outcomes including sleep, mood, and functional improvement also favored combination treatment although sedation was more common when the drugs were used together. These findings are consistent with other combination treatment trials in neuropathic pain and suggest that there may be advantages to combining analgesic agents with distinct mechanisms of action.
Take home message: Combining analgesic treatments with different mechanisms of action may help control neuropathic pain.
Pregnancy and parental leave during graduate medical education. Acad Med 2016; 91:972–8.
Adult learners, including anesthesiology residents and fellows, mold their education to learn and enable life events, personal life style choices, and relationships with significant others. Decisions, for example, about pregnancy, childbirth, and parental leave play a more significant role in the direction of many graduate medical education (GME) trainees’ learning trajectories than ever before. This survey of female and male resident and fellow (cross section of all specialties) behaviors and attitudes related to pregnancy, childbirth, and parental leave aimed to determine if and how these life events might affect GME. Forty percent of the trainees planned childbirth and its associated events during their GME years. Pregnancy during GME was noted to impact career direction of both genders and more so in females. Examples of effects on female GME trainees include: greater than 50% altered their training based on their patient’s diagnosis, for example, avoiding cytomegalovirus exposure; greater than 40% noted an impact upon their research productivity; greater than 30% anticipated completing their GME program in a longer time period than originally planned due to pregnancy; greater than 30% altered their call schedule during pregnancy; and slightly less than 20% changed their career plans during pregnancy. The authors’ conclusion is applicable to anesthesiology resident and fellow education: “Program directors must address the challenges related to pregnancy and parental leave for this growing group of both male and female trainees.”
Take home message: Program directors must address challenges related to pregnancy and parental leave for this growing group of both male and female trainees.