Regional anesthesia and analgesia after surgery in ICU

The aim is to demonstrate that ICU physicians should play a pivotal role in developing regional anesthesia techniques that are underused in critically ill patients despite the proven facts in perioperative and long-term pain, organ dysfunction, and postsurgery patient health-related quality of life improvement | Current Opinion in Critical Care

Regional anesthesia and/or analgesia strategies in ICU reduce the surgical and trauma–stress response in surgical patients as well as complications incidence. Recent studies suggested that surgical/trauma ICU patients receive opioid–hypnotics continuous infusions to prevent pain and agitation that could increase the risk of posttraumatic stress disorder and chronic neuropathic pain symptoms, and chronic opioid use. Regional anesthesia use decrease the use of intravenous opioids and the ectopic activity of injured small fibers limiting those phenomena. In Cochrane reviews and prospective randomized trials in major surgery patients, regional anesthesia accelerates the return of the gastrointestinal transit and rehabilitation, decreases postoperative pain and opioids use, reduces ICU/hospital stay, improves pulmonary outcomes, including long period of mechanical ventilation and early extubation, reduces overall adverse cardiac events, and reduces ICU admissions when compared with general anesthesia and intravenous opiates alone. The reduction of long-term mortality has been reported in major vascular or orthopedic surgeries.

Promoting regional anesthesia/analgesia in ICU surgical/trauma patients could undoubtedly limit the risk of complications, ICU/hospital stay, and improve patient’s outcome. The use of regional anesthesia permits a high doses opioid use limitation which is mandatory and should be considered as feasible and well tolerated in ICU.

Full reference: Capdevila, M. et al. (2017) Regional anesthesia and analgesia after surgery in ICU. Current Opinion in Critical Care. Vol. 23 (Issue 5) pp. 430–439

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How to better identify patients at high risk of postoperative complications?

This review summarizes historical and more recent scoring systems for predicting patients with increased morbidity and mortality in the postoperative period | Current Opinion in Critical Care

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Purpose of review: Preoperative risk assessment and perioperative factors may help identify patients at increased risk of postoperative complications and allow postoperative management strategies that improve patient outcomes.

Recent findings: Most prediction scores predict postoperative mortality with, at best, moderate accuracy. Scores that incorporate surgery-specific and intraoperative covariates may improve the accuracy of traditional scores. Traditional risk factors including increased ASA physical status score, emergent surgery, intraoperative blood loss and hemodynamic instability are consistently associated with increased mortality using most scoring systems.

Summary: Preoperative clinical risk indices and risk calculators estimate surgical risk with moderate accuracy. Surgery-specific risk calculators are helpful in identifying patients at increased risk of 30-day mortality. Particular attention should be paid to intraoperative hemodynamic instability, blood loss, extent of surgical excision and volume of resection.

Full reference: . & Kelly, B. (2017) How to better identify patients at high risk of postoperative complications? Current Opinion in Critical Care: Published online: 17 August 2017

Interventions affecting mortality in critically ill and perioperative patients

Martina, B.R. et al. Journal of Critical Care | Published online: 4 May 2017

Highlights: 

  • No systematic exploration of confounders in randomized controlled trials reporting a significant effect on mortality in critically ill patients has been performed.
  • Almost half of these trials were single centre and one third were not analysed according to the intention to treat principle, inflating effect size.
  • Blinded and/or multicentre design was associated with an increased number needed to treat/harm.
  • Major systematic biases exist and affect trial findings irrespective of the intervention being studied.

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Preoperative risk stratification of critically ill patients

Copeland, C.C. et al. (2017) The Journal of Clinical Anesthesia. 39 (June) pp. 122–127

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Highlights:

  • Preoperative assessment of critically ill patients is challenging and understudied.
  • ASA class, RCRI, and SOFA score were studied to predict survival to discharge.
  • One in four ICU patients did not survive to discharge after an intervention.
  • Available scores inadequately discriminated between survivors and non-survivors.
  • SOFA score (AUC = 0.68) outperformed ASA class (AUC = 0.59).

Read the full abstract here

Care of the eye during anaesthesia and intensive care

 O’Driscoll, A. & White, E. Anaesthesia and Intensive Care Medicine. Published online: November 26 2016

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Image source: Dianne Harris – Wellcome Images // CC BY-NC-ND 4.0

Perioperative eye injuries and blindness are rare but important complications of anaesthesia. The three causes of postoperative blindness are ischaemic optic neuropathy, central retinal artery thrombosis (these can exist in tandem and have been described as ischaemic oculopathies) and cortical blindness.

This review aims to improve anaesthetists’ knowledge of orbital anatomy, ocular physiology and the mechanisms of perioperative eye injuries to help reduce their occurrence.

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Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU

Swan, J.T. et al. (2016) Critical Care Medicine. 44(10) pp. 1822–1832

rubber-duck-1390639_960_720Objective: To test the hypothesis that compared with daily soap and water bathing, 2% chlorhexidine gluconate bathing every other day for up to 28 days decreases the risk of hospital-acquired catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection in surgical ICU patients.

Design: This was a single-center, pragmatic, randomized trial. Patients and clinicians were aware of treatment-group assignment; investigators who determined outcomes were blinded.

Setting: Twenty-four–bed surgical ICU at a quaternary academic medical center.

Patients: Adults admitted to the surgical ICU from July 2012 to May 2013 with an anticipated surgical ICU stay for 48 hours or more were included.

Interventions: Patients were randomized to bathing with 2% chlorhexidine every other day alternating with soap and water every other day (treatment arm) or to bathing with soap and water daily (control arm).

Measurements and Main Results: The primary endpoint was a composite outcome of catheter-associated urinary tract infection, ventilator-associated pneumonia, incisional surgical site infection, and primary bloodstream infection. Of 350 patients randomized, 24 were excluded due to prior enrollment in this trial and one withdrew consent. Therefore, 325 were analyzed (164 soap and water versus 161 chlorhexidine). Patients acquired 53 infections. Compared with soap and water bathing, chlorhexidine bathing every other day decreased the risk of acquiring infections (hazard ratio = 0.555; 95% CI, 0.309–0.997; p = 0.049). For patients bathed with soap and water versus chlorhexidine, counts of incident hospital-acquired infections were 14 versus 7 for catheter-associated urinary tract infection, 13 versus 8 for ventilator-associated pneumonia, 6 versus 3 for incisional surgical site infections, and 2 versus 0 for primary bloodstream infection; the effect was consistent across all infections. The absolute risk reduction for acquiring a hospital-acquired infection was 9.0% (95% CI, 1.5–16.4%; p = 0.019). Incidences of adverse skin occurrences were similar (18.9% soap and water vs 18.6% chlorhexidine; p = 0.95).

Conclusions: Compared with soap and water, chlorhexidine bathing every other day decreased the risk of acquiring infections by 44.5% in surgical ICU patients.

Acute kidney injury following cardiac surgery: current understanding and future directions

O’Neal, J.B. et al. Critical Care. Published online: 4 July 2016

Acute kidney injury (AKI) complicates recovery from cardiac surgery in up to 30 % of patients, injures and impairs the function of the brain, lungs, and gut, and places patients at a 5-fold increased risk of death during hospitalization. Renal ischemia, reperfusion, inflammation, hemolysis, oxidative stress, cholesterol emboli, and toxins contribute to the development and progression of AKI.

Preventive strategies are limited, but current evidence supports maintenance of renal perfusion and intravascular volume while avoiding venous congestion, administration of balanced salt as opposed to high-chloride intravenous fluids, and the avoidance or limitation of cardiopulmonary bypass exposure. AKI that requires renal replacement therapy occurs in 2–5 % of patients following cardiac surgery and is associated with 50 % mortality. For those who recover from renal replacement therapy or even mild AKI, progression to chronic kidney disease in the ensuing months and years is more likely than for those who do not develop AKI.

Cardiac surgery continues to be a popular clinical model to evaluate novel therapeutics, off-label use of existing medications, and nonpharmacologic treatments for AKI, since cardiac surgery is fairly common, typically elective, provides a relatively standardized insult, and patients remain hospitalized and monitored following surgery. More efficient and time-sensitive methods to diagnose AKI are imperative to reduce this negative outcome. The discovery and validation of renal damage biomarkers should in time supplant creatinine-based criteria for the clinical diagnosis of AKI.

Read the full article here